Lorien Psychiatry is Scott Siskind's (Scott Alexander) psychiatric practice site, with guides on antidepressants, Adderall, insomnia, and light therapy.
HN commenters recommend its writeups on antidepressants and Adderall, which they say clear up common myths, such as those about addictiveness.
> Ideally, a professional will prescribe them as a necessary helper to becoming (more) mentally healthy whilst tackling the root cause.
I wish people would stop saying this.
Our understanding of the brain is not sufficiently sophisticated to allow us to identify the "root cause" (whatever that means) of depression in most people. Indeed we have no reason to believe that there even is a root cause to most people's depression.
If you take antidepressants, go to therapy (or meditate or exercise or whatever), then go off them and still feel good, that's great.
And if you take antidepressants indefinitely because doing so improves your life, that's also great! Your life is improved! This isn't an "abuse" of the drugs.
No psychiatrist is making you do anything. They're advising you based on their clinical judgement and experience, but ultimately it's your decision to take the pills or not. If your goal is to go on antidepressants temporarily, any decent psychiatrist will support you in that (because, again, they understand that they can't make you take the pills one day longer than you want to).
I've been on Lexapro and done evidence-based therapy for years. They both have been helpful, but if I had to pick one, I'd immediately pick Lexapro. For me it is a miracle drug. And the miracle is, I can choose how I feel.
(I also added a small dose of Buspar to help with the sexual side-effects.)
If you're on the fence about trying an antidepressant, I really encourage you…
You don't understand one thing: we actually care. Like, we really, really care :) (at least that's my perception of many fellow EAs)
People behind those charities have diverse backgrounds in social sciences, philosophy, economics, and welcome better ways to do more good, better.
If we are not reducing suffering, we will investigate, and try to do better. If we're only decreasing malaria death statistics and increasing death by other means, if we're not effective, we really want to know. Some very skilled social scientists are working on this problem -- many in the field, talking to people, going to poor places where things like tropical diseases happen.
I think giving more weight to the psychological and broader human side is a fundamentally important point as well (which I agree with and have voiced opinions about), but we also have to remember the basic realities of the diseases (like malaria or diseases that cause lifelong blindness!), and the reality of living in extreme poverty. In the end I recommend that you see documentaries about people living in poverty, visit them if you can, to solidify your decision (and tell it to others -- communication is real and important!)
I have just heard of the Happy Lives Institute which seems to be looking at the global mental wellbeing perspective (note: I have done 0 research on them, but the idea seems good!), and I admire Scott Suskind's free website that gives evidence-based treatment guides for mental health issues[1]. Maybe…
You may have a circadian rhythm disorder, e.g., delayed sleep-wake phase disorder (DSWPD) [1]. It is rare in the general population (<1%) but my intuition is that software engineers are overrepresented. Irrespective of whether you do, there are likely concomitant behavioral issues that are exacerbating the issue.
I struggled with sleep for years. I had difficulty falling asleep before 2am or so, difficulty getting out of bed, and any multi-day period without obligations (e.g. holiday) inevitably resulted in my bedtime shifting by an hour or more each consecutive night. Tried everything. Described symptoms to several somnologists, primary care doctors, psychiatrist, psychologist, etc. Last couple of years I saw improvement. What helped was:
- 0.5mg melatonin 7 hours before bedtime [2] [3]
- Do a CBT-I program with a psychologist
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Taking melatonin near bedtime did absolutely nothing for me. Taking melatonin at 5pm was magic. Symptoms that had persisted for years evaporated within two weeks.
CBT-I is very effective for behavioral issues but it's not magic. It is expensive and take a lot of time and effort. Don't use a self-directed app or book. Find a psychologist who specializes in CBT-I. Insurance may not cover it. It will require a couple of months of effort and cost $2,000 or so. It is worth every penny.
Everyone knows that light can affect your circadian rhythm, but body temperature can as well. Cold = sleep, warmth = wake. Consider investing in something that…
Hard to answer precisely without knowing what conventional wisdom didn't stick.
The common levers I know and that worked at least a bit for me:
- start by having a fixed waking time, and get sunlight or bright light quickly after waking up. Normally relatively fixed sleep time is supposed to follow. For me waking up is the easy part, transforming that into getting up and going outside is harder. Another option here is a strong (like, really strong) lamp on a timer, or letting the morning light in your bedroom (this one is usually not recommended I think, most people seem to be blackout curtains style, but for me it gave me a nice 6am waking time with good sleep last summer).
- melatonin. Two main ways: using it as a kind of hypnotic, so ~30 minutes before sleep, experimenting with 0.3mg to ~2mg doses ; then using it as a circadian regulator, this is a good resource https://lorienpsych.com/2020/12/20/melatonin/, search for "TO TREAT" in the page.
- app timers, for me it was mostly no twitter and no youtube, or a very low time for each.
- light, ie reduc light before sleeping. Not just blue light and not just screens, if I'm on my phone in bed I'll reduce the luminosity a lot, same with computer, same with e-reader. I also try to avoid using too much the lights in my room. More light tend to make me feel more "wired" and less ready to sleep.
- "meditation" to cut rumination, by which I mean "lay down in my bed, gently try to find sensations in the body and to stay…
The evidence for antidepressants is not based on the serotonin theory of depression. It's based on blinded placebo studies. The serotonin theory was posited after MAOI antidepressants were discovered. It's been argued that antidepressants aren't significantly better than placebo. There's a good discussion of that here: https://lorienpsych.com/2020/10/25/ssris/#3_How_effective_are_SSRIs
There's also a background debate here over whether depression should be seen as biological/chemical or environmental. This comes up in the article toward the end:
> Although viewing depression as a biological disorder may seem like it would reduce stigma, in fact, research has shown the opposite, and also that people who believe their own depression is due to a chemical imbalance are more pessimistic about their chances of recovery.
The thing is, if you're not a dualist, there's no reason depression can't be chemical and environmental. Clearly life circumstances can lead to depression and making changes (diet, exercise, leaving a job, leaving a relationship, undertaking therapy) can be a way out. Most doctors understand this and that doesn't discredit medication as a potential option.
Interesting. I love Scott, but I didn't know there was a draft on ACX. The official page is on his website: https://lorienpsych.com/2021/06/05/depression/ I'll have to see how the articles differ...
1. Yea. It was hard to find someone with availability period, and our insurance isn't very good. You're probably right that I should just pay out of pocket, but I'm honestly pretty convinced that I have an actual brain chemical issue, so I'm dubious of the benefits to therapy
2. I think I do a decent enough job at this. I don't necessarily eat the best food, but at least I'm eating some fruits and vegetables and not Doritos all of the time. I don't really exercise much, but at least I go on 30+ minute walks every other day or so. I probably sit in my chair to much, but I imagine most on HN do that...
What led you to getting better? How were you able to function in such suffering for 10 years? Not to turn it into talking about me again, but I'm increasingly worried that I've wasted a year and may waste many more to this nothingness, which is quite concerning. How do you look back on your 10 years and say "it's OK, I needed to go through that/I'm happy I'm better now"?