Depression pharmacotherapy: lessons from/about research

Neural and Behavioral Sciences Senior Seminar

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. 

Background readings:

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

AttachmentSize
Sashablindspot.doc129.5 KB

Comments

dshanin's picture

Mental healthcare vs. all other medical issues

 

Sorry for the delayed response…I promise in the future I will be timelier. Part of the reason I did not post was that I returned home for two days in the middle of the week to see my doctor. I was there for a physical needed to enter medical school and it was the most intense examination I have ever received. A large part of it involved blood tests checking for immunity to all the diseases I have been vaccinated against since I was a toddler. Like everybody else I always assumed that once I got the shot there was nothing to worry about…measles, mumps, hep B, all taken care of. The idea that the vaccinations’ efficacies were so variable that testing was required was a serious shock. A great deal of our conversation focused on contrasted the mental healthcare system with normal healthcare. I was a strong proponent that the mental system was “50 years behind” the rest of the medical profession but I’m not sure that is really true. Instead I have come to believe that physical healthcare possesses the same degree of uncertainty and variability of mental healthcare but simply packages it in a way that hides it from the average patient. 

 

We indicted mental health for failing to provide patients with the full “menu” of treatment options and accused providers for suggesting what they know and specialize in rather than utilizing a holistic model of care that best utilizes each method for a particular patient. The same thing is really true of regular healthcare once we move beyond the most high-end of facilities. Certainly large, prestigious teaching hospitals and places such as the Mayo and Cleveland clinics utilize a multi-disciplinary team approach to care. However imagine the average person with chest pain right here in Haverford Township. Delaware County Hospital and Bryn Mawr Hospital are both the same distance away. Both are big ugly buildings with a red “emergency” sign out front. However Bryn Mawr has an advanced cardiac catheterization lab while Delaware County has no such thing. Thus a heart attack at Delaware County cannot be treated the same way and the patient faces a long wait to be transferred to another facility. 

 

Physical healthcare posses the same lack of standardization, however they have been able to dodge the blame. A heart attack has such a negative connotation that when somebody dies from one it is not a matter of whether they received a timely angioplasty but rather a serious ailment with an unfortunate outcome. The treatment (except in cases of malpractice) avoids the blame. In mental health, the conditions don’t come with a societal allowance for severity, you are depressed, nothing less than full recovery is acceptable. The crucial difference is that we can say somebody has a “failing heart” without being seen as attacking their character but the same certainly doesn’t work for a “failing brain”. Mental health conditions are so irrevocably linked to who we are that when treatment fails it must be the fault of the treatment and not the strength of the disorder. We cannot separate our brain from our “self” as we do any other diseased organ. I am not suggesting that mental healthcare is a perfectly (or even adequately) hard science based, just that physical healthcare only appears better in a topical sense.        

mrobbins's picture

who's to judge?

I believe that mental illnesses are stigmatized diseases that are confined to the evolving limits of technology. I completely agree with the idea that once technology advances to find the physical correlates of different types of mental illness, this stigma will dissolve and will find a new mysterious illness to burden. People are simply afraid of what they cannot understand. Science is on the brink of psychiatric comprehension but until society can pinpoint the exact underlying mechanisms, to many, mental illness will remain an illusion skewed by ungraspable perspective. This skewed perspective may be a product of societal standards, dictating that mania is bad, or by the individual artist who thrives on his inexplicable gifts of energetic inspiration. Where the collective we sees unhealthiness, the artist feels creativity. In this sense, mental illness is handicapped because in some cases, a mental illness’ entire existence depends on how you look at it.

Depression is usually seen as more one-sided. Those who feel it generally do not like it and those who witness it understand that something may be wrong or off, whether or not they agree that it is a mental illness or not. Depression is a disorder in which, the person feels sad, worthless, or pessimistic for a certain length of time. Depression is something that should be cured then, right? These people are not living healthy and normal lives, right? However, what if we're not right? Depressive realism is the proposal that people with depression actually see the world more accurately. Depressed people are less affected by positive illusions than are so-called “mentally healthy” individuals. Several studies suggest that moderately depressed people seem to have a more realistic grasp of their importance and relative abilities. Non-depressed people use illusory defense mechanisms, perhaps adaptively, to see the world in a more positive light. Depressed individuals are more likely to rationally gauge their control in certain types of situations.  Voltaire’s Candide sums it up perfectly, “Optimism is the madness of insisting that all is well when we are miserable." So, whom do we treat now?

EB Ver Hoeve's picture

It's Complicated.

 

Depression is complicated. More complicated than any of us are currently able to understand. As discussed in class and reiterated by Sara, mental illness, in general, lacks a cause and effect trajectory. It is impossible to pinpoint one definite cause. Even the term, “cause”, seems unfit when describing a condition such as depression. I mentioned in class that one of the ways I attempt to understand the biological basis for depression (and the action of antidepressants) is through thinking about receptors and the implications of the involved neurotransmitters. But this reductionist viewpoint will only get us so far. I guess I would have to disagree with VPina when he said that depression seems easier to understand when “broken down to its core”. Yes, understanding the biological “core” would be extremely useful, but it will not explain the full story. It will not fully explain the variability that exists nor will it offer simple solution answers such as, “be more healthy”.  

 

With that, I would like to say that I too was very moved by David’s question of how people with mental illness perceive their own condition. Again, I am sure that the answer to this question is variable. I mean, if every brain is different, than how could people’s self-perceptions NOT be variable? But at least for depression, I don’t think it is just a question of how a person perceives that he/she is out of sync with the rest of society but it is also becomes a question of how that person comes to terms with that fact that it may be a problem. Like Bkim noted, mental illness does seem to be more mysterious than other traditional physical illnesses.   And so quickly the “mysterious” becomes translated into the dangerous, the unknown, and the unexplainable. This becomes problematic when one is trying to come to terms with depression. No one wants to be thought of as weak. From my own experiences, people suffering from depression prefer to understand, at least initially, their own condition as a chemical imbalance rather than a socially induced adaptation or something that they COULD have controlled for. It may be easier to see depression from a reductionist’s viewpoint, but that does not seem sufficient for the full understanding of depression.      

 

 

 

 

 

 

EB Ver Hoeve's picture

Ok, I definitely did the

Ok, I definitely did the special Word Copy and Paste thing and it clearly did not work. Apologies...

Bo-Rin Kim's picture

stigma of mental illness

I think we really addressed an important issue during class when we talked about the differences between mental and physical illness—because our society clearly does not see them as being the same or equal (although the recent insurance policy change that made coverage equal for both is a very big step forward). I definitely do think that there is a stigma that exists against mental illness that does not exist for physical illness. This stigma exists in America, but I know there are other societies where it is worse. At least in America counselors and clinical psychologists are fairly accessible and are visited by clients regularly. In more collectivistic and conservative countries like Korea, people Koreans tend to keep any mental illness within the family and are very secretive about it. It is almost shameful to disclose that you are suffering from a mental illness.

I think a large part of this stigma arises from the fact that some view mental illness as a weakness or something that can be fixed by one’s own will. Contributing to this view is that fact that mental illness treatment involves things like verbal counseling and changes in lifestyle (which may appear simple but can be extremely difficult for the client). Psychologists do not perform surgery or run physical tests, and I think this lack of objective, structured treatment is what causes mental illness to be viewed as something that does not need treatment and can be treated with one’s willpower. Moreover, mental illnesses tend to be specific to the person—with no two cases being exactly the same. Thus, this high variability may also contribute to the argument that mental illness is a personal issue that has to be dealt with by the person and his/her family. Mental illness in this sense (in treatment and diagnosis) is not as straightforward as and more mysterious than physical illness. I feel like there is a fear of the unknown, in addition to the more subjective nature of mental conditions, that causes people to dismiss mental illness as not being as legitimate/valid (for the lack of a better word) as physical illness…
 

Jeremy Posner's picture

Issues of Diagnosis and Treatment

             Many of the conditions and disorders described by the DSM IV are defined by subjective symptoms, and Mood Disorders, including Major Depressive Disorder, are certainly among these.  Mood Disorders are, at the same time, among the most commonly diagnosed and treated conditions in the United States.  Among the criteria evaluated for a diagnosis of depression are depressed mood for most of the day, markedly diminished interest or pleasure in activities, particularly in normally enjoyable activities and feelings of worthlessness.  Not only are all of these criteria subjective to a certain extent, but all are also relative.  No two people are the same and if there is such a thing as a normal mental and emotional state for an individual it is certainly unique to that individual.  Individuals are also certainly not emotionally constant; everyone has ups and downs emotionally, and circumstance can potentially make what might ordinarily be abnormal behavior or thought into a very reasonable in other circumstances. 

The example that I’ve always been given is that the symptoms of agoraphobia may manifest in people living in a war zone, but because those individuals are legitimately afraid to leave their homes, and it is reasonable to say that those people are not disordered.  A similar issue that often arises when discussing mood disorders and MDD in particular is grieving and the distinction between normal sadness in response to a serious loss and depression.  The DSM does attempt to take into account normal grieving in its criteria for the diagnosis of MDD, precluding anyone from receiving a MDD diagnosis within three months of a major traumatic event, which is probably better than not including any provision, but still problematic because there isn’t necessarily a compelling reason why a proper period of mourning should end after three months, or have any set period.  Criteria for depression can also be adjusted based upon the age of the patient.  Depression in young children, particularly young boys, is often characterized by irritation and anger rather than sadness; and arguments have been made that ADHD is underdiagnosed in young girls because they tend to be inattentive without being hyperactive.  Disorders can include very different and sometimes almost opposite or contradictory symptoms that it is easy to wonder whether the distinctions made between disorders or the symptoms swept up into a disorder are based upon any real sameness of the source of those symptoms.  Of course this becomes a very significant question when dealing with treatment; if you proceed with the assumption that ADHD and Depression should be treated with the appropriate medications it becomes very hard to know how to proceed when faced with a patient with the symptoms of any number of disorders.  Is an angry disruptive boy depressed, hyperactive, does he have a conduct disorder?  Combine that with the inconsistent effectiveness of different medications and often treatment succeeds via trial and error when it does. 

 

David F's picture

Can we push it a little further?

I am glad to see that people find the issue of "can someone have a mental illness and not know it" as intriguing as I do. I think both Sasha and Vidya made some great comparisons in their interpretation of the question that shed light upon how we should look at it. For example, maybe having a mental illness is like having a tumor, or having scar tissue, and just not knowing it. I think these are very intuitive comparisons, but I can't help but wonder if we're leaving something very important out.

Vidya said,"Many mental illnesses have symptoms like mania which the patient would not recognize as mental illness.  Thus we are forced to tell a happy person that there is something wrong with him and perhaps to even push treatment on an unwilling person." Here, I do not interpret Vidya as meaning "wrong" in the strict, objective sense, but rather, at least, referring to our obligation to inform the patient that their symptoms fit criteria that we have of DSM illnesses. I think that is entirely fair; even if we are not entirely correct in what constitutes an "illness," we should let patients know our current medical opinion, in the same way we would inform someone about a tumor or scar tissue. But "push treatment on an unwilling person" is the point I want to consider. Does this truly follow from the prior statement (that we have an obligation to inform patients of the current medical paradigm)? I think there are a lot of implicit assumptions here, and ones that we no doubt make in the current medical world (just go to any involuntary psychiatric ward). But I wonder if these are the correct assumptions. If you discover a tumor or scar tissue in me, by all means, take them the hell out. But if you're telling me that, despite my harmlessness, my vivid reality is incorrect, that my feelings of euphoria are wrong, that my habits are abnormal, and that I have to take pills that will leave me feeling numb and apathetic, then I might say screw you. I'm not saying I entirely disagree with Sasha or Vidya, but I wonder if we can explore this a bit further before drawing such close comparisons to other physical but unknown illnesses: these importantly differ in how we *as patients* desire ourselves.

Sasha's picture

Can you have an illness and not even know it? Yes.

I found David's question about illness- whether or not someone can be ill and not know it- interesting and initially I was conflicted. I kind of liked the definition of "functionality" as a way to determine if someone is ill or not. However, upon further reflection I think that "functionality" is perhaps only really a measure for the severity of an illness and not really a diagnostic tool for determining illness.
With that in mind, I believe that it is possible to have an illness and not even know it. People have high blood pressure and don't know it unless they get it checked or it's too late and have a heart attack... my father had a heart attack and didn't even know it until he went to the doctor for a check up and they told him he had a significant amount of scar tissue on his heart and severe heart disease.
Individuals live with depression and anxiety and just accept it as a way of life- throwing up before tests because of nervousness or crying for no particular reason and not being able to sleep at night is just the way people think they are wired, when in fact they could have serious depression or generalized anxiety disorder and could get treated for it. Untreated depression has the potential to ruin peoples lives and lead people to suicide. Nausea doesn't do that.
It is important to acknowledge that mental disorders such as depression and anxiety are illnesses so that people who are affected by them realize they don't have to live with the pain. There are treatments available and upon recognizing that they have an illness perhaps people will be more likely to seek those treatments to improve their quality of life.
 

LMcCormick's picture

Depression & ADHD

Normal
0
0
1
358
2041
17
4
2506
11.1280

0

0
0

I am inclined to support the claim that depression is simply a disease that we do not yet fully grasp the underlying physical correlates of.  It is exceedingly difficult to study mental illness due to many practical and ethical limitations.  For example, researchers cannot induce depression in human subjects for obvious ethical reasons, but using a mouse model for mental illness is inherently flawed as well (even if a researcher finds differing serotonin levels in the brain, who’s to say the mouse was really depressed in the first place?).  If we find a way to study mental illness in a more controlled environment, I believe that the underlying mechanisms will become analogous to any other physical disorder.
 
            There was also a lot of discussion about the “events” that cause depression as opposed to the events that lead to other physical maladies.  However, I would argue that this process is really isn’t that different for physical and mental illness.  Cancer and depression are both mainly caused by as series of environmental factors as well as genetics.  Cancer’s environmental factors include carcinogens (such as UV, cigarettes, etc.), while depression may be induced by traumatic life events.  It really just depends on how far you want to stretch the term “environmental factor”.  Even genetic translocations common in cancer are induced by the cellular environment (enzymes present, etc.).  If our neurons are affected by our experiences in the world, then how are difficult life events really that different than environmental factors that impact our cells, leading to cancer?
                       
            I took an education psychology course last semester, and we discussed the possibility that our society creates people with culturally induced ADHD (as opposed to genetically induced).  For example, we do not impose stringent limitations, and the Internet provides people with instant gratification, possibly reducing the need to focus on tasks for long periods of time.  If ADHD has become integrated into our culture, then is it really fair to call it a disease?  Or perhaps it is still a disease, and we have simply produced a society that provides the “perfect” environmental stimuli to induce this illness?
           
            However, I have to ask, why does it really matter if we call depression (or ADHD) an illness or not?  We all know that it exists, it is an undesirable state, and people are going to be treated for it (with drugs, therapy, etc.) regardless of what we call it.

 

rdanfort's picture

I love to post!

 I have to say, if there's one thing that makes me want to tear my hair out, it's "argumentum ad back-when-we-were-all-cave-men".  Dan was, of course, speaking to a conceptual point and invoked his ADHD example as a hypothetical, but it is as good a place as any to bring attention to what I see as a Ganges of garbage science flowing turbidly out of evo psych journals the world over.  Name a regressive gender norm or exploitative social order, and it is nearly guaranteed that an evo psych paper is out there claiming that the behavior is in our genes because female cave-men needed to spot the best berries.  That's why women love shopping!!

Ugh.  This returns us to the earlier discussion of science journalism.  With the exception of that particular vein of evolutionary psychology, which comes to the journalists pre-ruined, there is some really cringe-inducing reporting out there.  Ben Goldacre’s bad-science.net has some great examples, and I think that I can comment on factors which contribute to science reporting being so bad.

 In class, blame for the misunderstanding of depression research was laid tentatively at the feet of the researchers.  While it is true that scientists should take care to make their findings relatable, I’m not sure if any person can be expected to pre-empt the myriad ways in which a news article can go wrong.  As was mentioned, science reporters are under a lot of pressure to report in a way that will interest their readers.  The vast majority of research cannot accurately be framed in that way.  Statistical significance, correlation and causation, and evidentiary standards are lost not only on most journalists, but on the reading population as well. 

Contentious issues, from evolution to treatment of mental illness, pose a particular problem in the modern journalistic climate.  Not only is research on these issues more likely to be reported on, it is likely to be reported on in such a way as to maintain the media’s particular understanding of “objectivity”.  That is, we report live today with this fellow’s published research, which you can (snort, chuckle) read in detail if you have journal access and a half hour, and his opponent, a man we found wandering the streets in Duluth.  We leave it to the reader to decide who is most credible.  This problem is not restricted to scientific development, but I think that it is most frustrating here because the gap in credibility is so severe and the “controversial” issue is often something the scientific establishment accepted decades ago. 

When it comes to depression research, there is legitimate scientific controversy and less ideological noise than there is concerning, say, evolution.  Still, I think that people do have a reaction to it because of our perception of mental illness.  Mental illness conflicts with our worship of self-determination and individualism, because our use of those concepts is highly dualistic.  At the same time, however, we have a (largely justified) faith in medical intervention.  I think that these ideas create pressure to read great significance into any emerging research on the subject.

There is something else that offends me about this discussion.  Is it really fair to give credibility to subjective and cultural framing of illness one minute, and to push a yes-or-no decision on whether depression constitutes illness the next?  This is, perhaps, a limitation of the Socratic method as a pedagogical tool and a call for more direct lecture.  It is no fun to guess at an instructor’s agenda and leaves me in the position I mentioned last week, where I cannot feel comfortable attacking positions that I am not sure have actually been taken.

Paul Grobstein's picture

education as conversation

My agenda is no more and no less than to faciliate the kind of exchange that helps people come to new understandings, individual and collective.  For more along these lines, see Evolution of science education as story telling and story revising, and On beyond a critical stance

Claire Ceriani's picture

Depression as an Illness

I can't really see depression as anything other than a physical illness.  Some of its symptoms are of the mind in the sense that a person experiences emotional and cognitive changes, but I believe that such changes are still the result of physical changes in the brain.  These changes are like changes to any other organ, except that they're capable of affecting someone on a level that we don't generally think of as "physical."  Using the term "depression" as if it were one illness, however, may not be accurate.  Depression may have a number of different causes, meaning that two people with depression may not necessarily respond to the same treatment.  I like the idea of depression being a symptom.  I think of it in the way we think of colds.  Because a virus is capable of rapid genetic change, the disease we call "the common cold" is really caused by many different, but related, types of rhinovirus or coronavirus.  The term "cold" really just refers to the collection of symptoms they all cause.  I'm sure just about everyone knows this, but we still use "cold" to mean the illness.  I think depression may work the same way.  As far as the sufferer is concerned, depression is truly a disease, but from a treatment point of view, it needs to be viewed as a symptom that may have many possible causes.  This has obviously made research extremely difficult; our understanding of the physical basis of depression is still developing, and pinpointing the cause in a specific person may not be easy.  As we discussed in class, the meta-analysis we read about barely scratched the surface of depression treatments.  The generalization made in the story that treatments are largely ineffective for many people is unfounded when depression is considered as class of many possible illnesses that manifest with similar symptoms.

kenglander's picture

depression as a symptom

I think the idea of depression as a symptom is very interesting, but I am not sure that I am willing to accept it just yet.

Symptoms usually describe a specific bodily phenomenon that indicate a larger problem (disease, illness, etc.). As it is currently used, the clinical defintion of depression encompasses too many other conditions and states of being to be a symptom. (Unless there can be symptoms of symptoms?) Specifically, the DSM requires that patients meet a number of criteria simultaneously for an extended period of time (depressed mood, loss of interest, fatigue, recurrent thoughts of death, insomnia or hypersomnia, etc.) in order for the patient to be diagnosed as depressive. This is not to say that the DSM is the definitive source on depression, but  to argue that we would have to define depression using more exclusive terms if we wanted to call it a symptom. While depression might be a symptom of a larger (unnamed?) disease, the term "depression" is too vague to be labeled as a symptom.

Despite my opposition to depression being labeled as a symptom, I think it is worthwhile to consider depression as a more generic term for a class of illnesses that may arise from a number of causes. By doing so we do not constrict ourselves to identifying two individuals as having the same illness when their symptoms may manifest themeselves in very different patterns and may require different treatments.  To make this argument, however, implies that physicians should consider cases of depression as sharing certain potentially linked conditions. Is this useful and (just as importantly) relevant? 

rdanfort's picture

Upon reflection, I do not

Upon reflection, I do not think that the apparent consensus regarding depression as a "reaction" or a "symptom" rather than an illness is one that i can accept.  I am having trouble with discussions driven by metaphor and references to theory.  While I am not uninterested in philosophical discussions, they alone are not sufficient to prompt a radical shift in clinical thinking.  It is ironic to attempt to do so in the context of Grobstein's (insightful) implication that we should not really view mental illness differently than other forms of illness.  Worse still, I think that the character of these philosophical discussions has completely muddied the epistemological waters.  Either we can use words in a fashion to clearly convey meaning, say, as the medical establishment and our society have come to use "illness", or words are ephemeral floating things as per previous talks*.  If they are to be both at once, we should at least separate our discussion to avoid this confusion.

Perhaps there is a body of data supporting Professor Grobstein's theory.  I cannot understate my interest in seeing it!  Without stronger empirical backing, however, I feel manipulated.

*this is not to deny obvious controversy regarding the use of a number of words and concepts. Please accept the simplification.

Paul Grobstein's picture

depression, mental health, and "shared subjectivities"

Thanks all for interesting conversation, both Monday night and here.  What particularly struck me is how hard it is to get one's head fully enough around the notion of "objectivity" as "shared subjectivity" to apply it effectively in concrete situations.  We look for explanations of depression and mental health conditions in terms of receptors and neurotransmitters because we want "objectivity" (ie "shared subjectivity"), but perhaps a lack of "shared subjectivity" is itself of the essence of many mental health conditions?   We want an "objective" (ie "shared subjectivity") criterion of mental health ("normalcy," "harmfulness" to others/self) when perhaps some degree of absence of "shared subjectivity" is essential for "mental health"? Interesting food for thought.  Perhaps "shared subjectivity" is useful in some contexts; it can productively unite groups of people in pursuit of particular goals.   But perhaps its less useful in others.  Maybe, as per last week, the more general aim is not to "figure out what's actually out there," nor to achieve "shared subjectivity" but rather to make use of multiple subjectivities to create understandings beyond those one starts with?  In that case, one needn't start with "shared subjectivities" but aspires to/has confidence in their emergence?  Perhaps, with regard to both depression and mental health generally, the important thing isn't the relative values and/or problems of existing "shared subjectivities" but rather the variety of different subjectivities and a commitment to finding out of them new "shared subjectivities"?  Perhaps the point of The Spirit Catches You When You Fall Down isn't that one cultural (or individual) "subjectivity" has to prevail but rather that out of multiple subjectivities new "shared subjectivities' can evolve?  

For more on the use of multiple subjectivities, see On beyond a critical stance.   For more on alternative ways to think about mental health, see Models of mental health: a critique and a prospectus, and for more on depression, see Exploring depression.  For more on depression as "adaptive," see Depression's evolutionary roots.      

VGopinath's picture

Being Wrong, Happy with Illness and Praying Cancer Away

      During the beginning of class, the discussion about the Flat Earth Society has made me think more about our conclusions about ideas being "wrong."  We said that we would define "wrong" as extremely unlikely (e.g. the probability we are made of beans) but that it has its uses in attaining "truth" when used in poetry or in a way that triggers other ideas.  I disagree that useless wrong ideas are that way because they do not spur others into thinking useful/ correct thoughts because some widely held "truths" that are critical in our most basic constructs are considered to be false by others.  In my personal opinion, I think the Flat Earth theory has as much credence as the Creationist perspective.  But there are many constructive members of society who I think have "right" ideas entirely separate from their perspective on the creation of the Universe.  No revelations are triggered in me due to people's Creationist beliefs, especially if they are not vocal about these beliefs, and I don't think they are useless.  Creationism is just the first example I thought of but there are many ideas strongly believed to be wrong and they are critical in the conception of the world to many people.

     On the issue of mental illness, I think David brought up some fascinating questions at the end of his post.  I especially liked his comments about the extent to which illness is defined by the patient and if a happy person could be "afflicted."  I think this is definitely possible, both with mental and physical illnesses.  There are tumors that can grow with no visible symptoms so if that person is cut open and examined, it's obvious that he is afflicted but otherwise he is happy and content.  Many mental illnesses have symptoms like mania which the patient would not recognize as mental illness.  Thus we are forced to tell a happy person that there is something wrong with him and perhaps to even push treatment on an unwilling person. 

     In describing the difference between mental and physical illnesses, I immediately thought of the the huge percentage people of that respond to one depression medication over another and the idea of psychiatry being "behind."  It's almost as though the distinction is that we don't really know how mental illnesses work and can be treated, even if they have a biological basis.  There are also some physical diseases that also lack a clear progression and treatment, cancer being the chief example. There are so many carcinogens and most patients with cancer can't point to X and say that caused my cancer.  Further, treatment is uncertain and imprecise, like with mental illnesses.  And also, we talked abut the ability of talking to change the brain and how we can't "talk away" a heart arrhythmia  but many, many patients who had cancer and went into remission would give lots of credit to the power of prayer and positive thinking.  

rdanfort's picture

many, many patients who had

many, many patients who had cancer and went into remission would give lots of credit to the power of prayer and positive thinking.

http://www.nytimes.com/2006/03/31/health/31pray.html

Prayers offered by strangers had no effect on the recovery of people who were undergoing heart surgery, a large and long-awaited study has found.

And patients who knew they were being prayed for had a higher rate of post-operative complications like abnormal heart rhythms, perhaps because of the expectations the prayers created, the researchers suggested.

Because it is the most scientifically rigorous investigation of whether prayer can heal illness, the study, begun almost a decade ago and involving more than 1,800 patients, has for years been the subject of speculation.

meroberts's picture

Legitimacy of "illness"

I agree that there is an inconvenient stigma associated with mental illnesses. I believe that the reason that psychology/psychiatry is so far behind the rest of the health care fields is, in large part, due to this stigma. Our society gives such deference to Western medicine and "hard sciences". As a result, these institutions have set the precedent for what is to be expected from a health care field and from health care professionals. Unfortunately, psychology, and especially neuroscience, is not as cut-and-dry. Psychology doesn't always "fit" in as a "hard science" because of the variability involved in the study of psychology (or neuroscience), especially the study and treatment of mental illnesses. With mental illnesses, there are multiple possibilities for presenting symptoms, as well as potential treatments for each individual set of symptoms.

When our conversation in class turned to the criteria of an illness, I was surprised to hear so many people agreeing with the dismissal of depression as merely a series of symptoms. To say that depression is not an illness would further stigmatize the condition, I fear. In a weird way, the term "illness" validates the condition and those diagnosed with depression. If it were not to be considered an illness, I believe more people would adopt the attitude of the military in regards to awarding Purple Hearts to people with PTSD or depression. That is to say, people may expect that depression would be easy to "get over" on an individual level even though evidence leads us to conclude that talking to anyone, especially a mental health care professional, helps people become less depressed. I believe that depression is an illness. There is a biological basis to the condition and it notably affects a person's daily functioning if left untreated. What makes it something other than an illness? If it weren't titled an illness, would it be considered a less legitimate condition?

Bo-Rin Kim's picture

I agree that depression and

I agree that depression and other mental illnesses are indeed illnesses. While the idea that these conditions might be symptoms caused by other illnesses is interesting, I think that it is also a way of trying to simplify/dismiss mental health issues. Like Megan said, not giving depression the recognition of being an illness may contribute to the notion that mental illnesses are not serious medical conditions, but just a personal struggle/weakness. I also think labeling depression as a symptom just allows people to not actively search out the causes of depression since symptoms are caused by a wide array of things. I do feel like the manifestation and cause of depression is specific to the individual. However, to effectively treat depression, psychologists have to get to the root of the problem, the cause of the depression and address that through counseling (and medication, if necessary). This is why I think depression is an illness because symptoms like fever or nausea can be treated across different people with the same drug without having to really know the cause of the condition. Depression may just give off the impression of being a symptom because it is so individualized, but illnesses, even physical ones (as we discussed in class), can be individualized as well.

sberman's picture

illness classification

I am torn as to the reason why we make a distinction in our vernacular between physical illness and mental illness. Is the distinction due to the fact that there is a certain stigma against depression, anxiety, bipolar disorder, schizophrenia etc. (what we term mental illnesses)? Or does it stem from the the lack of a defined "cause--> problem --> symptom---> treatment" trajectory for these "mental" illnesses? At least in the medical community, I'm inclined to think its the latter; medical professionals likely want to separate the illnesses which they can classically treat (strep throat, infections, even cancer) to those that may require talk therapy, exposure therapy, CBT and highly personalized, complex treatment plans. I think that this distinction, however, is a construction of convenience rather than of true difference. In fact, many "physical illnesses" may have their root in "mental causes." Migraines can be triggered by stressful events, and perhaps learning to better cope with anxiety or taking anxiolytics could lead to a reduction in the number of migraines. (I recognize that this a slippery slope, however---are migraines an illness themselves or a symptom of a larger illness?) 

In terms of the military community viewing mental illness as a weakness, and less difficult to deal with than physical illness, I feel that the issue of phantom pains in amputees throws a real wrench into this argument. Phantom pains result when after an amputation, the brain believes that the amputated limb is still there and functional, and consequently sends nerve impulses to the area. This seems to me a truly "mental" illness- pain in a limb that's no longer present? But the military views this as a legitimate physical condition and offers treatment. I feel that this example illustrates extremely well that physical and mental illness clarifications are merely a consequence of convenience and in some cases, bias.

vpina's picture

Same as physical illness

 Personally I believe that depression is just the same as a physical illness for a number of reasons.  First I believe it is something that can be reduced by following a healthy diet, if avoidance of a stressful environment is implemented than there is a lower risk of depression just like there is a lower risk of heart attacks if you eat less fatty foods. I also agree that there seems to be genetic underlying to depression but this is a predisposed position and just because it might run in the family does not mean it is guaranteed that you will be depressed. This is like a physical illness in that people are genetically predisposed to have a higher chance to become obese, but that doesn’t mean that with lots of exercise and a healthy diet people could not be obese. I don’t mean to simplify a highly complicated neural problem like this but it seems that it can be seen easier if broken down to its core. I also found the nausea argument compelling and the whole idea of we all have it, its just more elevated in some is also a possibility.

David F's picture

Another perspective on depression

The discussion of mental illness, including how it differs from "physical" illnesses, and whether it is an "illness" or a general condition, is undoubtedly complex, and has significant ramifications for how those afflicted are treated (socially, medically, in terms of insurance, and otherwise). However, our discussion tonight seemed to lack a crucial aspect of its definition: how those with the illness perceive their condition. Mental illnesses are given an additional dimension of complexity by the fact that, unlike most other illnesses, the patient might not always "know" he/she has an illness, or perhaps more importantly, want it to be cured. Depression offers a simpler case, in that I imagine it would be somewhat rare (although certainly not impossible) for a depressed individual not to know that he/she is depressed (in a general sense, not in a "do I fulfill the DSM criteria" sense), and even rarer for that individual not to desire for the mitigation of that condition. However, a patient who is delusional (putting aside what delusions imply for objective/subjective reality) might dismiss claims that he/she is actually delusional, and resent those who want to treat him/her, let alone "want" treatment themselves. Can someone be ill, and not know it? Can someone be perfectly content with their lives, and still have an illness? Or is it a contradiction to suppose that someone could be "afflicted" while feeling ecstatic or euphoric? Do the individuals have any say in the matter for what constitutes an illness? If not, what do we base our definition of an illness upon? We could choose an abstract definition of "normalcy," but we run into the age-old problem of defining a prototypically "normal" brain if every brain differs. We could use a standard of self-harm (is the patient a threat to him/herself), but would a life chained to a bed under heavy sedation be preferable to a psychotic ecstasy? We could choose a standard of harmfulness towards others, but then is depression an illness? The standard that many psychiatrists have seemed to settle upon is a concept of "functionality": can the patient engage in everyday activities and play a functional role in his/her society? But, as before, have we abandoned placing any importance on what the patient actually wants?

Post new comment

The content of this field is kept private and will not be shown publicly.
randomness