> As a former therapist turned software engineer, herein lies the problem. 87% antidepressants? How are we defining "treatment?" Depression is a complex beast, and does it always require "treatment"?

This is, admittedly, speculation on my part based on personal experience. Here goes. I'm sure you know this, but I'd like to throw it out there.

If I want to see a my regular GP and talk about mental health, I schedule a regular appointment and pay my co-pay for the visit and for any pharmaceuticals he prescribes.

If I want to see a mental health professional, I have to call my insurance company, describe my problem to someone who is not a mental health professional, have them pre-authorize visits (if they will), find an in-network therapist and complete treatment in the maximum 5 authorized visits per issue.

A system like this drives people to antidepressants.

There is one thing you forgot with the mental health professional: There is often a waiting time, especially if you get public assistance. I understand, in a way, as it is a specialty field, but then again, you might not have the bravery and motivation for all that long, yet not really qualify for even a semi-emergency visit.

My first spouse was bipolar/schizo affective: We were lucky enough to get a doctor fairly quickly, unfortunately it took a suicide attempt to figure things out. If he had to cancel an appointment, however, sometimes the waiting time was at least a month unless he was having a difficult time. Then it might be a couple weeks: More difficult than that probably meant hospital time. Luckily either the insurance I carried was flexible or the hospital was really good at negotiating with them so that wasn't an issue.

On the other hand, my nephew has needed a psychiatrist and therapist for some time. My sister had trouble even getting one in network, a harder time finding one to work with children, and generally had a long waiting time. Difficulty all around.

> What is "treatment"? Sleep, exercise and social experiences?

I would bet most doctors know that sleep, diet, and exercise are very important and they let their patients know that.

What do you do with a patient that's overweight and doesn't get enough sleep? Refuse to write a prescription that will likely help even if the patient doesn't have the basics under control?

I had high cholesterol (250 or something). With low HDL (the "good" cholesterol) and very high LDL. My doctor prescribed a statin, appropriate, and encouraged me to exercise and eat better.

I took the drugs, but didn't (for a couple years) do much about the exercise, and continued to overeat (to my credit, I ate healthy things, just too much of them). My cholesterol dropped, but I had to stay on the meds. Eventually I started exercising, cut my calorie intake, and lost 40 pounds. My doctor took me off the meds, cholesterol stayed low.

The point is this exchange with him: He was impressed that I'd lost the weight. Happy that I could go off the meds. But said, he prescribes the meds because almost none of his patients will bother to take his advice on diet and exercise. He has to help them somehow, but he's stuck in a situation where what they need is beyond his control to actually prescribe, but most of them will at least take a pill a day.

Depression (and anxiety and other conditions) are all, for the majority of sufferers, treatable with lifestyle changes. Buying a dayplanner and scheduling your work instead of running from fire to fire. Going out with people and having real, physical social interactions. Possibly moving to a healthier climate or changing jobs.

But most people won't do those things, so doctors are stuck prescribing a drug that will help their patients, but won't solve their problems.

Just to let you know that the data backs your doctor up. Every legitimate long term study of non surgical weight loss shows that it doesn't happen for the vast, vast majority of people.

1) ["In controlled settings, participants who remain in weight loss programs usually lose approximately 10% of their weight. However, one third to two thirds of the weight is regained within 1 year, and almost all is regained within 5 years. "](http://www.ncbi.nlm.nih.gov/pubmed/1580453)

2) Giant meta study of long term weight loss: ["Five years after completing structured weight-loss programs, the average individual maintained a weight loss of >3% of initial body weight."](http://ajcn.nutrition.org/content/74/5/579.full)

3) Less Scientific: [Weight Watcher's Failure - "about two out of a thousand Weight Watchers participants who reached goal weight stayed there for more than five years."](https://fatfu.wordpress.com/2008/01/24/weight-watchers/)

4) [The reason why it's impossible seems to be that although calories in < calories out works, the body of a fat person makes it extremely difficult psychologically to eat less.](http://www.nytimes.com/2012/01/01/magazine/tara-parker-pope-...) This is borne out by the above data.

5) [The only thing that does seem to work in the long term is gastric surgery.](http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1421028/)

I know. I'm not disagreeing with him. I was commenting on why doctors, at least my doctor who I generally consider good, go to drugs first. People will take them regularly, which gets them half-way to actually being healthy. But they won't do the things that will get them all the way to healthy.

> Depression (and anxiety and other conditions) are all, for the majority of sufferers, treatable with lifestyle changes.

That's quite a broad generalization. It's also naive and dangerous. All depression can't be treated with lifestyle changes, just as you can't cure type 1 diabetes or cancer through lifestyle changes. That statement is one of the biggest problems for people with mental illness: the stigma from the uninformed that someone who is depressed is weak, and that should "just get over it".

I didn't say all depression can be treated with lifestyle changes. Though my claim of this being true for the majority of sufferers is too bold. I should have stuck with my usual "many, if not most".

I wrote:

  Depression (and anxiety and other conditions) are all,
  for the majority of sufferers, treatable with lifestyle
  changes.

To restate this (including my too broad claim):

  The majority of cases of depression and anxiety are
  treatable with lifestyle changes.

And lifestyle changes are not "just get over it" prescriptions. They're major and incredibly difficult. Things like, move to an area with a better climate. Quit your job and take one with less stress. End some relationships. Pursue (challenging) physical activities to get in better shape and get more sun and fresh air. Those aren't easy to do or resolve, but stressful jobs, inactivity, lack of sunlight, poor relationships are the sorts of stressors that lead to many instances of anxiety and depression. Identifying the causes is incredibly important, and saying that people can't and that they can't effect change to improve themselves and their situation removes their self-agency, making them feel they are weak and incapable of controlling their own lives.

Drugs do work, and in many cases are necessary at least in the short-term. But they're poor solutions in the long-term for many, if not most, people who suffer from depression and anxiety.

Do you have any sources for your claims? "Majority of depression cases treatable with lifestyle changes" and "poor solutions in the long term for many".

I already said majority was too strong.

Regarding poor solution, here's a list of some of the side effects:

http://www.webmd.com/depression/features/antidepressants?pag...

These are some of the reasons people quit taking them, which can result in all sorts of tragic consequences if they don't stop taking them under guidance of a medical professional. Along with people who quit taking them because they "feel better". Cutting off these medications often results in a relapse (similar for anxiety medications). EDIT: And a lifelong dependence on a medication is a difficult thing for many people to deal with. When missing even one or two doses of these medications can result in a massive emotional shift, this is a fragile solution.

CBT (which is much more than just the "lifestyle" changes, my wording was, again, not the greatest) offers better handling of emotions and reduced risk (or mitigated effects) of relapse. Largely by developing coping skills and other mental/emotional tools in these lines.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2748674/

What also can work well is a combination of both. But a serious risk with medication only is masking of the underlying problems. The individual can feel good, or at least not depressed or anxious, but the stressors and causes are still present. So when going off the medication (self-decided or medically guided) and re-encountering those stressors, they lack the skillset to handle it any better than they did the first time (without some amount of either self-directed or therapy-aided development of coping skills).

I think this gets at a bigger philosophical question about depression that few seem interested in engaging in.

Sometimes depression is a correct, reasonable, and even necessary reaction to un-live-with-able life circumstances. It's a way of your body generating warning signals that others might see and then offer you help, not unlike shooting up a flare if you're stuck on a life raft.

If the circumstances truly are un-live-with-able, then medication that simply makes you superficially feel like the circumstance is live-with-able, when really it's just continuing to be destructive to your life in every single same way apart from your now-masked-with-medication feelings, then medication can be counter-productive.

Many people with depression don't actually have un-live-with-able circumstances. Instead, they have live-with-able circumstances and either they have medical issues preventing them from doing the actions necessary to manage that living, or else they have what I'll call psychological issues preventing them from it, where 'psychological' here is meant to mean the subset of mental health issues that are not well-treated by medication, but may be treated with counseling or changes to other life habits.

The problem I've always faced when seeking counseling or mental health help is that every single mental health professional I've ever interacted with, every single time across many years and highly varied geographical situations, has always, always, always dismissed completely the possibility that a person can actually have un-live-with-able circumstances within which the depressive reaction makes reasonable sense. Instead, they begin from a point of view fundamentally rooted in the belief that that cannot ever happen to a human.

I mean, if they were pressed to think about like a child soldier forcibly addicted to cocaine or something, maybe they'd agree people really can have circumstances such that depression is the correct reaction. But in general, with first world people, they just assume it's impossible and have a pervasive Occam's Razor sort of filter, before ever meeting you or even talking to you the first time, that, nope, you're wrong about how you view your own problems, that there's no way you could be thoughtful enough to have done meaningful introspection before seeing them, and that your circumstances are never a justifiable reason for feeling depressed.

And from this attitude, the next step is almost always to suggest medication right away. And any time I've tried to say something like, "well, I'll consider medication, but I'm not just going to jump right into it. I want to speak more about my circumstances and explain why I feel like it's a real life Catch-22 that truly, utterly is depressing, rather than the depression being a part of me as I respond to it," then it's like talking to a brick wall. The counselor / therapist / psychiatrist doesn't want to hear about about. They already know you need drugs within one 1-hour visit, and now that you're saying you won't just rush right out and get them, that means further that you are a problem because you won't just go get the drugs you need.

And what's crazy is that the underlying rationalizations from the different mental health professionals have been all over the place. One person thinks it's because I have issues about my childhood and my father. Another thinks it's because I grew up in a relatively more religious community. Someone else thinks I have PTSD from an abusive relationship in my late 20s. Yet another thinks that it's related to overwork and job stress.

All of these are important issues and some mixture of all of them is affecting me. But every counselor I see has their own colored opinion about which magic answer it is, all those magic answers are different from each other, and yet, every one of them thinks that drugs, drugs, drugs is what will magically solve the problem.

It really gives me no faith in the mental health treatment infrastructure, and causes me to be even more guarded about when or if I will consider trying anti-depressants.

From some of these statistics, it makes me feel like anti-depressants are way over-prescribed, and that counselors are just extremely lazy. They don't want to hear the whiny, tearful narratives of their hurting patients' lives -- just like friends and family also don't want to hear it. And so shoveling out some drugs is an easy way to focus on something different than the thing they find unpleasant (i.e. actually listening).

There's depression the feeling, which may be caused by un-live-with-able circumstances and serve as a stimulus to make life changes.

Then there is depression the illness, which and may or may not be brought on by some circumstances, but which is debilitating.

If it's serious enough, I'm not sure if it matters whether it is spontaneous or caused - you need to be brought out of it before you can deal with the un-live-with-able circumstances. Staying in the depression doesn't help you to take action at all.

But the huge difference is that with truly un-live-with-able circumstance, the most important thing you need is help to alleviate the circumstance itself. Changing your response to it isn't helpful if it doesn't contribute to changing the underlying circumstance, and when the circumstances are things that you don't control which happen to you, especially when they are on-going and it's not so much about how you process them but actually stopping them, it's questionable what role medication really plays.

> Staying in the depression doesn't help you to take action at all.

It definitely can. Precisely when you lack the power to change your own extrinsic circumstances, and it is those circumstances causing the harm that leads to depression, then staying in the depression keeps sending out that distress signal for help. Taking you out of the depression without also addressing the circumstances makes it seem like you're managing it, when really you're still being harmed.

On a slightly related note; with all of your life changes, it's pretty easy to become Magnesium deficient. Please look into taking Magnesium Glycinate. It's made a world of difference in my depression. (just make sure you're taking at least 1,000mg a day, two capsules every 4-6 hours).[1][2][3][4]

[1] http://www.ncbi.nlm.nih.gov/pubmed/16542786

[2] http://www.ncbi.nlm.nih.gov/pubmed/19944540

[3] https://examine.com/supplements/magnesium/#summary3-7

[4] https://www.amazon.com/KAL-Magnesium-Glycinate-400-tablets/d...

While there's no harm in supplementing with small doses of Magnesium, it's also very unlikely to be the sole causative or curative factor in most people's depression. I'll address your studies individually:

[1] Refers to case studies (e.g. clinical anecdotes) of depression recovery following magnesium administration, but the number of cases is omitted. More importantly, there are no placebo controls to differentiate between spontaneous or placebo response and response to the magnesium supplementation. Finally, the article is in the context of severe magnesium deficiency, which is a strong selection bias that prevents the anecdotes from being extrapolated to the general population anyway. (Yes, I am aware that much of the US population does not meet FDA guidelines for magnesium intake, but that's not the same as being deficient in magnesium in the body).

[2] Is a good example of the importance of noting which journal the article was published in: In this case, it was published in Medical Hypotheses, which is dedicated to promoting diversity in debate by publishing hypothesis and fragmentary ideas that don't yet have enough real evidence to publish elsewhere. The first study it cites is from 1921, which was not placebo-controlled. The second study cited is from a journal dedicated to Magnesium research, but more importantly which pre-selected for patients with hypomagnesia. In other words, the study examined whether Imipramine (an anti-depressant) or magnesium supplementation were more effective in elderly type 2 diabetes patients who were known to have hypomagnesia.

[3] Refers to animal studies, but 3 of the 4 cited articles are about magnesium in migraine headaches. Perhaps the full-text articles have some embedded murine studies, but otherwise I don't see much evidence for magnesium treatment in humans here.

In short: It can't hurt to supplement, but it's unlikely to be curative. More importantly, recommending weak or unproven supplements to depressed patients can send them down a path of attempted self-medication with supplements that do not work, when proper medical treatment can work much more quickly and effectively.

I don't think I ever made the claim that Magnesium would cure. It has helped my symptoms. Hypermagnesemia appears to be very rare so it was a low risk effort for me. I've had positive results with it whereas other touted natural antidepressants have quickly petered out (St John's Wort, 5-HTP).

I would like for this to be true. There are a bunch of red flags in the abstracts of those papers though. For example "Fortifying refined grain and drinking water with biologically available magnesium to pre-twentieth century levels is recommended." Seems to be overstating their case a bit. Anybody with more expertise care to weigh in?

Not a specialist in the field, but I note the journal where both those papers appear, Medical Hypotheses, explicitly disavows peer review, and was founded by a fellow [1] who seems to have spent his entire professional life under something of a shadow. I'd take those hypotheses with a grain of salt. But, if I were feeling myself unduly miserable (which happens sometimes), I might also take magnesium supplements for a while just to see what effect it might have on my state of mind.

[1] https://en.wikipedia.org/wiki/David_Horrobin

My experience is that cheap magnesium works better than the expensive stuff, at least when it comes to the mild sedative effects of magnesium.