Depression pharmacotherapy: lessons from/about research
Bryn Mawr College, Spring 2010
Depression pharmacotherapy: lessons from/about research
Recent news reports have highlighted conflicts in the clinical literature on the efficacy of existing pharmacological agents for the treatment of depression. We will look into these and reactions to them with the objective of assessing their significance not only for current clinical practice but also for thinking about needed directions of future research into the nature and treatment of depression.
- Popular drugs may help only severe depression, NYTimes, 5 Jan 2010.
- The wrong story about depression NYTimes, 8 Jan 2010. (letters to the editor)
- Before you quit antidepressants ... NYTimes, 11 Jan 2010. (readers comments)
- Just over half of Americans diagnosed with major depression receive care ... NIMH, 4 Jan 2010
Some relevant thoughts from last week:
I found myself oddly comfortable with the idea that objectivity does not exist and the closest approximation to it is the shared subjectivity of a community or culture ... Science needs subjectivity, it thrives on disagreements. Without subjectivity, there would be nothing left to "discover" or test out ... meroberts
Sometimes a person is just plain wrong and their being wrong is not helpful even indirectly! ... Bobby Danforth
if I was to tell my grandma that reality does not exist and there is no real way to determine “what is out there” since everything is constructed by our brain, she would probably cry! If anything, training in neuroscience should ease the transition into accepting the concept of shared subjectivity. As reflected in the forum postings and discussion, it isn’t an easy thing to just accept and move on from. The most significant way that I think we were affected by this discussion was in its question of practical implications and usefulness both for us as scientists and as human begins ... but like Sasha said, when it comes right down to it, does it really matter that we cannot objectively see and objectively interpret our world? And like Sara said, how do we negotiate our role as scientists? ... EB Ver Hoeve
I am currently reading Pedagogy of the Oppressed by Paolo Friere, a pedagogical theorist who emphasized the importance of social justice in education. Freire ... writes, “One cannot conceive of objectivity without subjectivity. Neither can exist without the other, nor can they be dichotomized… Subjectivity and objectivity [are] in constant a dialectical relationship.” He goes on to say that denying subjectivity leads to objectivism, which is ingenuous because it presupposes there is no “internal reality” that differs from what is perceived as “external reality.” However, Freire also warns against ignoring objectivity completely as that could potentially lead to a solipsistic existence and thereby inhibit action (particularly the liberation of oppressed peoples) ... kenglander
The discussion from last class, debunks the infallibility of science as an absolute but provides a gateway into many new avenues thought. It is exciting to me how we are trapped behind ourselves and only become further trapped into who we are when we try to free ourselves from it. Science, when viewed as a collective conscious construct no longer clashes with its objective heir. As a collective consciousness, science becomes an abstract but unifying force to push and discover the awesomeness of the limits of our own experiences ... mrobbins
practical implications of this new conception of what is truly "out there." ... I can think of at least three. The first concerns the nobility of the pursuit of science. It sometimes feels like scientists often believe that their studies bring them closer to some profound truth, that there exists some point at which "everything" can be objectively known ... But if the conception of objectivity developed today is correct, then this is a useless hope: for every new construct we discover, there will be another construct we will have to develop to explain that one ... From this follows a second implication regarding *what* we research ... why have we fallen into the reductionist perspective of truth, where the "most true" description of a thing involves elucidating its smallest components? What is the ultimate aim of researching the miniscule details, other than to make life more fun or for giggles, both of which are strongly subjective aims ... ? Finally, as Sara Berman's provocative example of epilepsy illustrated, doesn't a subjective notion of objectivity alter the way we regard radically different forms of science ... David F
My immediate reaction to the in-class discussion ... was to think ... about the subjectivity of the standards applied to behavior, and in the definition of abnormal behavior. The entire field of mental health revolves around the notion that there are certain standards of normal behavior and that behavior that falls outside of the boundaries of these standards is abnormal, and ... may require treatment to achieve a more normal behavioral pattern ... Jeremy
Within our community, while we can learn about how other cultures respond to what we view as mental illnesses, we will (and I believe should) respond to them according to our constructs ... VGopinath
a culture's own subjectivity gets in the way of validating, or legitimizing, a different perspective held by another culture ... meroberts
This discussion has led me to the personal conclusions that even if I view something as completely objective, I must consider other viewpoints, because nothing is absolutely objective. I also feel, however, that without a constructed reality in which we have at least partially/mostly agreed upon objectivities, it would be difficult for society as a whole to function ... sberman
How "objective" is research on pharmacotherapy for depression? What are the underlying subjectivities about clinical objectives/possibilities? About depression?
Some relevant Serendip links:
Discussion summary (Paul)
The evening began with some further exploration of "filling" of the blindspot, following up on last week's interest in what the brain would do with a field of randomly colored dots. Sasha's test pattern is here as a .doc file. Most people reported a blue dot, with some reporting grey or blue/grey alternately. An interesting question, requiring further exploration, is whether the brain is using a neighboring color or creating a default color.
The discussion turned next to continued conversation about the implications for science of perception as "construction," based on forum comments following our previous meeting (and excerpted above). Among the points made was that "normal" might need to be understood as "community consensus" ("shared subjectivity"), perhaps making phenomena like ADHD things that would be "abnormal" in some cultures but normal in others. There were also extended discussions of whether some things are "wrong" in any absolute sense, including a suggestion that there might be an important distinction between usefully wrong and "uselessly" wrong, and of whether what was "less wrong" was necessarily also "more right" (or more "true").
Reactions to the background readings focused initially on the need for scientists to be more careful in conveying findings to journalists, of the practices of psychiatrists versus those of primary care physicians, and of the exigencies of care giving in practice. There was a strong sense of a health care system in disarray, and an associated feeling that the background readings were more a critique of the health care system than of pharmacotherapeutic agents themselves. At the same time, it was noted that the literature suggests there is in fact a quite wide variability in response to pharmacotherapeutic agents in the case of depression and, in parallel, very poor understanding of their mode of action.
The wide variability and poor understanding in turn led to extended discussion of similarities and differences between "physical health" and "mental health," about whether the latter is more "subjective" than the former, and about how this related to the social/cultural/"scientific" stigma associated with mental health issues. One possibility is that the problem will be solved as more and more phyiscal correlates are found for mental health problems. An alternate possibility is that many mental health issues will prove to have highly individualized etiologies and physical expressions and require highly individualized treatments (as is proving to some extent to be true for cancer?). There may also need to be a rethinking of whether mental health conditions such as depression are best understood as "illnesses" as opposed to "adaptive responses" (like nausea?).
Continuing conversation in forum below