I agree with all of this, and I can’t help but ask: when did we start ignoring people’s environment and their circumstances? I have tens of thousands of dollars of student loan debt (my monthly payment is basically a mortgage payment) and I’m not particularly satisfied at work. Is it any wonder I find it impossible to get out of bed? Now, I try to be careful because, sure, perhaps the depression was already there and is just making my life complicated, but that seems less likely. I KNOW I’m not happy at work; I KNOW my debt burden makes me feel trapped and helpless. Look at Harlow’s monkeys. Turns out putting creatures in helpless, depressing environments makes them feel helpless and depressed. If seeing your friend get blown up by a roadside bomb can give you PTSD, couldn’t falling wages, no social safety net, stressful news media, crushing debt, and poor job mobility make you depressed?

a) We're a highly medicalized society with very weak institutions for providing informal psychosocial care and support.

b) Saturation marketing of psychiatric medication has caused the general public to grossly over-estimate their efficacy, even in countries where direct-to-consumer marketing is banned.

c) The wholesale price of a generic sertraline pill is about 4¢, so it's cheap enough to dole out like candy.

d) Medicalizing unhappiness is politically convenient.

If you're depressed, you go to your doctor. That's the message you've been told for decades, it's how our society is set up. In another culture, you might speak to your priest or a village elder. It's undoubtedly a net positive that we've got access to some kind of evidence-based psychiatric care, but a lot of the other structures that people used to rely on for psychosocial care have crumbled. We're less likely to know our neighbours. We have fewer close friends. Our employment is more impersonal and precarious. We're less likely to go to church. If we do go to church, it may well be a megachurch with a congregation of hundreds rather than a close-knit community church.

Doling out pills is the absolute cheapest treatment option, even if some proportion of those pills are expensive proprietary drugs. It's orders of magnitude cheaper than psychotherapy and immeasurably cheaper than building a more humane society. Your doctor can't prescribe a good friend, a sympathetic partner or a better job.

It suits your employer if you conceptualize your misery as the symptom of a "neurotransmitter deficiency" rather than a symptom of your crappy job. You probably won't be as productive, but at least you won't go on strike or burn down your office. It suits the government equally well if you see misery as a personal rather than societal problem.

Some people are just depressed for no discernible reason. Lots of people are being diagnosed with depression when they're just struggling with a shit set of circumstances that would make anyone miserable. The medical model helps some number of people in both camps. Society needs to do a better job of helping people live healthy and fulfilled lives.

This is essentially the learned helplessness theory of depression: https://en.wikipedia.org/wiki/Learned_helplessness

We're not ignoring their environment. But unfortunately, most of the time drugs are quicker and easier for the prescribers, and therefore cheaper and more available for the patient, than extended psychotherapy, etc.

If the underlying problem is a psychosocial stressor, the meds won't fix that, though they might help you control the symptoms long enough that they give you the opportunity/resilience to address the stressor. And sometimes, while maybe not ideal, just controlling the symptoms is enough even for the long term.

"We" absolutely are ignoring their environment in the USA at least. People cannot even access healthcare here without additional, significant financial stress and burden. My entire family and the strong majority of my region and a general majority overall oppose the policies and systems that would give someone like me a life and future. Even seeing how it's gone for me my family refuses to support social systems and offer help to those in need. It's "stealing my money" to them and ruined our relationships seeing how selfish they are turning their back on me AND society.

I know the causes of my issues, there are at a minimum mitigations available but I can't BUY them because everything here is a business and competition and someone else took me out of the race by taking lots of money to end my capacity to compete (poor medical intervention) and I was left holding all the additional baggage with no help. I have friends who suffered catastrophes living in countries who don't think social systems are evil, and they had the tools to heal as much as possible and improve their lives and be able to contribute to the whole again. I wasn't afforded that opportunity and it's been a constant downhill slide.

Pardon the tone and it is not directed at you, it just infuriates me that American society ignores such important things and once someone is not able to WIN in the Thunderdome they are cast aside and/or expected to live with little to nothing and even more needs, while it continues focusing on pushing what are in my view largely ineffective, but very profitable "interventions". I find the predilection for painting over damage in this country over restoring/shoring up someone's foundation to be maddening.

This is the main reason I stayed away from medication for 12 years. That is until 3 weeks ago.

I decided late 2017, after a major depressive episode, that I needed to get help after 12 years of dealing with this depression. I kept thinking that I had a handle on it, and then it coming back weeks, months or years later.

I read The Depression Cure (https://www.amazon.com/Depression-Cure-6-Step-Program-withou...) about 5 years ago, and it helped for awhile, but it started to worsen again, and after awhile, getting the right diet, exercise and sleep seemed impossible because of the depression and anxiety.

I started therapy about 3 months ago, and finally agreed to try medication. I started taking Zoloft 3 weeks ago, and the side effects are downright awful. I made it through the first 3 weeks though, and I'm starting to feel a lot better.

Zoloft might not end up being the right medication for me, and there might be a better one, but my goal is to find something that takes 10%-20% of the depression and anxiety symptoms away so that I can start my path to curing this beast with the methods Dr. Iliardi outlines in The Depression Cure. Once I'm at a point where I'm better, I'm going to try and ween off the medication and try to live a healthy, great life without SSRIs.

For the more severe anxiety disorders, the proof of efficacy above placebo is much better than what we have for depression. People don't get better by taking placebos for their OCD. For anyone experiencing anxiety problems, I highly recommend finding a competent therapist who knows CBT. For anxiety that constantly interferes with daily life, medication may be appropriate.

For me the SSRIs completely wiped out my OCD to the point where I sometimes forget that I have problems with anxiety. Depression is downright benign compared to how bad the situation can get with other psychiatric disorders. Unfortunately the demand for competent medical professionals far outstrips what is available.

I do agree that SSRIs are over-prescribed for minor depression problems, but let's not demonize a whole class of medications which are highly useful for more serious psychiatric issues.

Some people need it because their brains is just plain imbalanced, I get that. For some, that imbalance can be fixed with lots of work, however for some, it can't. I'm _hoping_ to be able to fix mine, but I'm willing to work with a doctor to figure out if that's possible.

> Depression is downright benign compared to how bad the situation can get with other psychiatric disorders.

No - you just have no experience of comparably serious depression.

I wish you the best. Definitely don’t be afraid to discuss alternatives with your doctor if you’re not happy with Zoloft...sometimes it takes a few tries before you find whaat works best for you.

Thanks for the reminder. I'm trying to tough out a month, because side effects tend to wear off within 3-4 weeks, and review with my doctor and therapist then.

NNT might be 7 for one drug and one try, but the therapist will try several drugs and doses.

I could imagine that NNT might significantly improve if you consider “use antidepressants” instead of “use 1 antidepressant 1 time”

Assuming that efficacy is randomly distributed, you're left with some very frustrating math. You'd need to try five drugs to have a better than 50/50 chance of getting a positive outcome. After seven drugs, there's still a 34% chance that none of them have worked. After fifteen drugs, there's still about a 10% chance that nothing has worked. I expect that most patients will give up on drug treatment well before that point.

I don't want to be overly negative about antidepressant drugs - they're a useful treatment for many patients - but I do feel that the popular perception of their efficacy is far greater than the reality. Many people seem to feel extremely disheartened when antidepressant drugs don't work for them, often believing that there must be something uniquely wrong with them. The language of psychiatry doesn't help, describing these people as "treatment-resistant" rather than "people we don't know how to treat".

If you try antidepressant drugs and they don't seem to do anything, don't keep taking them just because you think you're supposed to. Speak to your doctor about alternative drug and non-drug treatments. If you have access, try a range of psychotherapies. If your symptoms are relatively mild, look at lifestyle interventions. If your symptoms are particularly severe and/or chronic, give some serious thought to rTMS or ECT.

i agree with your points, but 50% is already good i think.

it is less than anyone might spontaneously guess, but it is still good, considering that you will try a couple of other things in addition, like cognitive therapy.

So getting some good months long treatment by a doctor can lead to (lets say) 70% curation rate. It then becomes sad if people choose to stay away from doctors and I just commented to not discourage possible ill persons.

You probably just wanted to stress that such pills are far away from doing guaranteed miracles and you are right.

> The majority of people with depression just get better of their own accord, for no obvious reason. The NNT for most antidepressants is ~7, meaning you need to give them to about seven patients for one patient to see a clinically-significant improvement.

Which is fine, as long as they stay alive long enough for natural changes to occur. If a prescription gives only hope, that could be enough to keep people strong enough to battle through another day, week, month, year.

>The evidence suggests that there's no significant relationship between SSRI use and suicide risk except for young people, for whom SSRIs may actually increase the risk of suicidal behaviours and self-harm.

The paper says: "However, in children and adolescents, there appears to be a bit of increased risk of suicidal ideations and attempts, but not of completed suicides."