Depression pharmacotherapy: lessons from/about research

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?

             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. 

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.
 

 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.

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.

      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.  

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?

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.