Depression’s Upside

On the Threshold of Eternity

Wonderful behavioral science writer Jonah Lehrer (Proust Was a Neuroscientist) writes for the New York Times Magazine on the idea that depression may be adaptive. It is not a new idea; I have followed the intriguing literature about possible evolutionary reasons for the persistence of depression ever since I was a psychiatric resident troubled by how readily we in the field want to obliterate any signs of the condition whenever our patients present with it. Some theories have focused on the advantages of resource preservation, given the social isolation, decreased motivation and lessened self-indulgence the depressed person displays. It has also been suggested that the depressive alteration in cognition, in the direction of impaired self-esteem, decreased sense of efficacy and control over one’s circumstances, and pessimism , may actually be more realistic, at least in some circulstances, than the rose-colored glasses with which we usually walk around.

But recent research adds neuropsychological evidence of increased brain activity in depressed patient in regions of the prefrontal cortex associated with problem-solving, proportional to the degree of depression. It is certainly not the whole explanation, as critics counter, because some of the maladaptive impact of depression, including poor self-care, impairment in childrearing, increased susceptibility to other illness, and last but not least suicide, will outweigh the problem-solving advantages it might confer. Furthermore, there are many different kids of depression both in terms of precipitant and symptomatology. At one extreme, a person may become depressed in response to an acute recent loss (or even a future anticipated one); on the other hand, some people can develop either a dense acute depression or a smouldering chronic one without substantial stresses or losses. The imprecisions in both the lay person’s use of the term depression and its more technical clincal utilization muddy the waters in this regard.

Still, it is worth asking why a condition that is so painful and takes such a heavy toll would persist if it were not at least some of the time of some use… and whether, at least some of the time, we do more harm than good in leaping to treat it. Except, of course, the unequivocal good done to the pockets of the shareholders and executives of the pharmaceutical companies, reaping the profits from the explosive growth in antidepressant sales of the last few decades. (New York Times Magazine)

Revising Book on Disorders of the Mind

List of psychiatric medications

FmH readers know of my preoccupation with psychiatric diagnosis, its follies and abuses, about which I am more likely to rant here than any other topic (other than George W. bush and his administration). Today, the American Psychiatric Association posted on the web the details fo the next proposed revision, version V, to the DSM (the Diagnostic and Statistical Manual), which is the ‘bible’ of accepted psychiatric diagnoses and their criteria. DSM-V is currently scheduled to come out in 2013 after a period of public comment on the revisions and several years of field trials. The release date has already been pushed back because of controversy about the proposals and the revision process, some of which is pointed to in this NYTimes.com piece.Several different things happen in these revisions. First, the universe of existing mental illnesses is reparsed and some of the afflicted end up going into different pigeonholes. By and large, this is a trend I welcome, as the new distinctions made, and the old distinctions collapsed and erased, appear to be generally in line with the clinical experience of frontline practitioners like myself who spend all our time actually treating the mentally ill. Some of my pet peeves, like the overdiagnosis of attention deficit disorder, of childhood bipolar disorder, and of posttraumatic stress disorder, may be improved. As Gregory Bateson defined it, information is a “difference that makes a difference”, and some of the refined distinctions here will of course be more useful to psychiatric research than to practice, but by and large I find them meaningful.

However, the other thing that goes on from revision to revision of the DSM is a proliferation of diagnoses, leading to a relentless expansion of the scope and incidence of mental disorders among the population. This is what has been referred to as the medicalization of ‘normal’ human variability and of personality differences. If a broader net is cast and more people are diagnosable with mental disorders, you can imagine some of the consequences, which include the increasing use of medications for more and more benign variations; changes in social stigmatization; insurance reimbursement for various states of distress; and various diminished responsibility defenses in criminal proceedings. More profoundly, we are rewriting the concepts of personal responsibility and autonomy and the balance between free will and determinism.

I already have far too much work to do to welcome such a broader net, but then again I don’t make a fortune on the basis of how many prescriptions are written. (Estimates are that anywhere from 50-70% of those working on the revisions derive substantial income or research funding from the pharmaceutical industry.)

Tonight, because one of their reporters has been a reader of FmH, I was interviewed by the BBC about my impressions about the DSM-V proposals. It remains to be seen whether I gave them any juicy quotes they can use.

The Americanization of Mental Illness

On the Threshold of Eternity

“For more than a generation now, we in the West have aggressively spread our modern knowledge of mental illness around the world. We have done this in the name of science, believing that our approaches reveal the biological basis of psychic suffering and dispel prescientific myths and harmful stigma. There is now good evidence to suggest that in the process of teaching the rest of the world to think like us, we’ve been exporting our Western “symptom repertoire” as well. That is, we’ve been changing not only the treatments but also the expression of mental illness in other cultures. Indeed, a handful of mental-health disorders — depression, post-traumatic stress disorder and anorexia among them — now appear to be spreading across cultures with the speed of contagious diseases. These symptom clusters are becoming the lingua franca of human suffering, replacing indigenous forms of mental illness.” (New York Times Magazine)

Placebo Response Under Genetic Control

Prozac, a selective serotonin reuptake inhibit...

Monoamine Oxidase A and Catechol-O-Methyltransferase Functional Polymorphisms and the Placebo Response in Major Depressive Disorder: “The placebo response shows pronounced interindividual variability. Placebos are postulated to act through central reward pathways that are modulated by monoamines. Because monoaminergic signaling is under strong genetic control, we hypothesized that common functional polymorphisms modulating monoaminergic tone would be related to degree of improvement during placebo treatment of subjects with major depressive disorder. We examined polymorphisms in genes encoding the catabolic enzymes catechol-O-methyltransferase and monoamine oxidase A. Subjects with monoamine oxidase A G/T polymorphisms (rs6323) coding for the highest activity form of the enzyme (G or G/G) had a significantly lower magnitude of placebo response than those with other genotypes. Subjects with Val158Met catechol-O-methyltransferase polymorphisms coding for a lower-activity form of the enzyme (2 Met alleles) showed a statistical trend toward a lower magnitude of placebo response. These findings support the hypothesis that genetic polymorphisms modulating monoaminergic tone are related to degree of placebo responsiveness in major depressive disorder.” (Journal of Clinical Psychopharmacology)

Some behavioral scientists consider the placebo response to be a nuisance that confounds psychopharmacological research; patients get better even when they do not get the active drug. Some of us, however, feel that the placebo response is a good friend of clinical psychiatry. Some meta-analyses of antidepressant efficacy studies suggest that the medications may not be that effective and that much of the therapeutic response to antidepressants may in fact be ascribable to the placebo response. (The psychiatrist’s role, as a corollary, may be not the art of picking a drug to prescribe but enlisting the individual into a mindset that mobilizes their self-healing capacities.) We already know that depression is related to the reward circuitry in the brain and that genetic susceptibility to depressive disorders relates to polymorphism in the catecholamine system. If the placebo response as well varies with differences in that circuitry, could it be that those patients with lower capacity for the placebo response could also be those patients prone to become depressed int he first place? If we cannot as effectively mobilize their placebo response when they are in the placebo wing of a drug study, perhaps they cannot as effectively bring self-suggestion, affirmation and other coping strategies to bear on the distressing situations in their lives?

Related:

Bipolar disorder and its biomythology: An interview with David Healy

Cover of "Mania: A Short History of Bipol...

Q: Part of what you describe in your new book Mania: A Short History of Bipolar Disorder is a fair amount of “biomythology” about the illness. What aspects in particular do you have in mind?

A: Biomythology links to biobabble, a term I coined in 1999 to correspond to the widely-used expression psychobabble. Biobabble refers to things like the supposed lowering of serotonin levels and the chemical imbalance that are said to lie at the heart of mood disorders, ADHD, and anxiety disorders. This is as mythical as the supposed alterations of libido that Freudian theory says are at the heart of psychodynamic disorders.

While libido and serotonin are real things, the way these terms were once used by psychoanalysts and by psychopharmacologists now—especially in the way they have seeped into popular culture—bears no relationship to any underlying serotonin level or measurable chemical imbalance or disorder of libido. What’s astonishing is how quickly these terms were taken up by popular culture, and how widely, with so many people now routinely referring their serotonin levels being out of whack when they are feeling wrong or unwell.

structure of serotoninStructure of serotonin

In the case of bipolar disorder the biomyths center on ideas of mood stabilization. But there is no evidence that the drugs stabilize moods. In fact, it is not even clear that it makes sense to talk about a mood center in the brain. A further piece of mythology aimed at keeping people on the drugs is that these are supposedly neuroprotective—but there’s no evidence that this is the case and in fact these drugs can lead to brain damage.

via Psychology Today Blogs.

Oh, I wish I had time right now to comment on this at length. Some great points here, but I think he is throwing babies out with bathwater, Read the entire piece. ..

I find, increasingly, that the practice of psychiatry for me is a difficult balancing act of believing in my role while increasingly disbelieving many of the principles by which our approach is ‘explained’ and justified. Biomythology is a great term for it. The emperor has few clothes…

Ethics of Physicians’ Sexual Relationships with Patients

Medicine

A good introduction to the issue; helps you to understand the strict medical ethical guidelines against intimacy with our patients and even former patients, even when the parties are two consenting adults insistent on the consensual nature of their liaison. The ‘transference‘ to the authority of the physician, the AMA says, makes free choice on the part fo the patient difficult. The situation is even more thorny, the violations more egregious, and the condemnation of the profession more emphatic in my discipline, psychiatry, as you might imagine.

Related:

What Doctors (Supposedly) Get Wrong about PTSD

This article in Scientific American by David Dobbs reports on the growing concern that “the concept of post-traumatic stress disorder is itself disordered”. The writer is critical of a culture which “seemed reflexively to view bad memories, nightmares and any other sign of distress as an indicator of PTSD.” To critics like this, the overwhelming incidence of PTSD diagnoses in returning Iraqi veterans is not a reflection of the brutal meaningless horror to which many of the combatants were exposed but of a sissy culture that can no longer suck it up. As usual, the veil of ‘objective’ ‘scientific’ evidence is used to cloak ideological biases.

FmH readers know that I too am critical of the frequency of PTSD diagnosis in modern mental health practice, but I think that is not a problem with the theoretical construct of PTSD but its slapdash application. With respect to domestic PTSD, the problem is one of overzealous and naive clinicians ignoring the diagnostic criteria and, more important, misunderstanding the clinical significance and intent of the diagnosis, labelling with PTSD far too many people who have ever had anything more than a little upsetting or distressing happen to them. Essentially, PTSD is meant to refer to the longterm consequences of either an experience or experiences that are outside the bounds of what the human psyche can endure. Both emotionally and neurobiologically, the capacity of the organism is overwhelmed and the fact of the trauma assumes an overarching and inescapable central role in future information processing, functioning and sense of self. Experience that occurs when the body is flooded with unimaginably high levels of stress hormones, when the nervous system is in the throes of the fight-or-flight response, and when the normal processes for making sense of what we are going through utterly break down are encoded differently in the body and mind, with immeasurable effects. Only someone who did not grasp this at all could misrecognize simple anxiety, depression or adjustment difficulties as PTSD. But it happens all the time, especially in the treatment of depressed women, largely because of do-gooder clinicians’ desires to be politically correct and not be seen as insensitive to their clients’ suffering. Unfortunately, what it mostly does is train these clients to remain lifelong inhabitants of a self-fulfilling inescapable victim role.

The concern, on the other hand, with soldiers returning from the wars in central Asia, is the opposite. All evidence is that PTSD is being underdiagnosed, because of systematic biases within the government and the military to deny the scope of the problem. Articles such as this, and the research that it depicts, should be seen as nothing but a conservative backlash, an effort to blame the victims. If coping with the scope of PTSD is a problem, deny the reality of PTSD. Certainly considerable research suggests that a proportion of soldiers returning from the battle front in bad shape will have shown their resilience, will no longer show a high magnitude of emotional disturbance, and will not warrant a diagnosis of PTSD if reassessed months or years later. Research also suggests that early intervention using a trauma paradigm may do more harm than good, perpetuating the vulnerability of the patient. And most Defense Dept. research on the effects of combat trauma is intended to figure out how to block the stress reaction so that a soldier can remain functional and return to a combat role as soon as possible. But it remains the case that the human nervous system did not evolve to endure the horrors of modern war, and that the indefensibility and anomie of this war in particular, based as it has been entirely on lies, amplifies the intolerability and makes it far less likely that a veteran can find sustaining meaning in the suffering they endured. This will inevitably turn into higher rates of PTSD than among veterans of other wars.

To deny the scale of PTSD in our returning veterans is to be an unquestioning apologist for the untrammelled American imperialist projection of power in lawless aggression. As Dobbs describes it, the PTSD deniers construe us as having a cultural obsession with PTSD which embodies “a prolonged failure to contextualize and accept our own collective aggression.” What horse manure. Our cultural neurosis, rather, lies in the unquestioning acceptance of suggestions like Dobbs’ that we should mindlessly embrace such aggression as natural. This was the neurosis that made it possible to elect Bush and his handlers to enact an administration that set about violating every supposed principle of our democracy and our humanity. I know we are not supposed to draw this particular analogy, but this brand of PTSD denial strikes me as akin to nothing as much as Holocaust denial. Via Scientific American.