What's your opinion of the claim that antidepressants have small impact on people with mild to moderate depression, but significantly more impact on people with severe depression [1]?
I ask as a nonexpert because this is a view I've read a few times from people I trust more than most, and I know two people who suffered from severe depression who credited SSRIs for getting them through.
Honestly, every time I look into if the "treatment by severity effect" is clearly established, I feel I come away only able to shrug. It is at least plausible, but hasn't been clearly established or refuted.
What does seem clear to me is that the whole cost-benefit considerations change in favor of anti-depressants when the depression is severe. I wouldn't say anti-depressants should be first-line treatments for ordinary depression, but for severe depression, I think they are a very reasonable first-line option.
Sure, they still might not help, but the costs / harms don't seem so bad compared to the potential costs / harms of leaving the severe major depression untreated, and the other options look all pretty terrible here too.
Wait, I finally found a paper that properly presents the results in a way that lets you decide for yourself! See figure 2 here: https://pmc.ncbi.nlm.nih.gov/articles/PMC9344377/#f2, you want to focus on the second plot with the dotted and dashed lines.
Basically, both placebo and drugs can have huge responses, but basically, for severe depression, yes, it looks like the drug is more likely to have a large positive effect than the placebo is likely to have a large positive effect.
There are still a lot of limitations, main one being that study criteria generating the data for this would exclude most cases of really high severity actually seen in practice. Also "blinding" is mostly BS in these kinds of studies, and antidepressants have massive, noticeable effects, so the proper comparison is really an active placebo, and we really can't be sure the whole apparent antidepressant effect is basically just "woah, I can really feel this doing shit", basically, at some level, and this is still bad because the placebo vs. drug difference is still super tiny and below what we would consider typical minimal clinically important differences.
So still hard to say. But, yeah, there is a good chance the drugs are more effective in severe cases, and, technically, you should definitely treat in a severe case.
I would love to read an update about your experience with antidepressants, as it's a path I'm thinking about more and more with the (losing) battle I've been fighting against my own long term depression.
I really resonated with your eventual realization that while others have their own battles, they are very rarely similar to this. I guess I knew it was unusual, but I took way too long to realize just how weird it was to feel soul-crushingly miserable for no identifiable reason, even when things are going well, even when I'm around friends I like and they're having fun.
I'm not OP but just wanted to add my own experience with anti-depressants as someone who has battled mild depression and extreme anxiety for years. Ultimately in my case it turned out that I needed to try several different antidepressants that my doctor prescribed until I found one that worked to aid in decreasing my depression and anxiety symptoms with pretty much no side effects. I tried several which did not work for me or had a lot of side effects. Some antidepressants that helped my friends and family in their struggles did not help me. So definitely ask your doctor if they'd be willing to work with you to try and find a medication that works well for you with minimal side effects if they recommend that you take such medications.
We know very little about how psychological drugs work in general. Having to try multiple things to find one that works well for you is par for the course
"while others have their own battles, they are very rarely similar to this" - meh, I don't think that's true. Being human is hard, and in some circumstances can be very fucking hard. If you've had a challenging time in your youth, that makes it exponentially harder.
That's most people. They just keep it inside, assuming everyone else is doing better than they are.
I'm happy to read evidence I'm wrong (I want to be wrong - it would make me much more optimistic about a fix), but my own life and everything I've read suggests the opposite - once someone develops a serious drug or alcohol addiction it leads to them destroying everything good in their lives and inevitably they either sober up or end up homeless. Nearly all of the people who stay homeless in the long term have some severe mental illness (including addiction). Short of an involuntary commitment which is its own kind of hell, helping these people is incredibly difficult.
I have multiple family members who fit this pattern and it's absolutely godawful. The addiction literally rules them. They will perpetually ask for money for "needs" then spend it on drugs. If another family member houses them, they will sneakily maintain their addiction and steal from family to support it when necessary. If you offer them housing on condition of getting sober, they will choose addiction and homelessness. If you offer them housing without condition, they will use it to stay an addict in perpetuity, who everyone else is paying for. I don't think this last is a remotely viable solution with the number of addicts out there, which is only growing.
I'm not saying this to condemn addicts/mentally ill people. I just want to give an idea of just how hard this problem is to fix.
> Nearly all of the people who stay homeless in the long term have some severe mental illness (including addiction)
The problem is that people can end up homeless for all sorts of reasons, and even if that reason is some sort of mental illness, being homeless is an often-traumatic experience that easily exacerbates and worsens a person's mental condition.
There was a period of my life where I slept rough (long story) and I can personally confirm that a lack of sleep security (not to mention "stuff security", the fear of having my meager possessions stolen) will start someone on the path to mental illness; some amount of paranoia and mental fog seems almost inevitable in those conditions.
A stable environment is certainly going to dramatically increase the chance of overcoming an addiction. It obviously does not guarantee success but it's a crucial first step in the process. As pointed out in the article the housing first approach is actually saving money in the long run by reducing subsequent costs incurred by social services, so the "everyone else is paying for their addiction" argument does not really work – there are going to be costs either way, and an addict who has a home is easier and cheaper to care for than one who is roaming the streets.
1) completely free units to destroy
2) 24/7 emergency care teams
3) completely free healthcare and mental healthcare
4) no sobriety expectations of any sort
5) no possibility to be kicked out of the program for any reason
is going to be cheaper than putting them in jail or an institution? wow sounds almost too good to be true
it would be interesting (or funny) to get a summary on exactly how they are deriving the cost metric for this. i would just about guarantee they've taken creative liberties to make the numbers fit.
according to HUD[0] infestations, flooding, and fires are "typical behavior problems" in housing first programs. only in "extreme circumstances" does this warrant switching them to another unit. there is no way these are cheap damages to fix.
housing first programs are often mixed into ordinary developments too. i bet families living near or adjacent to these units really enjoy living next to completely unstable addicts. housing first programs explicitly prioritize the least stable, most mentally ill addicts too. but it's the humane thing to do at everyone else's expense.
a lot of cities in the US have a housing first program, among many other programs in a similar vein (ie safe injection sites). take san francisco for example. they spend billions of dollars every year on programs for the homeless. from what i hear the situation is still terrible. there are even businesses moving out of SF directly citing quality of life.
the cost of living in my city is so expensive that there are adults that work full time who have to have roommates to live at subsistence level. there are also housing first programs here that give junkies units for free to continue getting high in indefinitely. this is a ridiculous situation. either way i would rather it cost more to have people institutionalized or put in jail for breaking the law. this would also do good for actually having resources to help the ones who are actually down on their luck.
I think perhaps your biases are showing in the language you deploy (junkeis, free to destroy). You're asking for evidence that's readily available, if you want it, from studies to meta studies. The evidence ranges from conclusive to inconclusive, which isn't surprising given the many different types of implementation and existence of support ystems (or lack thereof).
In terms of cost, we need to look at the total social cost. If (big if) we were to assume that property destruction in housing units costs money, it is no strech to think that any marginal decrease in for example medical expenses (much more expensive in total social resource terms) more than make up for it. And a marginal improvement in a long-term expensive social problem would easily justify a high initial upfront cost.
I'm not saying you're wrong for asking the question, just that I have no problem accepting the findings that housing first is a cheaper solution in the long run if it gets more people clean and off the streets--as the evidence indicates.
>marginal decrease in for example medical expenses
why would there be a decrease rather than an increase? they're linked up with a full time care team as well as paths for more healthcare services. they also are allowed to continue to destroy their body with drugs. a local newspaper just ran an article here about how many health problems they have when they get into the local program.
yes i am very bias about the topic, and it wouldnt matter to me if it were much cheaper. but it truly doesnt sound plausible. i do not think setting up society so that people can comfortably get high all day, for free, at everyone else's expense, is a good or fair setup. there are many people struggling to stay afloat. maybe we could focus on solving that first. or focusing on the sober homeless.
> yes i am very bias about the topic, and it wouldnt matter to me if it were much cheaper.
So is what the US is doing right now working? Just the in healthcare, the US pays more per person when addressing this problem than anywhere else in the world, and gets nearly the worst result. Isn't that alone worth trying something else?
You're entirely ignoring the fact that it is effective in getting people clean. That is the outcome we're trying for, and achieving with this policy.
The fact that you're paying for a drug user to be warm and safe may stick in your craw, but it helps more people get clean, and so is good for them, their families, society and even your neighborhood as they return to be productive members of society. The money spent on their childhood and education isn't "wasted". They are less likely to be a nuisance.
Your feelings of disgust towards these people is a natural reaction. But if you can manage to see past it and realize these are human beings no different than you, by far and away mostly people who want to get clean but find it impossible in their circumstances and need help doing so, then you could be part of the chorus of voices pushing for positive change.
Let's all pull in the same direction: strong social safety nets, community building and mental health care to prevent people falling to drugs. And if they do, the care and assistance they need to pull themselves out of it. Not everyone's going to manage to do it, but eveyrone deserves a solid second chance.
I'm sure there are extreme cases but the vast majority of homeless are not much different than you and I. It does not need to be cheaper for every single homeless person individually, just cheaper on average. If you can rehabilitate even 20% that's a lot of savings and extra tax dollars to offset the costs (in addition to simply being the humane thing to do).
> 1) completely free units to destroy 2) 24/7 emergency care teams 3) completely free healthcare and mental healthcare 4) no sobriety expectations of any sort 5) no possibility to be kicked out of the program for any reason
> is going to be cheaper than putting them in jail or an institution? wow sounds almost too good to be true
Both of those are very expensive (about $100 a day for incarceration [1] and up to around $1000 a day for psychiatric treatment [2]) – and obviously a housing first program is not a drop-in replacement for them either as being homeless in itself is neither a crime nor a mental illness. I would also wager a destructive addict in their own home causes less property damage (on average) than one in temporary housing / on the streets. A 24/7 emergency care team is not a thing in assisted living facilities in Finland, and the housing provided by housing first programs is not at all limited to assisted living facilities – it is often just a completely regular rental apartment. And healthcare and mental healthcare are (nearly) free for anyone, not just "junkies". And the other two points are not even related to costs.
> housing first programs are often mixed into ordinary developments too. i bet families living near or adjacent to these units really enjoy living next to completely unstable addicts.
Actually I think it's beneficial if addicts are not lumped together in a stigmatized "housing first development". To maximize chances of rehabilitation and integration in society addicts need to be surrounded by well-functioning people, not other addicts. Otherwise you're just creating a slum where being an addict is normalized, and the problems continue to spread and get worse.
> housing first programs explicitly prioritize the least stable, most mentally ill addicts too.
Of course sufficient resources must exist to help everyone so the prioritization does not mean some people get no access to help they need. In Finland we use a broad definition of homelessness which includes people staying with relatives or friends. Providing housing to those groups helps prevent long-term homelessness. [3, p. 13-14]
> the cost of living in my city is so expensive that there are adults that work full time who have to have roommates to live at subsistence level. there are also housing first programs here that give junkies units for free to continue getting high in indefinitely. this is a ridiculous situation.
I agree the situation is ridiculous. An essential part of the housing first approach (that seems to be entirely neglected in the US) is to build enough affordable homes.
>I'm sure there are extreme cases but the vast majority of homeless are not much different than you and I.
i have seen estimates saying 50% are addicted to substances. in any case housing first prioritizes the most unstable and mentally ill to give immediate housing. this is a very typical feature of the program. if you are finnish, you should check out some videos of what our homeless are like. it's obviously not the same for multiple reasons.
>Actually I think it's beneficial if addicts are not lumped together in a stigmatized "housing first development".
again, to everyone else's detriment.
>An essential part of the housing first approach (that seems to be entirely neglected in the US) is to build enough affordable homes.
this is a funny statement considering wages in finland vs real estate prices. ive been told by a top 5% income finn that buying a house is not really possible for most people there currently. you can only inherit. the wages are lower, the taxes much higher, and real estate more expensive. of course you probably mean the technical "affordable housing" definition which just means housing for anyone making under median area income. the money to fund these things comes from somewhere, and it seems to typically always be the middle class.
> this is a funny statement considering wages in finland vs real estate prices. ive been told by a top 5% income finn that buying a house is not really possible for most people there currently. you can only inherit. the wages are lower, the taxes much higher, and real estate more expensive.
Income is lower but actually taxes are fairly similar in the lower income brackets thanks to progressive taxation (and I'm not too concerned about the top earners starving). Buying a home in Helsinki – which is the only place in Finland where real estate prices are actually a problem – takes about 9 year median income, quite similar to cities in the US. Outside the Helsinki metropolitan area real estate prices are not bad at all. Either way if you're top 5% income you can easily afford to buy a house.
> of course you probably mean the technical "affordable housing" definition which just means housing for anyone making under median area income. the money to fund these things comes from somewhere, and it seems to typically always be the middle class.
Abundance of apartments affects prices for everyone including the middle class. The only ones not benefiting from affordable housing are (literal) rent-seekers, the people and companies owning real estate purely as an investment.
>Outside the Helsinki metropolitan area real estate prices are not bad at all.
outside the area where 30% of the entire country lives? ok. the actual number of years for helinski metropolitan area appears to be 10, and is higher than boston and nyc which are both INCREDIBLY expensive places to live. note that is generously comparing the actual cities to the metrpolitan area of helsinki.
the next largest metropolitan area is tampere, which is 6.9 years at median salary. this is very slightly cheaper than where i live which is also a very expensive city to live in. the city i live in is straight up not affordable to buy a house in at median salary.
>Either way if you're top 5% income you can easily afford to buy a house.
they are able to, but this wasnt the point of what they said. you have to be top 5% to comfortably own. doing some number crunching with chatgpt (lets pretend its accurate) to own at median salary in tampere requires more than 50% of your post tax income. that's with a 20% downpayment on a 300k house.
if i got any of those numbers wrong, feel free to correct. in the interest of time, they were done with chatgpt. i believe the prompts and data asked for should be simple enough to be accurate.
>and I'm not too concerned about the top earners starving
should also be noted that this top earning income is the equivalent of 80k USD. if they lived in the US they would be making double that. in the us, this is near median in a lot of places, and quite attainable in most.
My personal favorites are those games with simple rules and deep strategic depth and I play them regularly online or with other people who love those games in particular. I am also in two general boardgame groups and they both much prefer the complex rule games, I'll give my best guesses as to why.
1) They like the worlds of the complex games, building societies or facing some major broad challenge.
2) Elaborate games are so open-ended and hard to analyze forward strategically that they are much more balanced across people of different skill levels. People who would have no hope of a competitive, fun game of chess will have a more interesting game of Brass: Birmingham or Eclipse.
3) The games can be played with a lot of players and involve a lot more human-human negotiation and discussion, rather than pure strategy.
I love the simple but incredibly complex games myself, but I understand why they're not everyone's cup of tea.
Well, simple games are like simple procedural generation, just like how procedurally generated items all feel the same very soon every game of chess feels the same. To some they don't care about that they just want to play the same puzzle over and over, each chess board state is like another sudoku, to others they just want to consume more content designed by humans and then you need more elaborate rules.
To the ones who want human designed things chess is like this vast procedurally generated forest that just has trees everywhere with different branch layouts, so you have to climb them in different ways.
I say this as a straight non-religious white man who is disgusted by Trump and the fact that people support him.
Making the main character and his brother hispanic is not "the same" as the game, especially when the remaining straight white non-hispanic men in the show are absolutely awful.
Or take the US version of The Office, where the one Christian character is a running joke, an awful person with terrible takes not meant to be taken at all seriously. Can you imagine how it would've gone over if the one black or hispanic character on the show was just a running joke?
70% of Republicans think Trump was the real winner of the 2020 election and that's hardly the only misinformation they have. It's hard to imagine that that wasn't a huge factor in the election.
