In the transcript of Osherhoff v. Chestnut Lodge, there’s a confusion of tongues [to borrow a term]. The opening description talks about two kinds of depression, the longstanding prevailing view in psychiatry:
There are two kinds of depression known to psychiatry. One kind of depression is an individual’s reaction to external situations and events. It is usually milder and may respond to psychotherapy alone. This type of depression usually appears following a precipitating event such as a result of "symbolic" loss. Depending on the duration and degree of symptomatology, somatic treatments (i.e., medicinal and/or electroshock therapy) may or may not be indicated. The other kind of depression results from internal physiological causes and is called "endogenous" and may appear "out of the blue"; sometimes it begins as a "reactive" depression but then develops and independent biological life of its own and is transformed into a depression having the characteristics of an endogenous depression and is sometimes referred to as "endogenomorphic". The endogenous and endogenomorphic depressions have a physiological basis. They are of a more severe profound nature and present with clinical characteristics indicating a physiological disturbance in the central nervous system, such as sleep disturbance, excessive agitation as manifested by pacing and handwringing, weight loss and disturbance of mood. "Endogenous" or "endogenomorphic" depressions should be treated by somatic means…
That was true in 1979 when Dr. Osherhoff was hospitalized. But by 1982 or 1985, it was no longer true, because the DSM-III had been released and all those depressions had been lumped into the Major Depressive Disorder category. We can definitely rule out the possibility that the experts hadn’t read the new manual. So we must take a step back in time to look at the discrepancy, and why this wording was still in the suit. I spent a month of Sundays obsessing on the lead-in the the DSM-III classification of depression [the future of an illusion I…, the dreams of our fathers I…, a minority report 1…, a minority report II…]. The gist of it is that they were determined to eliminate the psychoanalytic category – Depressive Neurosis. Spitzer did it by lumping all the depressions together as Major Depressive Disorder. The distinction mentioned in Osherhoff was collateral damage. In the 11th hour Dr. Bernard Carroll wrote to Dr. Spitzer [February 19, 1979]:
There was some jockeying around with words here and there, but for practical purposes, the distinction in Osherhoff had become past history when the manual was released – at least officially. It severely hindered subsequent research on depression to lump all of these cases together. And worse, though perhaps also unintended, that creaking sound I was talking about [a loud creaking noise…] was the sound of the door opening for the drug companies to the vast market of "depressed people" rather than the former, very much smaller cohort of patients with endogeneous or endogenomorphic depressions. If there’s ONE single thing that facilitated the explosion of psychiatric drug use – this was it. The timeline below summarizes the events during the 1980s leading up to the Klerman v. Stone debate [respecting our limits…] and the DECADE OF THE BRAIN. Notice also the march of the SSRIs beginning in this time frame:
In Klerman’s paper, he didn’t mention the distinction between the two depressions. Thus, the major category of depressed people morphed away into the now ubiquitous MDD. It wasn’t just the psychoanalysts and psychotherapists who lost in this move, the Biological Psychiatrists testifying in Osherhoff’s behalf lost as well in that the category they were pursuing as the most likely to have a biological substrate faded from the rolls.
Chestnut Lodge and their psychiatrists were negligent. But let’s consider the flip side to the issue. Why don’t we go after all of the self-styled “biological” psychiatrists who mindlessly prescribed cocktails of antipsychotic (for augmentation purposes, you see) and antidepressants and “mood stabilizers” for the zillions of people suffering from the “other” life stress-related/childhood trauma “depressions”? Yes, all of those psychiatrists who refused to listen to a patient’s story and narrative because they just felt they needed to give a five minute checklist and whip out the prescription pad? Those psychiatrists who lied to their patients, and told them they had “a chemical imbalance” that caused their misery? This was malpractice of a different sort– but one equally damaging (and damning). Just look at all of those obese psychiatric patients walking around with abnormal lipid panels and tell me that no negligence was done???
Tom,
That is, of course, the point. The reason I’m hung up on this case is that this feels like where it started. Dr. Klerman’s 1990 article is a logical argument about Randomized Controlled Trials being the standard to measure treatments. It all sort of makes sense except we know where it lead – to a level of corruption unheralded in medicine. It was something like “the day the music died”…
This is fascinating. “Non-endogenomorphic” rolls off the tongue like “longitudinally extensive transverse myelitis.” I like it.
What are the distinctions between characterological and reactive depressions?
I’ve often wondered if perhaps some of the problems with psychoanalysis (beyond being excessively Freudian) is the fact that it was most used for so many years by people who could afford it, for “neurosis.” Which, for most people, made it kind of a joke about people with money to burn and silly problems.
I read this series – and look forward to what follows – with great interest. Although I do not dispute that there is a wide variety of presentations in what we now commonly call Major Depressive Disorder, I do not agree with you that we know that in fact there is some clear divide between what at the time categorized as endogenous vs. non-endogenous depression. This debate fostered a notion that we understood causality far better than we did then or we do now. The whole notion was predicated on the divide between the two camps in psychiatry: biological and psychoanalytic. It got codified as the divide between Axis I and II and led to profound dualistic thinking in our field and the popular culture. It may have been this impression – that we knew far more than we did (and do) that contributed to the blindness on the part of the CL psychiatrists, but we know it also led to a blindness on the part of the so-called biological psychiatrists in countless other examples that may have been less well publicized.
So I do not think the division was really lost; the broad category of MDD did allow for much less precise diagnosing but the other forms of depression were captured as adjustment disorders or personality disorders.
For me there is a bigger problem. Don’t you agree that time has taught us that it is all both “biological” and “environmental”, that multiple factors figure in to the phenomenology of dysphoria in all its many forms, that we still do not have a grasp on etiology and attempts to imply that we do will only lead to further confusion?
Sandra,
I think my focus is actually on how those controversies in the 1980s opened the door to the overmedication of dysphoria. The digital sorting of depressions certainly has its holes too. The whole idea of endogenomorphic was to encompass people who seemed to have depression related to life but progressed to a picture looking like the endogenous depression of the Manic Depressive. I’m looking at the various takes on Osherhoff himself, and am finding more rhetoric than clinical history. But that’s just the way these things go. The closer one gets to a clinical case, the more confusing things become. Actually, I will admit that it is the ambiguity of such cases that I find compelling and is probably what pulled me from the clarity of internal medicine in the first place.
Dr. Carroll who is a clinician extraordinaire reviewed this man’s case and saw him as having Manic Depressive Illness in the midst of an agitated depression. To highlight the point you are making, I’ve never seen a case of certifiable Manic Depressive Illness where the time between the episodes was altogether “normal.” Not to unfairly indict Dr. Osherhoff, but he had a tough time establishing a stable life. That said, Silver Hill was the right hospital for him.
I think I haven’t given up on the clinical picture in its most thorough version as the right way to classify mental illness. And to me, people with melancholic depression have a mental illness that’s totally in charge. I see Melancholia clinically as a noun. You can either wait it out, or you can interrupt it with antidepressants or ECT. I see the “other” depressions in a different way – adjectives or adverbs.
Now to your point. We don’t know the etiology. Your point about that dichotomy is solid as a rock. The powerful familial story with Manic Depressive Illness is suggestive, but otherwise, we’re still looking. My argument for the clinical separation is pretty simple. They feel very different to me. The response to treatment feels different to me. And if there is a hunk of biology involved, the compass points directly at melancholic depression. So I’d like them to be separated out to focus the research. If anything has come from research on “MDD,” I don’t know what it is. I agree with Dr. Shorter that “Major Depression doesn’t exist in Nature. A political process in psychiatry created it…”
Finally, looking back at Dr. Spitzer’s processes in destroying the previous distinctions among the depressions, I became convinced that the motive was more something-else than clinical. I would have preferred that he classified whatever wasn’t melancholic depression as big-time-unhappiness than lump all depressions.
…
This is the important point on which we agree: MDD is not something that exists in nature.
I was introduced to the concept of essentialism. I do not pretend to any level of philosophic sophistication but this helped me to think about this problem: is there any entity in psychiatry that is essential and can be distinguished from other entities in the same way that let’s say all hyodrgen atoms are essential and can be distiguished from all helium atom? When you say melancholia is a noun, I think you are saying you believe it is essential.
I used to think that entities like endogenous depression and schizophrenia were essential. However, my experience leaves me viewing all of this on a messy continuum. At the same time, if I am wrong, we have a problem when it takes an expert clinician to be able to identify the categories. I also remain uncomfortable with language that categorizes some entities as more “biological” than others.
I agree with you that at the time, we would have been better served with a more narrow definition of depression. However, it would in my opinion only postponed our reckoning with the compexity. I also do not think that it would have changed the rampant use of drugs. After all, Peter Kramer wrote his book popularizing the notion that the SSRI’s were effective for people diagnosed with personality disorders.
In my view, the problem was a lack of humility on all sides about the profound uncetainty and limits of our knowledge as well as the deception in the promotion of these drugs, a topic on which you are anexpert.
Frankly, this discussion is interesting from a retrospective/ historical perspective, and I do accept the fact we need to keep aware of mistakes we make from the past, but, where does it take us from here?
If a sizeable portion of colleagues just buy into a mantra without inherently challenging overt glorifications without merit, or more simplistically just do what is easy, convenient, or just fills the wallet, then what is learned?
Forrest Gump said it perfectly: stupid is as stupid does!
“the problem was a lack of humility on all sides about the profound uncertainty and limits of our knowledge”
Amen!
Sorry I can’t be more succinct. I’m trying to stretch my mind around this without formal training.
The perspective of essentialism is essentially a problem of Western thinking that is most sticky when used as a lens to view the most complex systems of humanity. I’ve been working on examining that in my own thinking for a long time, and see no reason to ever stop.
Naming “things” is, of course, necessary; but it seems to be stuck in a 19th century mentality in biological psychiatry. There is no “ah-ha” after manufacturing “Major Depressive Order” as a label that will then be reduced to a cipher and reified so that that becomes what people— individuals— are judged to be by the high priests of the industry that made the label.
Essentialism, reductiontionism, reification, and a severe problem with epistemiology, and an authoritarian subject/object view of the doctor/patient relationship in biological psychiatry has combined to create a mess of monstrous proportions— in the trillions of dollars! And there are billions of people who aren’t taking taking psychoactive drugs! Alas, the industry may be giving up on that effort to medicate 1 out of 4 humans, starting with infants and ending with the elderly who apparently weren’t dying quickly enough. Hurrah.
Biological psychiatry, writ large, doesn’t listen to patients anymore— it emphatically dismisses the patients’ lives and circumstances as being irrelevant to the doctor and the patients. How can a person who is ostensibly trying to help another person and ostensibly trying to figure out what is making a person suffer what they say they are suffering possibly make fine distinctions in this relationship? Forget the judge and judged situation and think of two people in that relationship,with it’s weird western, authoritarian, capitalist model being deployed globally with charts and checklists.
The human factory of mental illness real and imagined and its treatment evidence-based or a product of marketing (hard to tell) is a bull in a china shop.
There should be a whole lot more questions in this field right now than answers.
The antidote to essentialism is to un-ask the questions that led to the erroneous non-answers. Suddenly psychiatry writ large is having an identity crisis and is realizing so many of the errors of it’s ways and the dear consequences! This 30 year fever is starting to break, so psychiatry is becoming interesting again and dynamic.
Hurrah.
And here is Dr. Mickey Nardo and company thinking out loud about it. This is a healthy and promising process.
I am not discounting what works— drugs, ECT, therapy, vacations, health care, help getting out of a pathologically abusive situation, etc. If it works, it works. If it doesn’t, it doesn’t. But informed consent requires a lot more than telling a patient the effects of drugs being prescribed— it requires that those doing the labeling and prescribing give an account of themselves, their theory, their school, and their process. Fairness requires that a patient have the right not to be given an indelible label with one requisite treatment on the basis of research and rulings for which those who wield those powers can’t give a reliable scientific account of themselves.
Biological psychiatry has been wielding far more power over people, courts, the popular mind, and astronomical sums of money than it could possibly justify.
Finally, the chickens are coming home to roost from within and without. It’s an opportunity for the psychiatric “it” to grow. Inside. Even though it will hurt. 😉
Am hoping that my thoughts on this gel, and that I can express them more fluidly and more evidently related to these topics with which I am earnestly trying to engage, and I sincerely appreciate the knowledge and experience of all present. Thank you.
Mmm…speaking of the use of labels:
http://blogs.discovermagazine.com/neuroskeptic/2013/06/27/autism-psychosis-mass-murder/#more-4083