Mental Illness - a personal perspective.

This is an edited repost of something I wrote nearly three years ago. You can
see the original post and comments here.

Over at Dr. Isis's blog, there's a post answering a reader's question about whether to tell her
postdoc advisor about her troubles with clinical depression. I agree with Isis's advice - without
knowing the advisor really well, you can't be sure of how they'll react. If the postdoc
had become ill due to something like a diabetic episode, where the change in schedule and
environment caused by taking a new job messed up the PDs control of their blood sugar - well, there
wouldn't be an issue. The PD would be able tell their advisor they had a medical issue without
worrying too much about repercussions. But mental illness is different: the fact is that there is a
very strong stigma attached to mental illness, which makes it different from other illnesses.

This is something that's very important to me. I have people very close to me who have
dealt with profound mental illness, and I've seen them suffer from the effects of the stigma
associated with it. And I am mentally ill myself: I have clinical depression.

Clinical depression is a thoroughly miserable illness. I'm incredibly lucky to live at a time
when there are effective treatments for depression. I'm even luckier that I'm one of the people for
whom medication is, essentially, a cure. I just to take a pill every morning, and it's almost
like I never had depression at all. But if I stop taking my medication, after a couple of months,
it will return - and there's nothing that I can do to stop it.

The point of writing this isn't to tell the world that I've got clinical depression, or to say
"Gosh I like my drugs". The reason that I'm writing this is to talk about the stigma, and
how foolish and hypocritical it is. I get to see it on a fairly regular basis, by seeing
how people react when they hear that I take antidepressants. I don't make any effort to
keep it secret - I'm very open about the fact that I've got a depressive disorder. And
when people find out, for a large number of people, the fact that my brain has a problem
that's easy to fix using medication is somehow considered to be a huge strike against me, an
inexcusable sign of personal weakness.

I've got a somewhat unusual perspective on this, because, frankly, I'm not the
healthiest specimen of humanity. I take several different medications every day - for
allergies, for gastrointestinal troubles, and for depression.

For me, the hypocrisy of the stigma against mental illness is easy to demonstrate
using my gastrointestinal troubles. I've got serious stomach problems. It's not actually something with a simple name; basically, it's classic reflux disorder, but combined with an extremely irritable stomach which triggers extremely painful muscular spasms. Those two together are a bad combination: the spasms behave almost like a pump, spraying acid up my esophagus. (Which is exactly as much fun as it sounds.) Anti-acid medications didn't work well enough, so in order to treat this, I needed surgery. The surgery mostly cured the reflux, but it had other effects. Post-surgery, I now get espohageal spasms, which are excruciating; according to people who've experienced both, they feel very much like having a heart attack. The difference is that they are more or less continuous for weeks at a time.

To treat this, I take three different drugs. One is quite expensive; about $6/day. The other two are cheap, but both have unpleasant side effects, and one of them is addictive (it contains
a benzodiazapine).

For my stomach problems, if I didn't take my drugs, the main thing that would happen would be that it would hurt. It wouldn't be life threatening or dangerous. It would just be painful. (I might have some short term withdrawal symptoms from the addictive ones, but that's supposedly very unlikely.)

How many people have heard about my stomach problems? A lot of people. I need to take the drugs
three times a day, so people see me popping pills. And the spasms can create some peculiar symptoms
that are visible to other people. Out of the dozens of people who've heard about my stomach
problem, and know about the drugs I take for it, how many have lectured me about how I shouldn't
take those nasty drugs? Zero. No one has ever even made a comment about how I shouldn't be taking
medications for something that's just uncomfortable. Even knowing that some of the stuff I take for
it is addictive, no one, not one single person has ever told me that I didn't need my
medication. No one would even consider it.

But depression? It's a very different story.

What happens if I don't take my medication? I turn into a zombie. Everything turns flat, it
seems almost as if things lose their color, like all the colors fade. I feel like my body weighs so
much that I can't even hold my shoulders up. I become lethargic - I can't get myself to do
anything. I don't feel sad; I feel nothing. Empty, blank, flat. Great things can happen,
but they don't make me happy. Awful things can happen, but they don't make me sad.

What happens when I take my medication? I'm myself again. The medication doesn't make me feel
happy; it makes me feel. With the medication, my emotions come back; I can feel happy or
sad. I enjoy it when things are going well; I get sad or angry when they go poorly.

But how do people react?

Somewhat over 1/2 of the people who hear that I take an antidepressant express disapproval in
some way. Around 1/3 make snide comments about "happy pills" and lecture me about how only
weak-willed nebbishes who can't deal with reality need psychiatric medication.

I confess to being thoroughly mystified by this. Why is it OK for my stomach, or my heart, or my pancreas to be ill in a way that needs to be treated with medication, but it's not OK for my brain? Why are illnesses that originate in this one organ so different from all others, so that so many people believe that nothing can possibly go wrong with it? That there are absolutely no problems with the brain that can possibly be treated by medication?

Why is it OK for me to take expensive, addictive drugs for a painful but non-life-threatening
problem with my stomach; but totally unacceptable for me to take cheap harmless drugs for a painful
but non-threatening problem with my brain?

Stigma. The foolish notion that mental illness isn't really an illness. Mental
illness isn't considered a legitimate, real illness by most people. It's treated as
a personal weakness masquerading as a genuine illness. And so people like the postdoc who
wrote to Dr. Isis are caught in a vicious trap. They're really ill, and that illness does
affect their work, just like any other real illness. But they're unable to actually talk
about it. It's better for an unknown advisor to believe that you were lazy
for your first few months on your job, than to risk telling them that you've got
depression. That's truly reprehensible.


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If you or anyone you know are ever curious enough to find out other, better, more permanent, options than using drugs to heal from depression, you're welcome to check out which is an introduction of the needs that human beings have for growing healthfully, mentally and physically. A deficiency in these needs is what leads to illness, mental and physical, thus a cure for disease is fulfilling people's needs. Drugs can act as a band aid, but for a real cure, one needs to find out where the deficiencies are (there are usually several, from diet, to exercise, to social support, to meaningful work), and ensure that the needs are properly met.

One of the reasons for this is probably the fact that psychology is not as precise as other medical sciences. And there is also the problem where things like depression or ADHD are over-diagnosed, which tends to make people skeptical about anybody claiming to need drugs to deal with it. It seems to me that some psychologists take the fact that their patients merely show up to see a psychologist as a reason to prescribe them something, because after all, who would show up to a psychologist without having a problem some drug can fix?

I gotta say, I completely agree with everything you say, here. While I'm fortunate enough to have avoided depression (my mom has it), my wife has fought with depression for years. Originally, she had no idea what it was... in her case, she would get into deep, uncontrollable funks, and for a long time, she had no idea what was wrong with her. Then, finally, she was diagnosed, and with the help of anti-depressants, she's returned to being the woman I remember when I first met her. Of course, she has her up and down days, just like everyone else. But the point is, now she has up days in the first place!

And yet, she fights with the stigma every day. The idea that antidepressants are just "happy pills" is incredibly prevalent in society, to the point of being damaging. As an example, my former brother-in-law fought severe depression. Eventually his doctor prescribed antidepressants, and for a time, he improved. And then his idiot brother told him that the drugs were a bad idea, that he should be able to tackle his problem on his own like a man. It wasn't long before he was right back where he was, lethargic, uninterested in life, unfeeling... and eventually, thanks in part to the disease and the "help" of his family, that marriage ended.

In short: anyone who believes clinical depression isn't a real disease that deserves proper treatment and the proper medication is, at best, ignorant.

I think a lot of people just plain don't know the difference between clinical depression and regular depression.

By Paul Carpenter (not verified) on 19 Jun 2009 #permalink

I think some of it is that people have this idea that you can control anything in your brain. I'm beginning to think that things like willpower and mood and self-control are as much heritable traits as many of our other traits. It seems to me that it's always the people who have good amounts of control over those things who say that anyone can have the same control - someone with really good self-control tells an overeater "Just don't eat so much." Well, perhaps it's not actually that easy for them. Maybe it really is difficult, or impossible for them to "just not eat." Similarly, it's usually the people who tend to be in good moods most of the time who feel that all it takes to be in a good mood is changing your attitude.

I think our inability to actually experience what someone else is experiencing contributes to that. For someone who has self-control, their failures are generally related to not exercising it, so they assume that other people who have failures that look similar externally are experiencing the same thing internally. Same with moods and such. It's just how our mental hardware is set up to interpret the data, unfortunately.

snes: Is ADHD really overdiagnosed, or is it just a really common disorder, and people are disinclined to acknowledge that? Is ADHD misdiagnosis more common than with other non-mental illnesses?

I don't really have the answer to those questions. However, there has been a consistent myth that mental illnesses "aren't real" now and historically, which makes me suspicious of claims that the large number of people with ADHD are misdiagnosed.

It seems reasonable that just as there are very common illnesses in other parts of the body, there should be very common illnesses in the brain. If many people have poor eyesight, bad teeth, back problems, etc, why should the brain be immune to various defects?

I think the reluctance to acknowledge mental illnesses as being merely physical illnesses of the brain has a lot to do with the Cartesian view of the duality of the mind and body. Most people in our society subscribe to some variation of this view, and it doesn't really leave room for concepts like mental illness, since the mind isn't a physical thing in this view.

Also, it causes people to identify the mind as the self to a higher degree than the body. If you think about it though, there's no reason to do such a thing if the mind is really just a part of the body.

Re #1:

I don't buy it.

What precise tests were there to diagnose my stomach problem? At the beginning, it was just symptoms. Then we did lots of tests, and finally ended up with the surgery. And how did they diagnose the post-surgical stuff? They did lots of tests - none of which showed anything meaningful. It came down to "these symptoms look like X which is hard to observe, so we'll medicate you for X, and if it works, then we'll conclude that X was the problem".

And as for the "overdiagnosing": how do you *know* that it's overdiagnosed? I constantly hear people claiming that depression and ADD are overdiagnosed - but somehow, it's always just "common knowledge". Never any actual data, never any source for the claim.

Personally, I don't believe in the overdiagnosis claim, for *either* ADD or depression.

When I was a kid, they labeled a lot of kids who acted in hyperactive ways as troublemakers. They didn't ever look beyond whether they paid attention or not. Then, when we realized that there was a problem that could be treated, people starting getting checked and diagnosed. And the common claim and ritalin and friends is that they're sleepy-pills that just drug kids into a daze. ADD medications are stimulants. Ritalin is closely related to caffiene; adderal is an apmetamine. Anyone who claims that ADD drugs are just knocking kids out is full of it. (You should see what a kid without ADD is like on ritalin - I've seen it. It's scary. Agitated, agressive, can't sit still - like an adult who's been drinking too much coffee.)

The stats that I can find say that during their lifetimes, 4 out of 5 people will have some kind of reflux disorder. 1 in 10 will have heart disease. 1 in 4 people who live to be 60 years old will develop diabetes.

No one questions any of those. Why is it so hard to believe that 20% of kids will have ADD? Or that 40% of adults will have at least one serious depressive episode?

The overdiagnosis claim comes back to the stigma. Most of the time, we just don't believe that mental illness is real. Most people will admit that sure, sometimes, once in a while, there's a real illness. But *most* of the time, it's just pill pushers handing out happy pills, and drugging kids into submission.

Eric has hit on the basic problem most people have with responding to mental illness - it's the old Cartesian mind-body dualism. If you think that the mind has nothing to do with the body, then of course there is no such thing as mental illness.

By Another Eric (not verified) on 19 Jun 2009 #permalink

I think people are negative towards psychoactive drugs for several reasons.

Firstly, as has already been mentioned, mental illness is inherently more difficult to diagnose than traditional illness. In fact, you have to be very ill mentally, before anyone will even diagnose you(compare to colds). There is a lot of subjectivity involved, with one person's depression being others' Monday Blues and vice versa.(I have been accused of being depressed on occassion.)

Secondly, there is over-diagnosis of less severe and indeed frivolous mental illnesses, or worse "disorders". This is a huge problem for two reasons. Firstly, it means that there are people who are taking medication who shouldn't be and secondly, because these disorders are put on the same footing as things like bipolar disorder and clinical depression, they undermine respect for mental disease as a whole.

Thirdly, our society has a problem with psychoactive drugs. I believe this stems from the war on drugs, where mind altering substances as a whole are stigmatised, by default, not because they are dangerous, but because they are mind altering. Euphoria inducing or even anti-depressant drugs are frowned upon because they do what is said on the tin; they make people feel better. True, they are making people healthier "better", but its the "feel" part our society has trouble with.

Indeed, look at painkillers. Opioids are very powerful painkillers(so is cannabis), but a huge amount of research is put into painkilling drugs that do not induce altered mental states. Society would actually rather people suffer physical pain than any degree of altered mental state.

This viewpoint isn't helped when some people abuse a medical drug. Its rare to find people abusing stomach pills or the like, but mental drug abuse is common enough, and society really frowns on that. Even people who self medicate on otherwise completely legal drugs are severely frowned upon, and it's not the danger people are objecting to. They are objecting to the very idea of altering ones mental state!

The idea of "happy pills" is one which our society fundamentally objects to. Mental drugs that make you calm, drowsy or sleepy raise not so much as a peep out of anyone. People swear by sleeping pills. Yet we don't have "wake pills". Why is that? For the same reason people object to anti-depressants. You're not supposed to take any drug that make you, mentally, feel better.

By ObsessiveMathsFreak (not verified) on 19 Jun 2009 #permalink

Very interesting post - and very timely for me.

One thing that you didn't touch on is the idea of "mental health days" as sick days. I suffer from depression. I am on anti-depressants, and some days they seem to work better than others.

If I were to stay home because I had a bad cold, or a stomach bug, or a headache, that would be easily understood by most people. But to stay home because my depression is too overwhelming that day to be able to be a contributing member of the workforce seems lazy to a lot of people. More than once, I have lied about what is keeping me home. It just seems easier.

I'll be the first to admit that it can be easy to fall into a pattern where you confuse not wanting to go to work, or just general laziness, for depression. So I always make an effort to think about what I'm doing, and try to make sure that I'm doing it for the right reasons. And since I don't have unlimited sick time (I have a bucket of PTO, and both vacation and sick days are taken from the same bucket), I am especially careful! But the stigma has far-reaching effects.

Thank you for posting this - it's always good to hear from someone in a similar boat.

I think it's a matter of ignorance more than attitude. People think that "depression" is synonymous with "sadness". If that were true, then taking medication to alleviate it would seem pretty sketchy.

So, thanks for writing this. Maybe it'll help people realize that there's a difference.

Well written. I have (as someone who has been treated for depression, and been close to others with much worse depression) a couple of thoughts.

1. You describe your stomach problem as painful but non-life threatening, but then say the same thing about depression. I would disagree. Depression is very much life threatening.

2. "Darkness Visible" by William Styron, is a good book.

3. This one may be controversial, but I'm going to put it out for discussion. The issue arose because a postdoc was worried about telling her/his advisor about the depression, for fear of a bad outcome, as a result of the stigma that you so nicely document. I would agree that it's a risk, and one that should not be there, but is. However, what are the moral/ethical/professional obligations of the participants in this situation? Does an ill employee have the responsibility to inform his/her supervisor that a medical condition will make it impossible to work, or to work fully, or whatever, for some period of time? (I phrase this carefully, because there is, I believe, a legal issue, which is that a supervisor never has the right to know *what* that condition might be).

In the absence of any information, a supervisor has an obligation to assess the work performance of employees, and do what is necessary to make sure that a team functions well. If I put myself in the shoes of the supervisor in this scenario, would I be able to tell the difference between an ill employee and a lazy or otherwise unproductive employee, unless the employee gives me some information? It doesn't sound like it.

What I find myself coming to is a recognition that I see moral/ethical/professional obligations on both sides. The supervisor is obligated to *not* act out of the stigma about mental illness; indeed, to treat it just like a chronic stomach disorder, for example. In fact, under the standards that I believe are required by law, the supervisor would simply know that there was a medical issue, and not even be informed about what kind of illness it was. And I see an obligation for the employee to communicate her/his situation, in an appropriate way, to the supervisor --- partly so that the supervisor has a chance to satisfy his/her obligations.

That "appropriate way" is important, and is probably best developed in consultation with the Human Resources department, as Dr. Isis recommended.

Also, it causes people to identify the mind as the self to a higher degree than the body. If you think about it though, there's no reason to do such a thing if the mind is really just a part of the body.

As a materialist, I'd have to disagree with this statement. The brain may be "just a part of the body," in some sense, but it is not equivalent with the rest of the organs. People paralyzed from the neck down are still the same person. People who are braindead except for respiration and circulation and such are not the same person.

The brain is different from the other organs in that sense. Your conception of yourself directly corresponds to the arrangement of the neurons in your brain, but does not correspond to any significant degree to the arrangement of cells in your heart, or liver, or pinky finger (i.e., transplants don't change your personality, insofar as the brain is unaffected by it). Cartesian dualism may be wrong, but that doesn't mean everything about it is wrong. The world's biggest idiot may say the sun is shining, but that doesn't mean it's dark out - reversed stupidity is not intelligence.

It came down to "these symptoms look like X which is hard to observe, so we'll medicate you for X, and if it works, then we'll conclude that X was the problem".

Tell Dr. House that I say "hi" and his reality show is awesome!

Re #6: Well I myself am a data point for over-diagnosis. I was put on pills because my parents essentially had control over what information the psychologist received. And I imagine it is like this for other children as well. Who does the psychologist believe, the kid or the parents? And guess what, the pills didn't change a single aspect of my behavior (other than to give me uncontrollable shakes (no, not the yummy chocolate kind)).

I would go on further but comment #8 says it better than I can.

As I commented in a previous post, I'm an alcoholic, which is another mental illness. One with deep stigmas which, in my eyes, are awfully well justified. Because one of our symptoms is 'volutary'. And for me, I was able to stop. Many people aren't. And that has to do with many factors. But you can see easily why some mental illnesses are stigmatized. People who have them do bad things. I did. But I'm better now, through lots of hard work, medication, and therapy.

I've been a caretaker for my spouse who's had schizoaffective disease for the past 6 or so years (schizoaffective is basically a combo of schizophrenia and bipolar - best of both worlds). So I know more than I ever wanted to about mental illness...

It's natural to dissociate the mind from the body. The mind deceptively "feels" like a cohesive unit - we can't intuitively feel the modularity. If you don't realize that your brain is made up of tons of interconnected systems, you're not going to understand mental illness.

I've found stroke/brain injury studies to be the most enlightening ways of highlighting how the mind works. Some of the stories are fascinating - remember reading about somebody who was unable to talk, but still able to sing (something like that, can't remember exact result). Lots of things that you'd think are "global" functions, or interconnected (i.e. singing/talking go hand in hand), are actually made up of many separate, physical components that can be individually lost from localized damage (I realize this isn't universally true, and the weaknesses from over-compartmentalizing brain functions, but there's a certain amount of localization).

For some reason, it's easier to start with how physical damage to the brain can impact different, specific functions. Once this modularity is grasped, the jump towards understanding various classes of mental illness is a bit easier. Education, education, education.

On a personal note - I will say that severe mental illnesses are horrifying things to witness. They're so overwhelming, the instinctive reaction is to turn away. The mind has incredible potential - but all that power, twisted by a cruel disease, can lose a person in isolated, dark nightmares. I don't think I'm exaggerating when I say it's like watching a concentration camp every day from a glass bubble - and realizing you'll never stop the suffering no matter how much you kick and scream and fight. Eventually you just sit there and watch, and it's like pouring acid into your soul. (Spouse has treatment resistant form of disease - I realize that medicines can rescue many, many people, but the ones who fall through the cracks don't just disappear).

By CaretakerElf (not verified) on 19 Jun 2009 #permalink

Mark, this is a very brave post. Thank you for writing it. As I said before, depression and mental illness are as physiological as any other "maintstream" illness people seek treatment for. The problem I see is the inability of some to reconcile cognition and will power with basic physiology.

But, you're one important data point of many. For you medication has been effective and has changed your inability to function. It's done the same for many others. We should be encouraging people to seek treatment. Not stigmatizing them for doing so.

Mark- this is a great post. It's a little frustrating that some of the 'reasons' people think depression is handled differently don't actually make sense if you consider the stomach disorder.

"(i.e., transplants don't change your personality, insofar as the brain is unaffected by it)" Ohh, I don't know... ever get a thyroid transplant?

Allowing for some poetic license- if you feed a brain different hormones you can get a different conception of self (in too short a time to attribute it to neuronal re-wiring, which can also occur). You're putting the structure cart before the function horse.

You also pretty much define personality as things that route through the brain, which is fine. However, practically speaking, you can't always know where some traits originate- if somebody is slow to grab a ball, is a muscle firing problem or a personality difference?

Blame the Victorians. Before the workings of the brain were understood, the notion of clinical depression (or at least the symptoms that accompany it) was considered a personal failing. It only happen to people of poor character. The current stigma is the echo of that.

As to why it's held on so long, who knows? My pet theory is there are an awful lot of people personally invested in the uniqueness and exceptionalism of the human brain, and they don't like to admit it's a bunch of tissue that runs on electricity and chemical reactions. They don't want it to be as mundane as the other organs, so they refuse to acknowledge it as such.

I constantly hear people claiming that depression and ADD are overdiagnosed - but somehow, it's always just "common knowledge". Never any actual data, never any source for the claim.

Furthermore, even assuming arguendo that these conditions are overdiagnosed, there would still be some fraction of the patients diagnosed with one of these conditions because they really do have the condition. Separating the patients who really have the condition from those who have been incorrectly diagnosed as having the condition would require a knowledgeable expert looking at the case file, if not the actual patient. Unless there is good evidence that the diagnosis is incorrect, such as a second opinion from an expert with knowledge of the case, I would tend to assume that the diagnosis is correct.

By Eric Lund (not verified) on 19 Jun 2009 #permalink

Completely unrelated, but aren't you yourself a dualist Mark? How do you maintain the belief in a soul when mental diseases show that it's really all in the physical brain?

For people who believe in souls, I can see how it's easy to write off things like depression.

This is a wonderful post! Thank you!

I would like to comment about one thing you said, though. You said that your stomach problems aren't something that could become life-threatening; it's just painful. I have GERD. (I also have chronic depression, and attention deficit disorder. But those, thankfully, are now largely under control without medications. I am one of the lucky ones as far as that goes.) When I was pregnant, I ate Tums by the handful, because you can't take proton-pump inhibitors while pregnant. Now that I'm done having my kids, I'm on Prilosec, and it is heaven. My mother's is worse; Prilosec doesn't cut it, and she has to take Nexium. Same is true of one of my aunts.

My aunt's GERD was untreated for a long time; she was raised in a "just put up with it" philosophy, and is a pretty stoic individual, so she just put up with it. Today, she has Barret's Esophagus. Acid reflux, no matter the cause, puts you at higher risk of developing this. It's a precancerous condition, and it's a consequence of how the lining of the esophagus heals itself after injury.

You were absolutely right to get treatment for your stomach condition. If you hadn't, it could indeed become life-threatening.

Interestingly, I've never faced any criticism of my use of antidepressants or stimulants (Ritalin, which for me, actually worked better than the Paxil). But I *have* seen people express the opinion that it just means I have a bad diet, which isn't true. Changing my diet did bupkis.

Thing is, people have prejudices against any disease that they believe is influenced by behavior, whether it's true or not. The more influence they think a person's behavior has over the disease, the more they scorn the person for it. This is a very ancient tendency; it seems universal to at least suspect that disease is a reflection of the sort of life you lead. Which is rather sad, really.

By Calli Arcale (not verified) on 19 Jun 2009 #permalink

Eric, I think the sense of self is fungible and subjective. You can certainly point at the brain and say "this is me" but that is more of a choice than a statement of objective fact.

You gave examples that stem from your intuition of self. However, what is the foundation of the intuition of self? There is no objective criteria, not even in principle. It's unimaginable that we would look under a microscope and discover a self particle, or a self force.

To avoid confusing the issue here, I should say that I'm not really making a reference to Cartesian dualism in the preceding paragraph, merely distinguishing between statements about objective phenomena which are quantitative, measurable, and have true/false values and subjective statements which are qualitative. I am pointing out that they are categorically different kinds of statements.

Anyway, given that we *choose* who we are, I would say that it is not desirable to identify ourselves as solely the mind. The care of the body is essential to survival. From an evolutionary perspective, the mind is merely an adaptation that exists to serve the body. It is an organ of the larger organism. If the organ ceases to serve the organism, isn't that bad?

Now a totally valid response would be to just say you don't care. Maybe you see intellectual development as a good in itself, and the health and survival of the whole human organism as pointless except insofar as it enables intellectual development.

I think you have to argue at that level though. When discussing subjective interpretations of the world I think you have to discuss it in terms of "why I have decided to believe this" rather than "why this is true" because there is no true or false with respect to subjective statements.

Anyway, sorry for getting off topic from your original post. I like having this sort of discussions though.

And yet some brain disorders, like epilepsy or narcolepsy, where the chemical and electrical pathways aren't working quite correctly, don't have the stigma.

Thanks for a brave post.

Societal ignorance and the stigma of mental illness are indeed the keys to answering your question. The only solution I see is education but that is a long road and I don't know if it will ever succeed. I don't wish to appear pessimistic but just like so many other things in life, it is sometimes hard to see if any progress is being made at all.

The underlying premise many people possess is that mental illness is because of a lack of will or that it can be addressed as "mind over matter". I don't know about the Victorian paradigm mentioned above, but that is an interesting thought and I'll have to look into that further. The other stumbling block that gets in the way, also alluded to above, is that everyone experiences emotions and confuses or equates these emotions with being the same as severe, disabling symtoms of mental illness, especially when we are discussing non-psychotic disorders. Most people don't realize that the biochemical basis for mental illness was proposed when people began to experience significant Major Depression secondary to early anti-hypertensive medications like reserpine and subsequently beta-blockers like propanolol. This was truly the dawn of a new age and lead to investigations and development of neuro-modulators that can be and are effective for many people with a host of different mental illnesses today. While plenty of theories about mental illess still abound, there really is no denying the biochemical model for a good deal of this. Realistically though, no one operates in a vacuum and a multitude of other factors play a role such as life experience, stress, social factors and so forth. Issues such as Personality Disorders are a little murkier as far as their basis and treatment but nonetheless, real problems for many.

Another thing that I believe hinders people's acceptance of mental illness is malingering or other fabrication of symptoms for some secondary gain. While this aspect applies to a minority of individuals, the effect on the whole is rather profound. The diagnosis of mental illness does involve a high degree of subjectivity, but I'll offer you a clue, so does a good deal of the rest of medical diagnosis. The art of medicine is alive and well. Perhaps we can look forward to a time when all of this is completely objective, however, I don't see that happening anytime soon. Unfortunately, it is the lack of objective tests and societal inculcation that prevents many healthcare providers from having any better understanding of mental illness than the population at large.

The amount of popular press and hogwash regarding mental illness is astounding. It's difficult for a day to go by without hearing "there's no such thing as mental illness", "ADHD is so over-diagnosed", "doctors and drug companies just want you to get hooked on these pills for their own profit", etc. Are some groups over-diagnosed with certain conditions? I'm sure it happens. Are some under-diagnosed or mis-diagnosed? I can guarantee that happens as well. None of that changes the reality of the diagnoses and how much more productive and satisfying lives many individuals can have with proper diagnosis and treatment.

As someone noted above, unfortunately some have symptoms refractory to treatment or suffer debilitating side-effects to medication. We can only hope that as time goes by we will have better access to diagnosis and better treatment.

It is sad to hear from the poster above that he/she was not diagnosed or treated appropriately while a child or adolescent. This is a very difficult area. I assure you that a host of mental illnesses can and do occur in youth and this patient population has traditioanally been neglected and under-diagnosed, largely due again to ignorance of both the healthcare professions and the public at large. While the model for appropriate evaluation would hopefully minimize mis-diagnosis and inappropriate treatment, the reliance on the parents observations makes this even more difficult, especially if they have a separate agenda and the child/adolescent may be only the "identified" patient in a dysfunctional family or for some other reason.

Thank you for bringing this topic up and to everyone for sharing personal experiences. It is very sad indeed that the student mentioned above should even have to question whether or not they could or should be honest with others if a mental illness is interfering with their function. I agree with your advice that this student should not unless they are rather certain how it will be perceived. That is even sadder.

Thank you for this post. I have anxiety disorder and, after years of only mildly successful cognitive therapy, finally decided to try anti-depressant medication a year ago.

Since that time, I, too, have spoken freely about my anxiety issues and the ability of the medication to help my symptoms in the hopes that I can reduce the stigma associated with the disease. I'm happy to say that no one has spoken negatively about my use of medication, although I have to wonder if our difference in experiences stem from a difference in gender- perhaps, as a woman, I am not perceived as needing to be so 'mentally strong'.

I'd like to offer myself up as a datapoint that ADHD is overdiagnosed - but without making any claim that it's unreal, merely that ADHD -specifically- is overdiagnosed.

To wit: I got an ADHD diagnosis around the time I was in first grade. (it might've been the summer before, might've been the summer after, my memory of that is a little fuzzy these days.)

Some of the key symptoms that lead to this diagnosis:
I was disinclined to make eye contact with teachers when they spoke to me.
I used inappropriate tones of voice.
I preferred to read 300+ page books than pay attention in class.

So, I was diagnosed with ADHD, I was given ritalin, then when that started having the side effects that ritalin has, I was given clonadine on top of it, and then when the absurd amounts of ritalin I was eventually taking started inducing depression from withdrawl on a daily basis I was put on prozac (then when that caused muscular tremors I was put on Zoloft) ...

... and then my much younger sister hit age two, she had some problems, was taken to the same psych I was, he diagnosed her with ADHD ... except that she had almost -textbook- low-functioning autism combined with mental retardation.

Armed with that knowledge, my mother took me to a different psych - who promptly declared my last psych to be a moron and a quack, and rediagnosed me as having Asperger's.

So: Yes, I think ADHD is overdiagnosed, no I don't think mental illnesses in general are fake, and I think that the overdiagnosis of ADHD is a very bad thing - both in terms of harming public perceptions, and because it keeps people from getting the proper treatment.

Now, I didn't need any medication - but I did need to know that yes, people actually care about eye contact, and yes, looking them in the eyes is creepy. (I would get in trouble for not making eye contact, then I would immediately get in trouble for staring, for instance). I needed to know that in some regards I am -different-, so that I could learn the rules of interaction that neurotypical people just know, because it gives them exactly what they want out of social interactions.

By Michael Ralston (not verified) on 19 Jun 2009 #permalink

@snex: It is not a "fact" that psychology is less precise than other medical sciences. I'll put our research on, say, the efficacy of combining medication and psychotherapy in treating ADHD up against oh, for example, the efficacy of proton therapy in treating prostate cancer.

The practice of medicine in general is not a "precise" cook-book profession either--if it were, a technician could do it. It is, in fact, very imprecise insofar as it involves professional judgment. This is no less true in general medicine than it is in psychotherapy. Take any random lab result ("hard" science, right?) that you have received lately, send it to another lab for a second opinion, and you will see what I mean.

And, FYI, psychologists don't prescribe.

Sorry. This is the 2nd of my 2 cents, and I will say no more.

Misdiagnosis (e.g., ADHD for Aspergers') is not the same as overdiagnosis. And, I repeat, it happens in medicine too. All the time.

And misdiagnosis happens a lot when parents give inaccurate information about their children, whether to a physician or a psychologist. Ditto when a drug-seeking adult deliberately misinforms a physician.

And now, for a funny story about meds. A supervisor of mine, a psychiatrist specializing in family therapy, prescribed medication for a teen. The family came back for their next appointment and reported things were indeed going better. My supe asked why they thought that was, and the kid piped up, "Because I've been dissolving my meds in Dad's morning coffee!"

True story.

I've been dealing with depression for nine years now, and within the past year went off medication. Please don't get the wrong impression-I consulted physicians, and was seeing a psychologist before, during, and after I stopped taking antidepressants. I wanted to make sure I did it safely, and if I needed to go back on medication, I had someone to go to.

I started a post today (there will be a series) about my battle with depression, and forgot to say something that's rather relevant to your post here. When I was seeing the psychologist, I wanted an accurate diagnosis on what I had. No one had previously said aloud that I had depression. The psychologist wouldn't even say that, because she knew what stigma I might have to deal with in my beginning career. So, instead of saying I'm clinically depressed, she wrote it off as "situational depression," which meant I wouldn't have to necessarily report my "condition." Based on her own description though, I know that's not what I spent most of the past nine years dealing with. It's unfortunate that even some physicians are reluctant to make diagnoses because of the potential backlash the patient may receive.

And thank you Virginia S. Wood for reminding people that psychologists don't prescribe; it's the psychiatrists who are allowed to prescribe medication. :)

Thank you for a wonderful post. My experience similar to the PhD student involved being laid off from the position that I hoped to have for the rest of my career. I had been struggling to "fit in" with other members of the team and got into a discussion in my review where my boss suggested maybe I should seek some counseling. I told him I was already in treatment for clinical depression and PTSD. And yes I know that the conversation was legally questionable - especially since - thanks to good meds - I had not missed any work. But I have always been open about my mental illnesses when asked so I told him.

You should have seen the look on his face - he was horrified. Three months later, I was laid off due to "lack of work". This was about 6 months before the company started laying off administration people due to the economy. I was the only member of a 10 person team to be fired and was 6th in seniority.

Side note - I think that a lot of companies are using "the economy - BOOGA BOOGA" as an excuse to get rid of people that they never would have done two years ago because of the legal risk.

I think that the more open people are with things like this, the more mainstream acceptable it will become. I have seen several campaigns recently in regards to people "coming out of the closet" about their "sins". I think that awareness and the realization that 'people you know' suffer can help people process these types of concepts. I found your blog via and I think that everyone benefits from these types of awareness campaigns.

And I agree with an above commenter - depression CAN be very deadly.

Jen Smith

By Jen Smith (not verified) on 19 Jun 2009 #permalink

I strongly suspect that I've been mildly and consistently depressed all my life. It is hard to imagine how someone lacking the apathy and bitterness that seems to define my character could be in any sense the same person as myself, or how treating my depression could be distinct from suicide. If I had ever not been depressed I could see it as returning to a previous state, which would bother me less, but I can't see it that way for myself, and for some reason I am perversely attached to my current (fairly pathetic) existence. So I'm just too squeamish to consider taking anti-depressants even though I expect they would work since they worked very well for my mother.

By Anonymous (not verified) on 19 Jun 2009 #permalink

To clarify, I don't see the self as more than a useful fiction, but it's a very useful fiction and seems necessary in order for me to value my existence.

By Anonymous (not verified) on 19 Jun 2009 #permalink

Besides, if I tried antidepressants my boyfriend would leave me :/

sorry for venting here but it seemed like as good a place as any

By Anonymous (not verified) on 19 Jun 2009 #permalink

Behind the term "stigma" are realities easily addressed, only if the mask is refused.

Harold A. Maio

By Harold A. Maio (not verified) on 19 Jun 2009 #permalink

"One person's depression is another person's Monday blues"

If you think about suicide more than three or four times every Monday, odds are good that you are either in a really, really bad situation and need help or that you are clinically depressed and need help.

There are legitimate reasons to be wary of anti-depressants. They may conflict with other medications, or be inneffective for you, or possibly you might be worried about studies that cast doubt on their efficacy. But to be concerned about medication because you doubt the existence of depression? That's just prejudice or ignorance.

Either of which can be cured without pills.

Let me join in the chorus of commenters praising your courage, Mark. I wish there were more we could do to remove the social stigma of mental illness; it seems to be a remnant of the old solution of putting people away in lunatic asylums.

Two people close to me have a mental illness. One takes Paxil, and when she is on her medication is reasonably calm and friendly. Off her meds, she is prone either to highly emotional rants (I've seen one -- scary!) or to complete withdrawal.

The other is not on medication, but probably should be. If she would consent to a psychiatric evaluation, she would probably be diagnosed as paranoid delusional, a kind of schizophrenia. In her paranoid phase, she mistrusts everything and everyone, including the family dog and the lineman working on the electrical connections next door. Like the other woman, she can become quickly enraged. At other times, she is calm and fairly reasonable, though still possessing some pretty weird ideas.

People who need medication to deal with their mental illness not only lead happier lives, but make it possible for the people around them to leave happier lives, too.

Anonymous @35 and 37, are you reading this? If your BF leaves you because you take antidepressants, he's an ass. If you think they will make a difference in your life, then consult a pyschiatrist and see what he/she thinks.

The idea of "happy pills" is one which our society fundamentally objects to. Mental drugs that make you calm, drowsy or sleepy raise not so much as a peep out of anyone.

Many people believe that anti-depressants make people 'happy'. They don't. They aren't "happy pills" any more than insulin is. Instead, they make sick people feel closer to normal.

anon 12:23 AM, if your boyfriend would leave you if you tried antidepressants you need a different boyfriend. Not my business, but not a close call.

Comments like "You are very brave to say all this..." only contribute to the stigma. Is it very brave for someone to post on their blog that "I broke my leg yesterday?" Is it? Therein lies the discussion, I believe.

As someone who's been taking antidepressants for about 20 years, I can confirm that people just don't accept it as an actual illness. Most of my closest friends distanced themselves from me because I wouldn't "shake it off" and "get over it already." (Luckily, due to my clinical depression, I didn't care at the time that they were staying away.)

The stigma of mental illness even affects most doctors. I had one doctor lecture me about my failings. Despite having told him I was experiencing suicidal thoughts, he helpfully informed me that I was a burden on society. I was told to "buck up" and "get it together." He could just as easily have told me that changing my socks would solve my problems; it would have been just as effective as his advice.

Another doctor urged me not to tell potential employers that I suffered from clinical depression. I later wrote an aptitude test which resulted in me being interviewed for a training program for air traffic controllers (I just wanted to monitor weather stations; the test turned out to be for multiple career paths). I made it to a third interview before coming to my senses and backing out of it.

Stigma is bad. Doctors do the best they can, but I've never met one who seems to understand how limited my view of the world has become. I need my meds just to be able to get out of bed, to dress myself, to remember what day of the week it is. But for me, they're no cure. They just put a bit of an edge on the bland, flat, impenetrable nothingness that cloaks me. I knew I shouldn't try to become an air traffic controller, but I clung to my doctor's advice not to talk about my illness. If I'd had a broken back, would he have advised me not to tell potential employers about that?

People seem to think the mind is a magical thing that exists independently of the brain. It's not magic, people; if you disrupt the workings of the brain, you disrupt the mind. You can't just decide to be "sane" any more than you can decide to run on a paralyzed leg, decide to be a genius, decide to be taller, or decide to digest rocks.

Well, typing this far feels like it's used up all the oxygen in my brain. I'm gonna go take a nap.

"They did lots of tests - none of which showed anything meaningful. It came down to "these symptoms look like X which is hard to observe, so we'll medicate you for X, and if it works, then we'll conclude that X was the problem"."

This is pretty much the way psychiatry does things too--except without the "testing" part as there are no brain scans that are able to determine mental illness definitively(although there are a few exceptions). Psychiatrists just keep trying drugs until they find something that "works" without knowing the reasons behind the effectiveness; they have some theories about what they THINK might be happening, but nevertheless the field remains more speculation than science and that contributes to the "stigma" and the disconnect between brain and body.

"I'll put our research on, say, the efficacy of combining medication and psychotherapy in treating ADHD up against oh, for example, the efficacy of proton therapy in treating prostate cancer."

Deluded psychologists are another thing that adds to the problems of the mentally ill by equating HARD science with the horoscopes provided by the DSM. The vague inventories that psychologists use to back up their "clinical" data are problematic at best and useless at worst--I liken the field to the field of taxonomy which is currently undergoing a revolution due to the science catching up with the speculation. Now that taxonomists can verify precisely, the ancestry of a certain species, all the arguments have ceased about a "science" that used to be based on subjective visual determinations. With DNA technology, there are no arguments, and the field of taxonomy has been greatly improved as a result. My hope is that psychiatry will, in the near future , also enjoy the same type of certainty of diagnosis once PET scanning or other technology begins to demonstrate the ability to define mental illness as a physical illness. This was something Freud himself predicted would happen, and it is long overdue. We have had a 100 years of therapy and no one who is suffering from mental illness is ever "cured". Cured is the standard that we should be shooting for, NOT the ill-defined "feeling better" which is the clinical benchmark of most if not all psychological studies.

This dalliance into the pseudoscience of psychology has to end so that the science of neuroscience can begin to find ways to really make inroads into the treatment of people that are not weak willed, but sick--- and suffering. The sooner that happens the better for everyone.

By Autodidactyl (not verified) on 20 Jun 2009 #permalink

Really interesting discussion.

What's the evidence for psychoanalysis or counselling for depression? That's the only treatment I was given, and I went to a few sessions before deciding that this was merely a useless (to me) attempt to get money out of teenagers. They might as well have given me a chocolate kettle.

Thank you for this post. I think it's really important for people like yourself to speak up and get the message out that mental illnesses are real illnesses.

I myself make an effort to speak out on another mental illness: addiction. The stigma surrounding addiction is even worse than that of mood disorders. In neuroscience, it is common knowledge that addiction is a brain disease, but the general public is downright hostile to the notion. There aren't a lot of well-respected addicts and alcoholics out there to speak out about the reality of addiction of a brain disease, so I think people like yourself are really important not only for removing the stigma around mood disorders, but also around addiction.

Unfortunately, I do not have time to read all the wonderful comments on this piece right now.

Thank you for standing up. I recently graduated with a BS in Biochemistry. I have somewhat periodic clinical depression. This essentially caused lower grades, particularly in my sophomore and senior years. This past year, it had become bad enough for various reasons that I finally went on medication. I feel that if it weren't for stigma (which I recognize that I've used against myself) I'd have made this decision much more promptly.

On the topic of overdiagnosis, I firmly believe that the majority of mental illnesses are underdiagnosed and/or misdiagnosed, which is also a serious problem. There's also the fact that psychiatrists themselves have a hard enough time drawing the lines. It's easier to stigmatize someone with a vague "mental illness" than it is to stigmatize someone with Bipolar Disorder.

The words "shrink" and even "psychiatrist" also are stigmatized.

Some medical illnesses are still also stigmatized, the one I know of the most being fibromyalgia (a blatent example of stigmatization is here: - the writer is basically saying to fibro sufferers "Suck it up, it's all in your head".)

To sum it up: Most people need to shut up and trust the person who is feeling the effects. That means, you know, believing that they themselves know more how about their own bodies and minds are functioning than someone else does. Many people just don't get this. Even many doctors.

i've been middling-to-low grade depressive for most of my life, too (although it seems i've put my actively suicidal phase behind me), and i have to echo some of the comments anon@#35 made. my depression, such as it is and has been, is part of my personality; i could not remove it and remain me.

comments like Mark's, about how medication helps him "be himself", to me sound very much like superstitious mind-body dualism --- speaking as if a part of one's personality was a glue-on sticker that could be taken off with the right chemicals to dissolve the adhesive. to me, things just don't work that way.

By Nomen Nescio (not verified) on 20 Jun 2009 #permalink

The weird thing about most people's depression, including that experienced by the woman who wrote Dr. Isis, is that it seems to coincide with events that should make you sad! I've known too many people prescribed anti-depressants when their parents died, or when they lost a job, or when they had a miscarriage---or maybe when they had just started a new job and found it a bit overwhelming.

I mean, honestly... if your parents die, is it really an illness if you are incredibly, cosmically sad? Different people cope with stress in different ways, and for some people things may be harder than for others. But I don't see how that's a sign of an illness? The biggest issue is that psychiatry is really based on nothing. I have no doubt that brain chemistry CAN get screwy, and I have no doubt that this actually happens to a number of people. Unfortunately, physiological psychiatry has nothing to show.

I'm actually a child of the anti-psychiatry movement (, and my father was/is an important figure in it. Nonetheless, I've wrestled with these issues and find the science unconvincing and there to be no real reasons behind diagnoses.

As of right now, clinical psychiatry is a joke and truly represents a slippery slope. Until someone can give me a good reason for prescribing ANYONE, no matter how sad, a drug because they miscarried after trying for years to have a baby, I will hold my ground.

When my wife got postpartum depression (PPD), I advised her to e-mail everyone she knew. I reasoned that if she confided in a handful of people, most everyone would hear through the grapevine and her condition would have a stigma attached to it.

So, now that everyone knew, there was no reason for people to whisper, or for us to wonder if people were talking behind her back.

Some of her older coworkers (nurses!) who didn't seek help for PPD in their younger years continue to think she should have 'powered through it.' And we lost one supposedly close friend who fled at the first mention of depression. It's a little awkward for that person because we live in a small community and see sees us at birthday parties.

Nonetheless, we would handle PPD the same way again. We found out who are true friends are. The experience hasn't hurt her career either.

Also I think that many people think that everyone sees life the same way. They believe that because they don't need medication to control their mood, other people don't either.

I greatly enjoyed your post.

Re #50:

That's just the same old "you should be able to get over it yourself, don't take happy pills" nonsense.

Depression isn't sadness.

Antidepressants don't make you happy.

Let me try a different tack. My mom has diabetes. When my father died, my mother's blood sugar went crazy. She's always had problems controlling it, but immediately after he died, it just went crazy - shooting up into the 500s, dropping below 50.

That was normal. The physical symptoms of strong emotion have a great biochemical effect on the body, and that in turn has a huge effect on the way that her body was processing sugars. The response to that from doctors was to monitor her sugar very carefully, and manipulate the doses of insulin and other diabetes medication to try to control it.

As I've mentioned, I have dreadful stomach troubles. When my dad died, my stomach also took a dreadful turn. The muscle spasms in my stomach went off the chart. Again, the physical symptoms of my grief affected my stomach and my intestines in a dramatic way. I needed to increase the dose of my stomach medications in order to stop the muscle spasms.

I've never met anyone who'd say that since my mom's diabetes became worse as a result of emotion, that she shouldn't have changed her diabetes medication to manage it, because after all, she *should* be sad, and the diabetes changes were just a symptom of her sadness. I've never met anyone who'd tell me that I shouldn't have needed to increase my stomach medications, because I was sad, and the stomach trouble was a symptom of my sadness.

So why is it so surprising that the affects of grief could affect your brain, in a way that's more than just sadness?

Stress and similar emotions have a biochemical effect that goes beyond just the feeling of the emotion. And the changes affect all different parts of your body, in a variety of ways. The effects of that are much more than just "feeling sad".

When I was in the worst part of my depression - which was a time when I had absolutely no significant emotional stressors - I wasn't sad. I wasn't anything. I didn't feel anything. Looking back at it, it was like I was seeing things in black and white - the color, the sensations, the meanings of things - everything was just blanked out.

That wasn't sadness. That was one of my body's organs malfunctioning. But because it was my brain mulfunctioning, people like you want to insist that it wasn't really illness.

* Depression is like infinity. Or, rather "depression" is like "infinity." They are words that have different meanings in different contexts yet most people don't realize that. Infinity is a number to some people, but not to a mathematician. Depression is sadness to some people, but not to a mental health professional.

* While some depression is situational, many people don't understand that some depression is caused by a problem with the brain that affects the mind. It is tragedy when it is an admitted depressive who canât accept that medication is sometimes necessary. I use myself in the following analogy. It is like I was born without legs and no amount of therapy was able to get me walking. It wasnât until I got a set of legs that the therapy was able to start helping me. (For my fellow computer geeks, here's another analogy. Sometimes software can be debugged; sometimes the hardware needs to be fixed.)

* I was in total denial about having a problem for decades. It wasn't until a very intelligent psychotherapist convinced me to try medication that the hell that I'd been putting my family through started to subside. It took about a decade of therapy and medication to build up my coping skills and get my depression into remission. I no longer need therapy; but, I will need medication for the rest of my life.


As I said, I have no doubt that some people really experience a biochemical problem. I have no doubt that there is a genetic basis to it. In fact, I tacitly accept many of the claims of biopsychiatry because it'd be weird if it weren't possible. I'm merely arguing that most people I know who were prescribed anti-depressants after a tragic moment in their lives most definitely did not need them.

I've known people with all kinds of diagnosed mental disorders; while I've never been diagnosed with anything, both my parents have been diagnosed as schizophrenic, manic-depressive, shizoaffective, and other things, multiple times often simultaneously. Because of my father's involvement in the antipsychiatry movement, I've had the opportunity to meet a number of people diagnosed with various mental illnesses. For the most part, these people were seriously strange people, and I'm happy to admit that. However, they did not seem to be comforted when people told them they were broken---they just wanted to be themselves. In fact, I've almost never met a person with shizophrenia that likes to be told they have a brain disease... but you know who loves it? The family groups, because it means they didn't do anything wrong ;-).

The biggest problem, as I said, is that psychiatry has nothing to show. Again, I would be utterly, totally, completely shocked if it weren't possible for brains to malfunction in a biochemical way. However, we literally have nothing to show for it. I'm not expecting the biochemistry of mental illness to be simple, or its genetic basis to be Mendellian, but this is getting a bit sad. 40% of adults are prescribed anti-depressants at some point (iirc) and most people aren't helped by them, and we people smuggly assert that there isn't a problem?

Finally, speaking as a materialist, I'm not sure what it means to "feel like yourself" when you're on medication. If your brain is you, isn't fixing your brain, by definition, making you NOT like yourself?

By the way, I want to be clear that I am not intending this as a personal attack. I realize that my first post came off as a bit flippant and attacking, and I apologize.

The Enteric Nervous System interface with the central Nervous System that Marc CC describes is to be taken very seriously.

It sounds like a joke: âYou have a gut feeling; are you sure that you donât have a gut thought?â Christof Koch, when asked during his lecture at Caltech Seminar Day, said that years ago he would have dismissed this as a joke, but after more than 20 years on the nature of consciousness, much with Sir Francis Crick in his post-DNA second career, now considers this a legitimate puzzle. As we shall see, asking this question leads to asking similar out-of-the-box questions, such as: âCan your immune system think?â and âCould consciousness be coded in DNA?â

âThe physical basis of consciousness appears to be the most singular challenge to the scientific, reductionist world view. In the closing years of the second millennium, advances in the ability to record the activity of individual neurons in the brains of monkeys or other animals while they carry out particular tasks, combined with the explosive development of functional brain imaging in normal humans, has lead to a renewed empirical program to discover the scientific explanation of consciousness.â [Koch & Crick, 1999]

If in any sense your digestive tract is conscious, is it âprivateâ in the sense of [Crick & Koch, 1998] âthat it is inherently impossible to communicate the exact nature of what we are conscious of?â

If in any sense your digestive tract is conscious, in what way does it have meaning in its content, in the sense of representation of the external or internal world?

If in any sense your digestive tract is conscious, is it connected in a significant way to your brain and CNS (Central Nervous System)?

This problem of qualia is what Chalmers (1995) calls "The Hard Problem": a full account of the manner in which subjective experience arises from cerebral processes. As we see it, the hard problem can be broken down into several questions, of which the first is the major problem: How do we experience anything at all? What leads to a particular conscious experience (such as the blueness of blue)? What
is the function of conscious experience? Why are some aspects of subjective experience impossible to convey to other people (in other words, why are they private)?
We believe we have answers to the last two questions (Crick and Koch, 1995c). We have already explained, in the section "Why Are We Conscious," what we think consciousness is for. The reason that visual consciousness is largely private is, we consider, an inevitable consequence of the way the brain works. To be conscious, we have argued, there must be an explicit representation of each aspect of visual consciousness. At each successive stage in the visual cortex, what is made explicit is recoded. To produce a motor output, such as speech, the information must be recoded again, so that what is expressed by the motor neurons is related, but not identical, to the explicit representation expressed by the firing of the neurons
associated with, for example, the color experience at some level in the visual hierarchy. [Crick & Koch, 1998]
Note further that I need not actually define âconsciousnessâ to ask these questions, and begin to design experiments to answer them. âConsciousness is a vague term with many usages and will, in the fullness of time, be replaced by a vocabulary that more accurately reflect the contribution of different brain processes (for a similar
evolution, consider the usage of memory, that has been replaced by an entire hierarchy of more specific concepts). Common to all forms of consciousness is that it feels like something (e.g., to ``see blue," to ``experience a head-ache", or to "reflect upon a memory").

Self-consciousness is but one form of consciousness. It is possible that all the different aspects of consciousness (smelling, pain, visual awareness, affect, self-consciousness, and so on) employ a basic common mechanism or perhaps a few such mechanisms. If one could
understand the mechanism for one aspect, then one will have gone most of the way towards understanding them all.â [Koch & Crick, 1999]

I've had some trouble with depression in the past and I have also had major gastrointestinal issues, but my experience has actually been the opposite of what others are reporting.

My early signs of depression were taken very seriously by my doctor, employer, and family. I started on antidepressants almost immediately and they were very effective. I eventually reached a point where I didn't need them any more and was able to stop.

Gastrointestinal health was another matter. I had ulcerative colitis - gone now since I had a total colectomy about 5 years ago. It was almost two years between onset of symptoms and diagnosis, during which time I was in severe pain, lost 65 pounds, and became anemic to the point of requiring hospitalization for a transfusion. Things got much better after diagnosis and treatment, but it was still no picnic.

Stress was a major factor in all of this. In fact I believe long term stress at work is what led to my depression. I made some changes there and that more than anything solved my problem.

My UC was different. My UC would kick in not when I was streesed, but rather when the stress went away. And it didn't take all that much to trigger an episode.
So I would go on a short and semi-stressful business trip and do fine, but would then spend an absolutely miserable 1-2 weeks once I got back.

Getting people to understand this proved to be next to impossible. Nobody ever called my a hypochondriac to my face, but it was clearly what many people thought was going on.

It actually shocked the hell out of a lot of people when I had my colectomy. (Almost all UC sufferers eventually need one - UC causes displasia that leads inexorably to cancer.)
They truly had convinced themselves this was all in my head. But everyone knows insurance companies aren't going shell out a quarter of a million dollars for unnecessary surgery like what I had.

Thank you for posting this. By openly discussing our mental disorders and engaging in thoughtful discussion we are able to reduce the stigma.

When initially diagnosed with depression and PTSD 15 years ago I worked in the insurance industry and kept my condition a secret. I did not use my health insurance for treatment out of fear my company would regard me as a liability. Since my firm wrote our own employee health coverage this was a real possibility.

Several years ago when no longer employed I began opening up on occasion, when appropriate. Since then I have found more people are understanding than not. There is still a high level of ignorance, but it has become easier to deal with. Also, only by revealing my own condition I've come to meet many who admit to their own disorders-people who otherwise keep it a secret.

Now that I've been rediagnosed as bipolar, which carries its own brand of stigma, engaging in these conversations has become increasingly important to me. Sadly, there are those who will remain purposefully ignorant regardless.

There is a tremendous amount of freedom in not having to keep it a secret. I am grateful for how far we have come in the past twenty years; that we are now able to have these discussions more openly.

There are still reactions and attitudes that bother me, though. Even some of the most understanding people who do not have a mental disorder can have a patronizing attitude. And I often encouter those who equate mental disorders with mental deficiency. It can be frustrating.

Slowly but surely the stigma is being erased and we will all benefit when no one need hide.

By Brenda Mayer (not verified) on 21 Jun 2009 #permalink

I don't think depression is an "illness" any more than pain is. You become depressed when there is an unresolved problem that's screwing up your psyche. So what about the case where your anti-depressant medication prevents you from processing (and eventually overcoming) the underlying problem? Isn't that like taking meds to lower a fever without doing anything about the disease that caused it, thus making the disease worse?

I was prescribed antidepressants a few years ago when I was 19 and absolutely miserable. Not knowing any better, I took them for a few months. I would never do it again. Frankly, after those months of so-called "psychotherapy" (in addition to the pills), I think psychiatry and psychology are a load of crap. Those pseudoscientists don't know any more about your psyche than any layman, except that, unlike the layman, they are deluded into the conviction that their guesses must be correct (because they're "experts" and all).

Of course, if you really want to alter your mind to be "normal", I wouldn't stop you. But you know what I think? If there's something that makes you miserable, you should either solve the actual problem or do nothing about it - you should NOT try to "fix" your mind to adapt to the situation. Better be miserable than convince yourself that you are the one who is "abnormal". After all, if the world is so shitty that it makes you depressed, then it's only fair to get back at it by not being a productive member of society. Maybe my opinion is extreme, but there it is for what it's worth.

By TentacledBeast (not verified) on 21 Jun 2009 #permalink

It's odd how difficult it is for people who aren't depressed to understand what it is like for those who are. It's not like epilepsy, yet the two have some similarities in that both are rooted in the same organ and are the result of something not working right. Yet no one complains of a lack of will for the epileptic.
Granted, there are things that can be done to improve the situation with clinical depression and I've tried several. However, to those who complain that it is a matter of will, consider that the will is in the brain as well. If the brain is the source of the problem mightn't it be the case that the will is compromised for the same reason that the mental outlook is: bad neurochemistry?

I went through a bout of depression once; I got over it with some counselling, but I remember what it was like being stuck in that state. Ironically, the depression gave me heartburn.

I'm glad the meds are helping Mark and keeping the black dog properly kennelled.

By Stephen Wells (not verified) on 22 Jun 2009 #permalink

@61: you really don't know what you're talking about. I've been unhappy and I've been depressed, there is a very big difference between them. Lewis Wolpert wrote about his experiences with depression in a book entitled "Malignant Sadness", which is a good way of putting it.

By Stephen Wells (not verified) on 22 Jun 2009 #permalink

Let me address the practical issue raised by the post.

I'd advise any grad student or junior faculty never to reveal anything about themselves that could be construed as a serious weakness. It's a competitive world out there and people who write letters of reference are charged with picking the best. I myself would not support a student I felt would fall apart down the road nearly as strongly as one that I felt would not -- in fact, I'd feel that it was my professional obligation to do this. Academia should be a meritocracy, full stop.

Let me also say a word about this passage:

the fact that my brain has a problem that's easy to fix using medication is somehow considered to be a huge strike against me, a [...] sign of personal weakness.

I think this is correct as a description. But I'd like to point out that you offer NO ARGUMENT whatsoever in your post for why people who draw this conclusion are wrong. What concretely are the reasons why we should not consider a debilitating mind/brain condition a significantly more serious weakness than (say) seasonal allergies or diabetes? I am not unsympathetic; I'm just unconvinced. Calling my attitude 'hypocrisy' is inadequate both as a description and, more importantly, as an argument.

Among the slightly odd cultural phenomena in the United States and Canada is that people expect to both tell their colleagues everything about themselves (including what they like to stick and where they like to stick it) and that they expect to be loved unconditionally while doing it. Tact and discretion have apparently vanished. Someone who has a serious clinical condition but keeps it under wraps is, as far as I am concerned, every bit as qualified to do their job as anyone else. On the other hand, someone who advertises their condition while expecting to be treated 'no differently' is most likely looking for an occasional free pass. In the context of a personal relationship or friendship, I have all the sympathy in the world. At work, I have none.

Good luck to you and all the best.

By Victorian (not verified) on 22 Jun 2009 #permalink

Re #65:

The problem isn't that mental illness is a concern - it's how that concern is treated.

Mental illness is not treated the same as other illnesses. As I said in the post - by many/most people, it's not treated as a real illness at all; it's treated as a personal weakness. Other illnesses that have an equivalent effect on life, health, and work are not treated that way.

Again, compare to my stomach problem. I missed a *lot* of work back when we were trying to figure out what was wrong. I definitely wasn't working at my best, because I was constantly in pain. And I cost my employer a huge amount of money through their (self-paid) insurance plan - the tests that I went through ran to something in the vicinity of $100K.

But the lost work and expense of that isn't considered a strike against me in any way. It garnered a lot of sympathy, lots of offers of assistance, lots of concern from my coworkers and managers, but never a hint of negative judgment, never the slightest suggestion that my history of gastrointestinal problems should be held against me.

Mental illness is *very* different. Even though in my case, it was easy to treat, the treatment is incredibly cheap, and my work performance didn't suffer as a result of it (I got one of my best performance ratings at IBM the year my depression was the worst), depression *was* considered by many folks to be a major strike against me.

It's that difference that's the problem. People with mental illnesses are held to different standards, penalized in ways that people with equally debilitating non-mental illnesses aren't.

I think people who've never had a bout of serious clinical depression have a difficult time understanding what it's really like. As Mark describes it's basically an abscense of feeling. You don't feel sad, you don't feel happy, you don't feel anything. Imagine going through life and being completely unable to process emotive input - the only real feeling is one of quiet discomfort: like something is wrong, but you don't know what, and oh well you can deal with it later when you feel rested. Except later never comes, because there's not enough sleep to make you feel rested.

You start to do things to try and get a feeling back, any feeling, you don't even care what. I tried exercise - didn't work. I tried drinking - didn't work (of course). Eventually I got to cutting and that worked at least - I could feel it, it was a real sensation that I could feel. Fortunately, not long after that, I managed to go to the counseling center at my university and get some actual treatment.

I was one of the lucky ones - six months of talk therapy and antidepressants gave me the tools to handle things without further interventions. That doesn't work for everyone, and I think you're both brave and lucky, Mark. Brave for telling the entire world about a very stigmatized disease and lucky that the medications get you over the hump. That's all they do - they get you to the place where you can deal with things, where you can process.

I have ADD. I was diagnosed in second grade, and I'm now 24 and quite successful. I really doubt I could have made it this far if it weren't for the medications available to me.

I've run into many people who have made comments about how ADD isn't a real disorder; that it is the parents fault or a diet issue, or just bad kids. They generally don't know that I have ADD, and somebody with my qualifications doesn't fit their ignorant mental picture of what ADD is. This doesn't make their ignorance any less infuriating, and I admit I thoroughly enjoy giving them a thorough verbal beating. I'm actually a bit in awe of your ability, Mark, to be so calm about this in the face of such people.

My experiences with mental health professionals are pretty mixed: there's been good and bad. However, one thing that continually colors my perception of the science is listening to the psychology students who are tutored in the room where I tutor math.

When I'm explaining some sort of physical model, I try to make sure the student understands that it's only a model, and things like air drag or friction can make the real-life behavior a little more complicated. Nothing really has, for example, constant acceleration, but imagining something that does is useful for learning. Most other science tutors seem to talk the same way. Having listened to a couple of tutoring sessions with psychology students, I haven't yet heard a tutor make a similar caveat.

This worries me because it amounts to describing a theory -- say, that a boy's psyche is overwhelmingly formed by sexual longing for his mother -- as authoritative and irreducible fact. There is no discussion of supporting evidence. (I'd be happy with "This has been validated by experiments/studies, though we don't have time to discuss them in detail now.") Neither do they mention any criticisms or weaknesses in the theory, of which there are several (to my understanding).

Of course, it doesn't always make sense to teach the basics of a survey course in that much detail. It's also probably not fair to judge a whole science on the basis of one or two tutors whose understanding of the material lacks nuance. Nonetheless, it's not hard to see the potential for bad psychology if those tutors and their students take that unquestioning approach into professional practice.

Thank you for your post, Mark. I deeply appreciate your honesty about your medical conditions. I too have severe clinical depression. I take 2 different antidepressants every day and another med for PTSD. A few years ago I had ECT, which helped for a while. When I told my graduate advisor about my condition, he said I was lazy, "made the whole thing up," "just trying to get attention," and threw me out of his lab. He also told all the other faculty members, and I heard talk of the "psycho" student. Unbelievable. So I would advise a grad student or postdoc NOT to disclose her/his depression, even if s/he thinks s/he knows her advisor well.

Re #70:

The stigma of mental illness is a real problem. People who would be very sympathetic and understanding about anything else can be totally unreasonable when mental illness entered the picture.

The close-to-home example of that is my own father. I loved my dad dearly, and he was definitely the single largest influence on me. He was a great person, and a fantastic father. But when my mom started to suffer from depression, he had a terrible time dealing with it. He just *couldn't* wrap his head around it. It took him years to accept it as a real, serious illness, and even then, I don't th
ink that he really deeply believed that it was as legitimate an illness as my mom's diabetes.

If my first serious depressive episode had happened in grad school, I probably would have told my advisor. And even now, I think that she would have responded in a supportive way. But I don't *know*. And I certainly wasn't as aware of the depth of the stigma against mental illness then. So I probably would have told people that I shouldn't have.


(You should see what a kid without ADD is like on ritalin - I've seen it. It's scary. Agitated, agressive, can't sit still - like an adult who's been drinking too much coffee.)

I've often wondered about this. If anything, I have the opposite of ADHD -- in college, I'd spend six hours at a time reading my real analysis textbook. But my experience with ritalin and aderall is that they just focus me in. With aderall, I can work on real analysis for 12 hours instead of 6. I never took ritalin to get work done, but essentially my experience there is of hyperfocusing on arranging harmonies on guitar for three hours at a time.

In other words, the effects I got from these substances were essentially exactly what kids with ADHD are supposed to get out of them. When I took them without anything directly in front of me to focus on, it was a little more like drinking 12 cups of coffee. I would simply be very animated and very conversational (which is not natural for me), probably something more like you are describing in the quote above.

So I've had to wonder whether the drugs affected me as they would affect a person with ADHD because I was (physiologically almost) an adult every time I took them, or because I used them "right," with a particular activity to hyperfocus on in each case.

I'm not sure the question of diagnoses is as clear cut as you suggest here. Human behavior doesn't fall into discrete lumps like "depressive," "hyperactive," etc. It's almost always spread across a spectrum, and a diagnosis is to some extent an arbitrary line demarcating part of that spectrum.

That said, those far to the ends of the spectrum often have trouble coping with everyday problems, and that is through no fault of their own. I'm sure there are cases more towards the center of the spectrum where a patient or parent chooses to medicate a condition that could have been overcome through hard work, but I agree that the number of such cases is almost certainly exaggerated.

Ultimately, it should be one's own choice whether to medicate. For many people, the decision to do so is life-saving; for others, it can improve quality of life to the point where it might as well be life-saving. While I think the question of diagnosis is more difficult than you allow, I think it is more or less orthogonal to the point you make: we all do what we can to make our lives better day to day, and if someone finds that medication is an effective way to do so, that person should not be judged on that account.

I did not read all of the comments just want to ask: how about having math as a source for depression? Taking drugs _only_ seems to be as ignorant a position as judging a drug-taker by telling him to be a weakling. Think about it a bit.

By ex student (not verified) on 22 Jun 2009 #permalink

Great post! I have no depression, but a few of my friends do. I know what it means to have one of these illnesses.

Re #73:

I honestly have *no* idea what you're trying to get at.

The one thing I'll point out is that the most effective treatment for a person with depression varies by the person. The success rate for talk therapy is roughly the same as the success rate for drugs alone. Whether to treat with medication, therapy, or both; and if medication, which drug to use is not an easy call, and is very dependent of the particular patient.

In my own case, the doctor that I saw spent close to 9 months trying to do therapy with me in addition to the medication. But the medication seemed to do the trick, and in nine months of talking, he never found anything for which I really needed therapy. In my case, the depression seemed to be entirely physical, and therapy did nothing.

I'm frankly incredibly lucky. The first medication that we tried pretty much took care of it. For some people, none of the anti-depressant medications have any effect. For the SSRI family, only something like 40% of people respond to medication alone. I happen to be in that lucky 40%. And I haven't suffered any of the side-effects of the SSRIs. And my wonderful wife stuck by me even though I was miserable to be around during my depression. When it comes to depression, I've been incredibly lucky: I'm easy to treat, and I managed (by sheer luck) to avoid doing any serious damage to my personal life or career.

I haven't read al comments thoroughly so I apologise if this has been said before:

I guess part of the stigma is due to people trying to convince themselves (out of fear) that mental illness could never happen to *them*. So if it is *your fault* that you are depressive, then I don't have to fear that I might become depressive myself.

Sometimes this also happens with cancer patients or so - if someone gets cancer, people will ask "Does she smoke?" - and if she does, then they'll dismiss it as "her own fault". I think cancer is in this respect a bit similar to mental illness because people are so afraid of it; but since it is much more common, the "their-own-fault" argument is more difficult to hold up.

First, I'd like to say that I'm in a very similar position; someone who suffers from clinical depression for which therapy didn't work but meds did.
While the stomach may be a fairly complex organ, compared to the human brain it is absurdly simple and well understood. So while it is relatively easy to understand the physical basis for a gastric problem, the physical basis for a mental health problem isn't even well understood by those studying it. This isn't because the illness is 'less real' or not taken seriously by the medical profession, its because the organ affected is incredibly complex. With that lack of understanding, it shouldn't be surprising that many are skeptical.

Also, I think drugs like Ritalin do fall in a slightly different category. As far as I know, anti-depressants are not going to have much of an effect (mood wise) on someone who isn't clinically depressed. They aren't 'happy pills' which simply make you feel good, so I don't see much of a danger of them being abused by people without the condition. Ritalin, on the other hand, can be abused by people without the disorder to get benefits such as an increased ability to concentrate. I would not be surprised if in the coming years a major university has a Ritalin abuse scandal on par with the steroid scandals currently plaguing professional sports. Of course that doesn't make ADHD in any way a fake condition, any more than medical conditions that require the use of steroids are fake.

Finally, I would like to correct one error you made. You call depression a non life-threatening problem with your brain. But depression certainly can be life-threatening. Consider how many people commit suicide each year, combined with the drug related deaths that occurred because the individual was self-medicating.

Re #77:

I didn't mean to suggest that depression isn't a life threatening disease. In my case, it wasn't life threatening. The severity of my own personal case of depression wasn't bad enough for it to be life threatening. Of course, I can't say whether it would have gotten worse had I not treated it; some cases of depression are basically a steady-state, where you never get better, but you never get worse; and some cases have a downward spiral.

The one milligram of sense that I can find in #73: "... how about having math as a source for depression?" is that there is such a thing as Clinical Mathematics Anxiety, a psychological state related to Dyscalculia.

But it isn't Math as such that panics and depresses the sufferers (or 2/3 of those clinically diagnosed, anyway according to the literature).

It's having had an incredibly bad Math teacher very early in schooling, who has taught the WRONG stuff at a fundamental level. So the student performs poorly, is unhappy, doesn't try, performs worse, is unhappier, and so forth until (usually) becoming a drop out.

The cure is not a drug. It is one good teacher, who knows the methodologies which have worked with students suffering Dyscalculia.

The student is, to make an analogy, UNTAUGHT and debugged, regressed back to just before going onto the wrong track, and than brought forward on the right track.

This really, really deserves to be repeated.

Calli Arcale, in #25, said:

"Thing is, people have prejudices against any disease that they believe is influenced by behavior, whether it's true or not. The more influence they think a person's behavior has over the disease, the more they scorn the person for it. This is a very ancient tendency; it seems universal to at least suspect that disease is a reflection of the sort of life you lead. Which is rather sad, really."


As I was reading over your post, one statement that really stood out for me was about the addictive property being a undesired side effect.

If, as I understand it, you will taking this medication for the rest of your life to alleviate your pain, why does any addictive property matter?

In fact, to go a step further, for mental illness drugs, wouldn't addictiveness be a benefit in that it would provide a strong physical incentive for people to continue taking their medication?

I'll admit that my knowledge about mental illness treatment is mostly based upon television shows where the "crazy guy goes off his meds and kills somebody", so I don't know how often this sort of this actually happens or how to weigh the pros & cons of addiction to a drug for long term treatment of a chronic condition.


I have no idea what #73 was getting at either. I think that most people experience mental illness to some degree, but they're functional enough that they can do without treatment. I'm thinking about common things like rationalization, projection, superstition, etc. that come from growing up in an irrational and chaotic environment. Some forms of irrational thought processes can be corrected with counseling, some are helped with drug therapy, some require both, and sometimes we have no effective treatments.

I'm considered clinically depressed, and probably suffering from PTSD. I get some improvement from drugs, but not enough to stop me from contemplating suicide. Counseling has been largely ineffective. I understand that I might be seeing things a little more pessimistically than most, but I don't think my suicidal thoughts are irrational. I think a lot of it comes down to personal preferences. I just have different desires than most. I don't think what I want is attainable, and those things I could achieve aren't worth the effort. I also don't think death is going to be worse than life. So... is it actually irrational to want to die?

Re #81:

Being addicted to a medication, even if it's a medication that you need, isn't a good thing.

Just for example... Back in 2001, my wife and I went on vacation to Italy. We were staying in a villa in Tuscany on September 11th. And on the morning of September 11th, before we knew anything about the attack, my wife realized that she'd left her green card at home. We wound up spending an extra week in Italy. What if I didn't have enough medication to get through the extra week?

If I ran out of Zoloft, it would be no big deal. (I know that some people have severe mood swings when stopping SSRIs, but I've done it a couple of times due to forgetting to get new prescriptions in time, and it wasn't a problem.) (And I wasn't taking Zoloft yet back then.)

If I ran out of most of my stomach medications, I could get something over the counter to cover for a week or so. But for the addictive one, if I were really addicted, and for some reason I ran out in a place where I couldn't get more, I'd be in serious trouble.

(As it happens, I tried stopping the potentially addictive one earlier this year - the doctor thought that I might not need it anymore. No withdrawal effects, but my stomach troubles returned, so I'm back on it. I'm on a very low dose, low enough that I haven't been hooked by it.)

The "crazy guy off his medication" scenario is not nearly as common as it's made out to be on TV. But it does happen. The most common causes are bipolar disorder and schizophrenia. In both cases, a big part of the problem is that the medications that work for most people with those diseases are very crude, and have severe side-effects. People really don't want to take them, because they make them miserable. Combine that with the constant pressure that you should be strong enough to get by without medication, and a lot of people repeatedly try to get by without their medication. Some manage it, some don't. Of the ones who don't, some very small number can wind up being dangerous. (But it's important to stress that small number part. Schizophenia is one of the more common causes of psychological illness induced violence; but the number of people with schizophrenia who'll ever be dangerous to anyone but themselves is extremely small. Bipolar people are even less likely to hurt anyone else; a severely bipolar person without medication is mostly only dangerous to themself.)

#61, depression often has no connection to "whatever's bothering you." Life might be just peachy, no big stressors, no hidden angst-- yet getting out of bed might be impossible.

That's part of the stigma. "What have you got to be unhappy about? Nothing, that's what. So get over it."

William Styron's Darkness Visible is the best explanation I know of what depression is like-- the immense, all-consuming, numbing wet blanket of utter apathy. I seriously disagree with the commenters who have remarked that changing that state is somehow changing one's real self to a false one.

By Faithful Reader (not verified) on 24 Jun 2009 #permalink

Thank you for this post. One of my very best friends of many years is mentally ill. She is schizophrenic and has to take medication to stop hearing voices (among the milder symptoms). If you think you get judged harshly for having depression (which I'm sure you do), try telling people you're schizophrenic; most people will think you're like an axe murderer or something, and those are just the ones who sort of know what schizophrenia is. Fact of the matter is, my friend is kind and smart and would never hurt a bug.
Anyway, I appreciate the post. Keep up the good work!

Brendan has it. The sooner we stop thinking of the "mind" as some sort of magical nonphysical entity of pure light and love that can't possibly have anything wrong with it, the better off we'll be. Mind is brain, it's physical, and it can break just like your bones.

People's view of mental illness and its treatment is akin to treating a broken bone by waving flowers over your chakras. It might take drugs and/or it might take talking, but it takes *something.*

~~ Paul

By Paul C. Anagno… (not verified) on 26 Jun 2009 #permalink

drugs don't solve the problem ... they merely hide the symptoms while the problem continues to fester inside. In fact drugs are like rugs...the sweeper sweeps the dust beneath them each day and finally one day when you shake the rugs all the dirt comes out. Similarly drugs take theburden but the moment you try to do without them you are faced with a series of symptoms of massive proportions.

Drugs are like dogs too. They can protect their owner but sometimes they turn on their master and harm him. All drugs have side effects and believe them they are truly nasty!

Instead of drugs a network and regular cognitive psychotherapy is the way to go. Drugs only hav a life saving function.

By yoruba yam (not verified) on 26 Jun 2009 #permalink

Mark, how have I missed your blog for so long??? Nice to meet you! :)

I have hypomanic bipolar disorder and high-functioning autism, and both went undiagnosed until I was in my late thirties!!! Then I got on meds and went, "Oh, WOW, this is what NORMAL emotions feel like!!!" It was literally like coming up for air after being underwater all my life. I am cheerfully willing to take meds for the rest of my life-- no problem here! :) And I, like you, have no worries talking about my condition/brain structure/what have you, because I don't feel it's anything that needs to carry a stigma. The more people talk about it, the less trouble depressed people will have asking for help, hopefully!

Depression is to normal sadness like the Grand Canyon on a moonless night is to a small sinkhole. No one should ever have to live like that.

My first reaction to your post is that you are one of the lucky ones. I've known at least two people who've had depression, did not respond to medication, and wound up committing suicide. They were not lucky. Depression is a serious illness.


My take on ADD is that it is still poorly characterized from a medical point of view. I read one survey of studies, and the comparable statistics had extremely broad ranges and high variances. Yes, there are clear cases of ADD, and there are clear misdiagnoses, but there is also a huge middle ground, much larger than that for heart disease, acid reflux or depression. There are big differences in its diagnosis based on location, economics and a host of extrinsic factors. There wasn't all that much to inspire clinical confidence. (For example, the reported range of insomnia as a side effect of treatment ranged from 10% to 100%. Is this a serious problem or not? We don't know.)

Re #89:

Yes, I am incredibly lucky. Depression is awful, but I'm incredibly fortunate to be treatable, and I'm extremely lucky that the first medication I tried did the job.

As for ADD: I think that it's become increasingly well characterized. There've been some really interesting brain studies done that have shown physical differences between the brains of people with ADD and people without. Of course, it's a spectrum. Like many things, there's a continuum.

One of the strange things, though, is that people insist of focusing on the continuum of things like ADD, while ignoring the continuum of other things. To pull another personal ailment, GERD.

GERD is caused by a loose sphincter (called the LES) at the top of the stomach. Because it's loose, when gas builds up in the stomach, it's able to force the sphincter open, which allows acid to get from the stomach to the esophagus.

Some people, like me, have such a loose LES that it might as well not be there at all. For us, the existence of GERD as a disorder is absolutely clear, obvious, and undeniable.

For other folks, it's not so clear. The LES works pretty well; it's tight enough that it mostly stays tightly closed when it should. They're usually OK, but when they eat something that either produces lots of gas, or that causes muscle spasms in the stomach, they'll sometimes have acid getting out. That's normal heartburn. For people with that, it ranges from very frequent (in which case they're considered to have GERD) to very infrequent (in which case they're considered normal).

Some people have a very tight LES. It's tight enough that it never lets acid into their stomach. They never get heartburn, and it never causes them a problem.

And finally, there are some people with a very tight LES - so tight that it's a problem. They have difficult swallowing, because it won't open up enough to let food it. They've got a disorder called disphagia.

I've described five points - but they're five points along a spectrum. It's really continuous. There's no clear point where you can say "On *this* side of the line, you don't have GERD; on *that* side of the line, you do".

Next time you're in your drug store, take a look at the antacid section. It's downright *amazing* how many drugs there are on the market for treating heartburn. Why are there so many? Because the overwhelming majority of people live in the middle ground, where they don't quite have enough of a problem to be considered to have full-blown GERD, but they still have enough symptoms to need some kind of intermittent treatment.

The middle-ground clearly does exist. It's a multi-billion dollar market for drug manufacturers! The only real difference between the GERD spectrum and the ADD spectrum is that people have no doubt that heartburn is a real problem that interferes with the lives of people who suffer from it.

What an amazing post, and an even better discussion afterward! I'm cheering for you and your readers. I experienced an illness related to postpartum depression called postpartum OCD. My recovery happened to include both medication and therapy. I now write the most widely-read blog in the US on perinatal mood and anxiety disorders (Postpartum Progress) and I can tell you that the NUMBER ONE topic is whether one should or shouldn't take medication as part of their treatment.

There are people who spend every waking minute of their lives trying to deter women with PPD from taking psychiatric medication -- some because they are anti-psychiatry, some because they themselves had bad experiences with medication, some because they worry there isn't enough research on the impact of such medication, etc. Their efforts have an impact. Many women who are suffering terribly (and whose babies are suffering as a result) won't reach out for help because they don't want to be prescribed psychiatric medication. Little do they know that the lack of treatment for postpartum depression and related illnesses can negatively affect both the physical and mental health (yes, I know physical and mental health are not different, but people treat them as if they are) of mother AND baby for the REST OF THEIR LIVES.

Are there doctors who whip out prescriptions and don't monitor their patients and consider also making sure these patients receive therapy or coping tools for any underlying trauma? Yes, unfortunately. Are there people for whom antidepressant medications either don't work or are toxic? Yes (see the Mayo Clinic's cytochrome p450 test). Are there women who can recover from PPD and related illnesses without medication? Sure. Are there effective treatments aside from medication, like therapy? Yes. This doesn't mean, however, that antidepressants don't work and should be avoided at all costs.

I've met or spoken with THOUSANDS of women at this point for whom antidepressants significantly helped, women who will say these medications helped to save their lives. They are the only evidence I need that it can help. I am the only evidence I need that meds can help. People can take their stigma and shove it. I have OCD and I'm not ashamed. I take an antidepressant and I'm not ashamed. Thank you Marc for your post.

The stigma problem is huge - it is rare but there are even a few people who work in mental health who stigmatize mental health problems. I had the misfortune of having a supervisor who fell into that camp and she fired me after I had a severe depressive episode.

I am very selective about which friends and family I will mention my depression to. Even as a mental health nurse I can not get some people to listen to info on what mental illness is or how it is treated.

As far as the mental health denialists who have posted -Their beliefs, attitudes and behaviors have caused so much damage to so many people that I can not make a civil response to them.

By depressed nurse (not verified) on 30 Jun 2009 #permalink

I second the comment made earlier that people tend to be judgmental towards illnesses that they think have an element of being caused by a person's volitional behavior - but I think the main source of stigma towards mental illnesses is that they change the personality of the person suffering from them. Very often radically. So much so that the person in the grip of a serious mental illness can appear to be somebody else entirely - not at all the person you thought you knew before they became ill. Generally somebody much worse.

Stomach problems, cancer, back problems, broken limbs, etc etc - these are issues which primarily affect the body. Yeah, they'll all have a secondary impact of one kind or another on the mind, but generally not to the extent that your entire personality will disintegrate. Mental illnesses, though... can and will cause your entire self, your you-ness, to vanish. Ultimately, if not successfully treated. Leaving behind nothing but a body and a collection of automatic responses.

If you're in the hospital recovering from, say, surgery for removal of a tumor, your friends and family can come and visit you and they'll be able to talk to *you* - while you may be in pain and drained and exhausted, you'll still be you. They'll recognize your personality, your mind and memory will be intact, and they won't feel like you've disappeared.

If you're in the hospital being treated for some kind of, say, severe bipolar meltdown, though, and your friends and family come to visit you... they very probably won't be able to talk to you. It's very likely that you just plain won't be you. Your mind will be warped, unglued, scrambled, only vaguely connected to reality. If you try to talk, often scary nonsense will dribble out of you. Or maybe you can't remember how to talk, and will just stare blankly at everyone. For days and weeks on end. Stuff like that is extremely disconcerting for anyone trying to bring you comfort and support.

Plus - you can be deeply mentally ill and at the same time robustly physically healthy. That is - you can look *completely fine* from the outside. And have your entire mind just plain gone. Which is very confusing to anybody encountering you. Physical illnesses tend to be physically apparent - you don't look well. With mental illnesses - you can look fine and be profoundly sick. The contrast creates a sense of cognitive dissonance that I think most people have difficulty dealing with.

So yeah, that would be two additional sources of stigma then - that the personality of a mentally ill person can disintegrate so completely, and that you can be extremely sick while looking entirely physically well.

Good post, Mark. Thanks for sharing your experiences.

By Random Canadian (not verified) on 01 Jul 2009 #permalink

to #23, snex:
YES! YESSS!! That's my theory regarding the reason mental illness is treated that way by the public!
People still believe in souls, mind over matter, or some other fruitcake concept. That is the reason why they believe psychiatry is itself crackpottery! They think "Pills can't treat THE SOUL".


By Anonymous (not verified) on 03 Jul 2009 #permalink

I must say, I rather envy you for what sounds like an incredibly straightforward case of depression. Not that the experience of the depression itself was easy, but having such an ideal reaction to the first antidepressant you took certainly makes conceptualizing the whole thing as an illness much easier.

I don't disagree with the idea of depression as a physical illness, and I'm fairly certain I owe my own depression to a large degree to a physical/genetic vulnerability. Mental illness seems to run in the family. But unfortunately, my depression surfaced in the midst of many other problems--anxiety, pathological perfectionism, etc.--that fed into it. As such, I required both therapy and antidepressants to start to straighten out the whole mess.

There really shouldn't be any shame in that, but surrounded by all the debates and doubts about the legitimacy of depression/antidepressants/etc., my failure to either solve my problems through JUST therapy and hard work or JUST medication seems to position me uncomfortably in between sides.

But it only SEEMS that way. The fact that therapy helps doesn't negate the physical model, and vice versa. As you pointed out, the brain is an organ, a body part. Like any other part of the body, it can malfunction due to all sorts of causes. And when it malfunctions severely, as in depression, that is a serious illness. And seriously ill people deserve treatment and compassion regardless of what initially caused the illness.

That's a lot of babbling just to essentially agree with you, but there's my two cents.

Part of the reason that depression sometimes seems to be triggered by "stuff that makes you sad" (my mother's death in my case) can be that the depression has been there for a while (more than a year for me), but 1) you haven't acknowledged that that's what's wrong, 2) you've been able to cope by directing (subconsciously) a lot of energy into repressing whatever's bother you and into just getting on with life as usual.

Then when outside trauma hits, there're are no reserves left to deal with it. All your effort has already been spent on just surviving.

I won't say that that's all there was to my case, but I think it's part it. I, too, am one of those lucky enough to respond to SSRIs. I have had great benefit of therapy too, since in my case there was a lot of bundled up 'issues'. But I didn't have the excess energy to really benefit from the psychologist before I was fully medicated.

I have been incredibly lucky, though. I don't recall meeting anything but support and understanding. It took me a long time to get out of the house, but the council was incredibly helpful in getting me into jobproofing so as to allow me to slowly get more and more hours. I'm now well enough to actively look for 'real' work. Something I wouldn't have been able to two years ago. Nöone I've met in the process has acused me of simulating. Hearing some of these horrorstories makes me very grateful for all the help I've had.

Here's an interesting post on SSRIs prescription and problems related with withdrawal symptoms written from the perspective of a person who's used them for a while. Raises some issues that might be of interest in relation to this discussion.


Your posts are a tremendous service to the community. I just read your high school post and I was so concerned for someone having to deal with all of that that I suggested you may want to talk with a professional. Now I read this post, and I feel much better. Toss me in with the group that says when someone says they are getting treatment for mental illness or are working to overcome their circumstances, mental, physical, or emotional, I am happy for them, and wish them the best outcome!

Now I am looking for your blog posts where you say we should stop writing code and start writing grammars. I figure if you are into Math you must have figured that out too!

Thank you for writing this. From late elementary school through the beginning of college I was depressed. There were times I couldn't even move. It took a few medications to find one that worked but, eventually, one did. I took it for a couple years, with talk therapy, and since then have not had to take anything. But without it I would probably not be here today. I almost never talk about it because I am afraid of people's reactions, and I hope that someday it will be more acceptable to talk about.

By anonymous (not verified) on 17 Jul 2009 #permalink

As someone who also lives with clinical depression I think the reason people react like this is the fact that they can understand the symptoms of the other pains you have, such pains works similarly to some injuries/problems that people encounter during their life fairly often, but the symptons of depression are really unlike anything else, and people usually act with prejudice against things they dont understand

By Anonymous (not verified) on 25 Jul 2009 #permalink

I can relate to what you feel that most people misunderstand mental illness because they think the brain is perfect and that it shouldn't be given any attention like your other body sickness like sore throats for example..It's like a taboo for most people when you speak about mental illness

By Anonymous (not verified) on 09 Jan 2010 #permalink

I'm currently emerging from a major depression and doubt that I would've had the capacity to fully understand this mental illness prior to it's occurrence. No amount of counselling, conflict resolution, exercise or other behaviors on my part were able to stop the onset of depression.

I believe more education needs to be given to bring mental illnesses into the light from an early age to prevent stigma and reduce ignorance.

By Anonymous (not verified) on 19 Apr 2010 #permalink