(2014-06-16) Alexander Things That Sometimes Help If You Have Depression
Scott Alexander: Things That Sometimes Help If You Have Depression. first I’m going to talk about figuring out if you need help. Then I’m going to recommend you see a psychiatrist. Then I’m going to accept that in reality a lot of people for whatever reason can’t or won’t see a psychiatrist, and grudgingly recommend some lifestyle interventions you can make. Then I’m going to accept that in reality a lot of people for whatever reason can’t or won’t make lifestyle interventions, and grudgingly recommend some over-the-counter medications and supplements that might be helpful.
I. Do You Have Depression?
The PHQ-9 is a well-known and validated screening tool for depression
II. Please Go To A Doctor
You do not need to go to a psychiatrist to get antidepressants. Your family doctor will be able to prescribe them. You will only need to go to a psychiatrist if your depression fails treatment with normal medications and someone needs to figure out a more complicated plan.
There are dozens of different depression medications. If one doesn’t work, very commonly another one will. Depression treatment is difficult, because there’s no way of knowing beforehand what medications will or won’t work for any individual person. The correct solution is to start with the safest medications, see if they work or not, and gradually move up to stronger medications with more side effects
A lot of people are reluctant to second-guess their doctor on this sort of thing. So let me provide you with a loose approximate algorithm
1. Rule out organic causes
2. Choose between pharmacotherapy, psychotherapy, or both
Many to most doctors and psychiatrists will assume that you want medication. This is a pretty good assumption most of the time. Medications and psychotherapy are about equally effective in treating depression, but psychotherapy costs a lot more, takes more time, and is harder to get your insurance to cover.
Cognitive-behavioral therapy is a nice neutral therapy for depression with as high a success rate as any other. It usually consists of a couple of sessions in which somebody talks to you about the way you deal with and think about problems and maybe assigns you some homework. There’s no talking about your mother or about your sexual fetishes. 6 to 12 one hour sessions would be a pretty standard starter course.
Having both psychotherapy and medication has been associated with a better treatment rate than either one alone.
3. Start with an SSRI
There is a lot of worry that SSRIs are not much better than a placebo for people with mild to moderate depression (almost everyone agrees they are effective for severe depression). Some studies have seemed to confirm these fears, others have seemed to refute them. I am leaning towards “marginally better than placebo”.
All SSRIs are approximately equally effective. Your doctor or psychiatrist’s choice of SSRI comes down to which side effects you are most willing to tolerate
Celexa or Lexapro (citalopram or escitalopram) are good first choices for most people
Many people worry about the side effects of SSRIs. In my opinion many of these worries are exaggerated. The most common side effect is decreased sexual drive and performance, which can occur in more than half of users
Some antidepressants have discontinuation syndromes, which mean you feel sick when you’re withdrawing from them. Effexor (venlafaxine) and Paxil (paroxetine) are particularly bad
4. Give it a little while to work
give an antidepressant at least four weeks
5. Fiddle around
*If a drug seems to work a little bit in the first month or two, it might be worth raising the dose.
If it doesn’t work at all within the first month or two, you could still try raising the dose, but you might also want to try switching to a different drug*
6. Get serious
Once treatment with SSRIs and the usual SSRI replacements has failed, you get to start trying more serious stuff
Modafinil shows some promise as an antidepressant supplementation
7. Get very, very serious
Electroconvulsive
There are a lot of worries about side effects
Some people experience some memory loss, especially of the couple of weeks before the treatment
Speaking of miracle cures, a couple of people have asked me about ketamine.
that required long-term ketamine therapy (say, a ketamine dose a week) would be impractical both because of the hallucinations and because the drug has serious side effects and is addictive
How do you find a good psychiatrist?
How do you see a psychiatrist without worrying you will be committed to an institution?
The first and most important point is that very very few psychiatrists, whether good or bad, will commit people to a mental institution unless they are very sick
Until you are sure your psychiatrist is trustworthy, you may want to steer clear of statements that sound suicidal, homicidal, or paranoid. Even in jest. Especially in jest. Until you have established absolute trust, please treat joking about suicide or homicide around your psychiatrist the same way you would treat joking about terrorism around airport security agents
III. Lifestyle Interventions
1. Do therapy on yourself
If you can’t or won’t go to a therapist, a therapy workbook (self-help) is a practical alternative
2. SLEEP!
Depression is weirdly linked to circadian rhythm and sleep. Poor sleep habits probably help cause and exacerbate depression
In a recent study, people who received cognitive behavioral therapy for sleep disturbances had double the recovery rate from depression of people who didn’t
3. Exercise
*Exercise seems to increase release of BDNF, an important brain chemical that depressed people don’t have enough of, and there have been several studies showing good effect.
Fast walking for a half hour five days a week seems to be enough to help*
4. Light therapy
there is still uncertainty about whether they add extra treatment to somebody already being treated with antidepressants (blue light)
Experts recommend a light therapy box emit 10,000 lux (a unit of light).
5. Drugs are bad for you, mmkay?
6. Other things that make you happy
Cure Together is a really neat website where people with illnesses record all the things – medical and nonmedical – they tried and how well it worked for them
Just from looking at it, exercise and SLEEP! are right up at the top, but people also mention things that more scientifically-inclined people would probably never think of, like spending time with a pet, listening to music, and watching funny TV shows.
IV. Supplements
here are some supplements that seem promising for depression, in approximate order of recommendedness
1. S-Adenosyl methionine (SAM-e)
One experiment got good results with 800 mg two times a day for six weeks
2. Creatine
One RCT found good results at 5g per day. May be more effective in people likely to be protein-deficient (eg vegetarians) and possibly in women.
3. Folate or l-methylfolate
form of Vitamin B9
Several RCTs have found positive effects from supplementing antidepressants with folate, although the evidence for folate on its own is still lacking
4. Saffron
5. Fish oil
I’m more skeptical
Instead, I would eat a lot of fish. The degree to which the level of depression in a country correlates with the amount of fish eaten in that country is staggering. Two salmon dishes a week ought to be a good start
6. -afinil
There are fewer studies about whether it works on its own. I would guess that it does, because the most likely mechanism is its well known tendency to increases energy and alertness, which is pretty useful against depression’s fatigue and tiredness
worth noting that modafinil disturbs sleep and disturbing sleep is very bad in depression, so take it at the beginning of the day and if you still can’t sleep at night, cut the dose.
Adrafinil is a prodrug that turns into modafinil once in the body. It is perfectly legal without a prescription, because the medical licensing regime makes no sense. You might as well just get that – as far as I can tell the risk of liver damage is overhyped if your liver is otherwise healthy.
7. Other things
What if you want to buy antidepressants illegally without prescription?
For weird political reasons, tianeptine, a well-regarded foreign antidepressant, is not a prescription drug in the United States.
It is available from nootropicsdepot, a supplier I regard pretty highly
V. Other things
outcomes get better the more stuff you try. According to STARD, which tested an algorithm a lot like the one I mentioned above, by the last step of the algorithm 70% of patients experienced complete remission, and many more experienced significant symptom reduction.* (intervention roulette)
This is not a resounding victory, because the average depressive episode only lasts six months and the study took more than six months to complete, which makes it really hard to figure out how much of the improvement was due to the drugs.
The most important thing I’m writing this for, and the lesson I want to hammer home, is that if your doctor just gives you an SSRI and tells you to stay on it even when it clearly isn’t working, there are other options.
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