Biology 103
2003 Third Paper
On Serendip

In this day and age depression is a catchword. It is applied to all imaginable situations, from grieving after the loss of a loved one to simple foul moods. Although such a loose usage of the word is hardly warranted, the statistics of the World Health Organization suggest that there is some real basis behind it: about 4-5% of the world's population suffer from depression, and it is the reason behind about 60% of all suicides (1). United States is ahead of the world's quota in this sad race: according to the National Institute of Mental Health, about 9.5% of the population (or about 18.8 million adults) experience a depressive disorder in any given year (2). With such prevalence, one can hardly wonder why the issues of diagnosing and treating depression are so urgent and controversial both in the United States and around the globe.

While the growing awareness of the reality of depression as an illness gradually removes the stigma from those suffering from it, the public's attitude, at least in America, seems to be shifting to the other extreme. Almost any sadness, change of mood, or less-than-happy-go-lucky behavior is suspected of being a herald of depression, regardless of the possible causes. On the one hand, people began to be less reserved about seeking psychological help (which is a good thing). On the other hand, both psychiatrists and primary care providers are sometimes too quick to give a verdict "depression" and even more prone to use antidepressants as a cure-all. Although the causes of depression are by no means well-defined (3), drugs that supposedly adequately treat it are publicized without reservation and often regarded as the only possible solution to the problem. This is especially true in America, partially because most new anti-depressants are developed, produced, and hence marketed here, partially because of the methods of diagnosis commonly used, and partially due to the time restrictions placed by the health insurance companies on health professionals.

Since this situation is beginning to raise some concerns among the general populace and physicians, it would be beneficial to compare and contrast the diagnosis and treatment of depression in America and in a country, whose historical conditions shaped a different attitude towards this illness and towards the methods of dealing with it. Russia, being akin to the U.S. in both size and population, but sharply different in the organization of its medical system, could become a suitable subject for such a study. Without focusing on minute details, one can undertake a brief overview of the situation in both the United States and Russia and develop a general, but by no means definitive list of pros and cons for both systems. Although multiple variations of depression can be considered, we will focus on major depression in this study in order to keep the argument succinct.

Major depression, a combination of symptoms such as sadness, hopelessness, feelings of guilt, loss of interest in life, decreased energy, sleep and appetite disruptions, difficulty concentrating, etc. that interfere with one's daily life (2), has a long history of being recognized as an illness in America. Before 1960s, the methods of its diagnosis and treatment were largely left to the discretion of one's psychoanalyst. When first tricyclic anti-depressants were developed in 1960s (3), the psychoanalytic community was more than suspicious about their efficacy, often to the point of outright rejection (4). Medications were thought to provide temporary relief of the symptoms of depression, but the etiology of the illness was traced to the deep psychic conflicts that could only be approached with the help of a psychoanalyst (4).

As the research went on, various studies have suggested that the reason for major depression lied in the disruption of the functioning of certain neurotransmitters, which, in its turn, disturbs the communicative processes in the brain (5). Tricyclic anti-depressants and monoamine oxidase inhibitors stabilize these processes, although the mechanisms of this stabilization are multiple and in many cases contradictory (3). These medications were still not widely used due to rather serious side effects, but with the arrival of the selective serotonin reuptake inhibitors (SSRIs) in 1980s this ceased to be a major problem. The new medications, while providing the same relief, were more safe and produced less side effects for most patients (6).

From 1980s on, the use of anti-depressants to treat major depression is widely accepted and encouraged. Primary care physicians, psychiatrists, and psychoanalysts prescribe anti-depressants, often in combination with monoamine oxidase inhibitors, in the majority of the cases, regardless of whether counseling services or psychoanalytic services are provided (4). The readily discernible reason for promoting the use of anti-depressants is their apparent (and relatively fast) effectiveness; however, there are other factors that may contribute to their often being a treatment of choice in the United States.

One such factor is the official system used for diagnosing major depression in the United States. Popularly called DSM-IV, it is based on The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. It provides psychiatrists with a list of particular episodes and then outlines various mood disorders based upon this list. It also specifies the details of the behavior and states of the patients with different disorders and provides information on the cycles associated with each (7). DSM-IV is often praised for not attempting to define the causes of depression, but for rather striving to delineate some useful categories based on the symptoms of the illness, thus providing a framework of terms and possible treatments, while not assigning the patients to any harsh categories (3). However, there is another reason for its popularity. Since the examination performed using this system results in very orderly forms with explicit delineation of the possible diagnosis, it is a god-sent to the insurance companies and researchers looking for consistency of their results (7). It can also provide an established and safe backdrop for psychiatrists not wanting to deal with the nuances of each individual case, much like the widespread acceptance of anti-depressants labels them as a safe choice despite the still-unknown mechanisms by which they function.

Many psychiatrists find fault with both the DSM-IV diagnosis system and with the unlimited and often indiscriminate use of anti-depressants for essentially the same reason: the lack of attention to the nuances of the individual case. Thus, Simon Sobo, the Chief of Psychiatry at New Milford Hospital, CT notes that anti-depressants are often used in order to simply alleviate the symptoms of the illness, with "treatment" stopping short just as the desired effect is reached. Even if one puts aside the dubious and uncertain nature of the usefulness of anti-depressants and accepts them as a helpful tool, there remains a problem of the physician often relying too much on the "fixing" power of the drug. Counseling, which should be used to acquaint the patient with the methods for dealing with stressful situations in the future, to teach him useful modes of thinking, and to elucidate certain behavioral patterns of the brain, is overlooked. The patient, in effect, remains dependent upon the drug, which, given the fact that major depression usually recurs several times throughout a person's life, does not constitute an optimal treatment. Sobo also notes that using anti-depressants often rationalizes the illness in terms of purely physiological disorders and discourages the patient from facing personality or attitude issues, which plays a crucial role in the process of recovery (8).

Similar arguments could be levied against DSM-IV diagnostic method. However, the issue is more complicated here since money comes into the forefront. U.S. medical insurance companies often allow as little as 15 minutes per a physician and 30 minutes per a psychiatrist visit. The lack of time necessarily results in the doctors' opting for faster, but not necessarily thorough methods of diagnosis and treatment. Filling out questionnaires provided by DSM-IV and prescribing anti-depressants may well become their legitimate choices, because of their apparent credibility and convenience. The doctor only has to evaluate a patient, prescribe a drug, and then continue to administer routine 15-minute check-ups to ensure the effectiveness of the anti-depressant (8), (9).

Insurance companies also play an unsavory role in misdiagnosing depression, since many primary care physicians simply do not have the time (in the 15 minutes allowed) to do a thorough examination and to detect a possibility of a major depression. Given the fact that major depression is often masked by somatic symptoms, many depressed patients never receive proper treatment for their actual illness (9). The same time-and-money problem often forces the patients and the physicians to discontinue treatment (both pharmacological and psychiatric) when the patient first responds to the treatment but before a full remission is achieved. Such cessation of the process results in recurrent episodes of depression, which could have been avoided, had the patient have enough financial resources to continue therapy (6).

Despite all of the above problems, there are important steps taken by the U.S. medical and insurance systems to ensure that major depression is recognized and treated as an illness. There are resources for patients who lack money or insurance coverage for proper therapy; a thorough publicity campaign is waged in order to make people acquainted with this "disease of the century"; governmental and private funds are allocated each year to the continuing study of the causes and processes behind this illness. New drugs are developed and tested, and new networks of support are built. (3)
This is not the case in Russia, however. The concept of depression as an illness is relatively new there and has not gained widespread recognition, despite the health professionals' attempts at popularizing it. This is warranted historically, since psychiatry in the Soviet Union dealt almost exclusively with the cases that threatened the social structure, in other words, with the patients who were potentially harmful to others. The other "branch" of psychiatry in the Communist regime was wholly dedicated to keeping the dissident movements in check. The psychiatric wards were filled with perfectly healthy Soviet citizens who for one reason or another did not please the authorities. They were kept placated by the means of heavy psychotropes and electrical shock. Needless to say, the word "psychiatrist" still associates for some people with these "doctors," while others think that psychiatrists exist only for the clinically insane patients who are threatening to society (10).

There are also cultural reasons for not recognizing major depression as a legitimate illness. Russians are a pretty melancholic and pessimistic nation: for instance, it is in bad taste to answer "Great!" to the question "How are you?" A person happily smiling without any special reason is considered a fool. This mood of universal sadness is darkened even more by the current economic situation, so much so that even severely depressed people often rationalize their condition and feelings by saying "And who is happy nowadays?" On the other hand, a person who openly admits to having depression or, worse, to going to a psychiatrist is considered at best a weak and lazy character and at worst a hypochondriac, a maniac, or both. Needless to say, in both cases this person stops being socially accepted and is often blamed for his "imagined" sickness. (11)

This attitude towards depression is so widespread that sometimes even physicians are unaware of or skeptical about it being an illness. This leads to frequent misdiagnosis, so much so that about 80% of patients suffering from major depression is thought to be currently treated by general practitioners, while every fifth patient seeking treatment from a physician really needs the help of a psychiatrist (1).

Of course, this also means that the current knowledge about depression is largely borrowed from Western studies, and, in particular, from American experience. Among psychiatrists, the United States, with its social and medical guarantees for depressed individuals, with research programs, and especially with an adequate attitude towards depressive disorders (at least by Russian standards), is highly regarded (14). Nevertheless, despite the Russian psychiatrists' attempts to emulate American approaches to diagnosis and treatment of major depression, certain specificities of the medical care and social security systems and cultural differences ensure sufficient variance between prevalent Russian and prevalent American methods.

Thus, although all Russian psychiatric reviews stress the utmost importance and effectiveness of anti-depressants, the economic conditions are such that they are simply not available due to their cost for most patients. Even though most anti-depressants are currently on the Federal List of Essential Drugs and, therefore, not only should be available in all drug stores and hospitals but also sold at bargain prices to qualified individuals, this regulation is rarely followed due to the lack of money in federal and state budgets (13). Therefore, psychiatrists are often forced to treat their patients in the absence of anti-depressants or with the help of the older brands, which shifts the emphasis from pharmacotherapy to various counseling methods.

These methods are very similar to U.S. counseling methods. Psychodynamic therapy focuses on the inner psychological conflicts, trying to help the patient recognize and identify the conflict and to learn to resolve it constructively. Behavioral psychotherapy attempts to solve the most bothersome current problems of the patient and to alleviate certain negative behavioral symptoms: passivity, monotonous life style, isolation from the loved ones, inability to plan and make decisions, etc. Cognitive psychotherapy in the Russian practice is a synthesis of the above two branches that combines working with the concrete difficulties in the patient's life as well as with his or her behavioral patterns and inner conflicts. Cognitive psychotherapy also aims at breaking the patient's habit of negative pessimistic thinking and at helping him or her to establish a new way of looking at the self and the world. (12)

Unlike their Western colleagues, however Russian psychotherapists do not have any time limits set for the course of therapy allowed to a patient. Medical care is still mostly state-owned, so each citizen is entitled to free medical help, including free psychiatric visits and counseling. This allows the Russian psychologists to lead their patients on a gradual path to recovery, making sure that they reach complete remission before treatment ceases. Since the majority of their patients cannot afford anti-depressants, the doctors focus more on teaching the patient self-regulation, thus providing him or her with a framework which would be applicable to all stressful, but not necessarily depression-inducing situation (12).

The lack of pressure from insurance companies also allows both general physicians and psychotherapists to ensure that each patient receives adequate examination, so that most possibilities for somatic disorders are ruled out before the patient is directed to the psychiatrist (1). This comparative freedom as well as the specific Russian situation concerning the misconceptions and misinformation about depression conditions certain research interests of Russian psychiatrists, which often include masked depressions and borderline depressive disorders (14).

This interest in diagnostics also manifests itself in the Russian method of diagnosis of major depression. While the official system for identifying and classifying depression is the World Health Organization's ICD-10, which is rather like the American DSM-IV, it is often, if not always, supplemented by the more individualized and carefully worded methods of such prominent Russian psychiatrists as Behterev, Topolyansky, and Strukova (14). These methods focus more closely on the patient's individual symptoms, on his attitude to life, on his expectations (or the lack thereof) from the psychiatrist, from himself/herself, from life. They also presume that the patient's family will be as involved and supportive as possible, since a Russian cultural trait assigns great significance to the social aspects and causes of depression (13).

Thus, the major strengths of the Russian system for diagnosing and treating depression are particular attention to detail, focusing on psychotheraphy rather than pharmacotherapy, allotting enough time for thorough evaluation and treatment of the patient, and involving the family into the recovery process. These services, however, are only available to patients already diagnosed, which is a relatively small number, given the general unawareness of and even disdain towards major depression. Russian psychiatrists would benefit from emulating their American colleagues in their efforts to publicize the condition. They would also benefit from anti-depressants being more generally available; however, that is beyond their control.

American methods for treating depression could also be improved by learning from the Russians. Methods of diagnosis, particular attention to counseling, and, perhaps, an attempt to re-evaluate the universal effectiveness of anti-depressants could all safely be borrowed from across Atlantic. Physicians and psychiatrists should lobby to increase the time allocated by insurance companies per doctor's visit, while continuing to do the good work of making the general population aware of the concerns and dangers of depression. Overall, the American system needs to be less money-and-time and more individual-and-quality oriented, keeping in mind the fact that giving drugs to a patient does not remedy the problem, but teaching him or her to cope with stress on their own potentially will. However, one should not underestimate the gains of the American doctors in the fields of awareness and social support of people with depression, which are unquestionably more advanced than their Russian counterparts. Both countries would benefit immensely from productive dialogue and exchange of experience. Hopefully, such a dialogue will be started in a foreseeable future.

References

1)"Depression in Medical Practice." The Research Center for Mental Health of the Russian Academy of Medicine.

2)National Institute of Mental Health Home Page.

3)All About Depression, A Comprehensive Overview of Depression.

4)"Psychoanalysis and Pharmacotherapy - Incompatible or Synergistic?" By Leslie Knowlton. Psychiatric Times online.

5)An article on depression on the Continuing Medical Education, Inc. website.

6)"Applying Innovative Approaches for the Treatment of Depression." on Critical Breakthroughs, an online compilation of recent publications for practicing physicians and psychiatrists.

7) A comprehensive review of DSM-IV.

8)"A Reevaluation of the Relationship between Psychiatric Diagnosis and Chemical Imbalances." By Simon Sobo, M.D.

9)"Discovering Depression in Medical Patients." By Kurt Kroenke, M.D. In Annals of Internal Medicine online.

10)"I Have Depression." By Frumkina, R.

11)"What Is Depression?" By Egorova, Elena, M.D.

12)"What Do You Need To Know About Depression?" By Holmogorova et. al. Russian Psychiatric Research Center.

13)"Masked Depressions." By Dmitriyeva, Tatyana. The Russian Academy of Medicine.

14)"Depression." By Petrov, M.D.


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