Plus Ca Change?

“On the surface, recent votes in Congress appear to signal a new Democratic determination to withdraw from Iraq. But the reality is otherwise. It is not only that the resolutions were drafted and adopted with the certain knowledge that they would be vetoed. More important, even if a future Democratic president did try to implement the new plans, the results would likely end up looking oddly similar to the Bush administration’s current strategy. In politics as in war, things are seldom what they seem.” — Noah Feldman (New York Times Magazine)

Depression or Just a Little Emotional Blow?

Many Diagnoses of Depression May Be Misguided, Study Says: “About one in four people who appear to be depressed are in fact struggling with the normal mental fallout from a recent emotional blow, like a ruptured marriage, the loss of a job or the collapse of an investment, a new study suggests. To avoid unnecessary diagnoses and stigma, the standard definition of depression should be redrawn to specifically exclude such cases, the authors argue.

The study, appearing today in The Archives of General Psychiatry, is based on survey data from more than 8,000 Americans; it did not analyze the number of people who had been misdiagnosed.

Psychiatrists and other doctors who take careful medical histories do so precisely to rule out such life blows, as well as the effects of physical illnesses, before making a diagnosis of depression.

But the American Psychiatric Association’s diagnostic manual does not specifically exclude people experiencing deep but normal feelings of sadness, unless they are bereaved by the death of a loved one. And an increasing number of school districts and health clinics use simple depression checklists, which do not take context into account, the authors said.” (New York Times )

The study compared 157 bereaved individuals and 710 who met the criteria for major depressive disorder whose episode had been triggered by another loss. Grief specifically precludes a diagnosis of major depression, but the investigators showed that those diagnosed with depression after other losses did not differ significantly from the bereavement group on a well-chosen spectrum of indicators of the severity and impact of their symptoms. They concluded that the data “do not support the validity of uniquely excluding uncomplicated bereavement but not uncomplicated reactions to other losses” from the diagnosis of major depressive disorder.

The researchers are a social worker, two sociologists and one psychiatrist — interestingly, a psychiatric epistemologist who participated in the formulation of the latest version of the Diagnostic and Statistical Manual (DSM-4), the official ‘bible’ of acceptable psychiatric diagnoses and their defining criteria. This should be a clue that the study should be interpreted in light of the perennial conflict within mental health care between the medical and social models; it is a shot across the bow aimed at biological psychiatry. When psychoanalysts dominated in shaping the psychiatric paradigms of diagnosis and treatment in the era before modern psychopharmacology, a crucial distinction was made between “endogenous” and “reactive” depression. One still hears vestiges of that outlook when healthcare personnel observe, “Wouldn’t you be depressed too if you had gone through what he/she did?”

With the ascendency of biological models and medication-based treatment, roughly since the ’60’s, however, the distinction was largely thrown out (with the exception of the exclusion for acute grief), and a generation of psychiatrists were trained to see it as quaint and archaic. The focus in diagnosing and treating has come more and more to be on the description, the symptoms, of an episode of emotional distress (such as can be captured in the symptom checklists the article mentions) to the exclusion of the meaning of that distress to the individual and its contextualization in an individual life. With the development of medications that can treat depressive symptoms, what has been lost has been the question of whether they should be treated in all instances. Recent dogma emphasizing that depressive episodes not be seen as self-contained but as manifestations of a lifelong relapsing condition mitigates for preventive treatment through indefinite antidepressant maintenance. Relapses are explained with disdain as the result of inadequately insightful patients failing to comply with that paradigm. I will leave it to my readers to draw their own conclusions as to whether this deserves to be seen as an aspect of the medicalization of everyday life driven by market pressures and the selling of healthcare down the river by the unholy alliance of Big Pharma and its handmaiden physicians.

On the other hand, I quibble with the implication of the article that this finding points to wholesale “misdiagnosis” of depression where it is unwarranted. That would be too simple, and I doubt it is what the authors intended. What is at stake is not just tidying up diagnostic criteria or diagnostic practices. There is no “true” definition of what depression is to aim for; it is a social construction that reflects dominant values and assumptions. We are in the midst of a full-fledged clash of conflicting paradigms, with a study such as this at its nidus. As Kuhn suggested in The Structure of Scientific Revolutions , evidence inconsistent with the dominant paradigm is explained away or ignored until a sufficient accumulation occurs.

What are the dangers of ignoring these challenges to the dominant conception of depression, markedly broadened from that of a generation ago and ignoring context almost entirely? One of our real social ills may be not the prevalence of depression but of the narcissistic expectation that we are entitled to have any depressive distress eradicated, and the parallel assumption that it is the fault of a ‘chemical imbalance’ rather than the way we make sense of the world, process our feelings or treat one another. What is at stake is something very basic about the parameters of the social construction of the self in modern society. There may be biological consequences as well. I have been troubled by the possibility — which I cannot get many of my colleagues to take seriously — that having too low a threshold for beginning or maintaining our patients on antidepressants may actually perpetuate or worsen depressive dysfunction of the brain. Although antidepressants are not, in a rigid sense, addictive, their use may cause a self-perpetuating necessity to continue to use them. I hope to have more to say about that in the future as I clarify and extend my thinking about this issue.