{"id":23852,"date":"2012-05-28T22:08:47","date_gmt":"2012-05-29T02:08:47","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=23852"},"modified":"2012-05-28T22:12:15","modified_gmt":"2012-05-29T02:12:15","slug":"a-mistake","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2012\/05\/28\/a-mistake\/","title":{"rendered":"a mistake…"},"content":{"rendered":"
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I’ve been moderately obsessed with a single topic of late. It’s something that happened to psychiatry back around 1980-ish with the coming of the DSM-III. My obsession is personal, because it happened to me. We all know that both Managed Care and the Pharmaceutical Industry were major forces in how things have played out, but that’s not what obsesses me. I’m sure that I am over-playing it a bit, but my thoughts about it remain focused on the diagnosis – Major Depressive Disorder. From the days back when it was happening and throughout my career, I’ve thought it was in error, a mistake. At times, I thought it was something evil, something somebody created just to build a market for medications. But I’ve come to believe what I’ve been told, that the Pharmaceutical and Third Party payers may have jumped on the Diagnosis like it was heaven sent, but they didn’t create it. I was doing what paranoid people do, assuming a malevolent motive based on a negative phenomenon. I now think it was just an error, a mistake that started a brush fire the industries then exploited and perpetuated – aided and abetted by some among us who became the devil’s own helpers. Back in those days, I wasn’t close enough to the forest to know what ignited it. By the time I was aware of it, it was a raging inferno. So I’m obsessed with reconstructing the kindling point.<\/em><\/sup><\/td>\n<\/tr>\n<\/table>\n

When I wrote what price reliability…<\/font><\/strong><\/u><\/a>, I was trying to figure out how in the world the category Major Depressive Disorder ever came into being in the first place, and I wasn’t having much luck. It just seemed to appear. By 1978 [Research Diagnostic Criteria: Rationale and Reliability<\/font><\/strong><\/a><\/u>], it was a diagnosis and all the former kinds of depression were listed as under it as subtypes in Robert Spitzer’s Research Diagnostic Criteria<\/font><\/strong> [RDC]. By then, he had concluded that there weren’t clear borders for the subtypes. I started trying to look at why they were ever subtypes<\/em> in the first place. <\/p>\n

Later, in hypothesizing…<\/font><\/strong><\/u><\/a>, I chased it back to 1975, and was playing with what I facetiously called the 1boringoldman-inertia-of-serendipity-hypothesis<\/font><\/strong>. That was the very unsatisfying idea that the unitary class, Major Depressive Disorder<\/font><\/strong>, wasn’t really ever a thought-about thing. It just sort of happened. That it started life as a placeholder for a bunch of former diagnoses, but because they couldn’t be easily separated, it endured and ended up passively being declared a Disorder. What makes that so unsatisfying and actually tragic is that as Major Depressive Disorder<\/font><\/strong>, something I consider a non-discrete entity, it became a vehicle for an epidemic of clinical trials that ended up with FDA Approvals. Playing like Major Depressive Disorder<\/font><\/strong> was a genuine bonafide Disease with a genuine bonafide treatment gave Pharma a market for their SSRI blockbusters<\/em>, and ultimately gave psychiatry black eyes for massively over-diagnosing and over-medicating. It sure wasn’t right for our patients. Here’s how it had been before:<\/p>\n\n\n
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DSM [1952] – DEPRESSIONS<\/font><\/strong><\/sup><\/div>\n
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PSYCHOTIC DISORDERS
      000-796 Involutional psychotic reaction
      000-xlO AFFECTIVE REACTIONS
      000-xll—000-xl3 Manic depressive reactions
            000-xll Manic depressive reaction, manic type
            000-xl2 Manic depressive reaction, depressed type
            000-xl3 Manic depressive reaction, other
      000-xl4 Psychotic depressive reaction
PSYCHONEUROTIC DISORDERS
      000-x06 Depressive reaction <\/font><\/strong><\/sup><\/div>\n

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DSM II [1968] – DEPRESSIONS
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III. PSYCHOSES NOT ATTRIBUTED TO PHYSICAL CONDITIONS LISTED PREVIOUSLY [295—298]
      296 Major affective disorders…
            296.0 Involutional melancholia
            Manic-depressive illnesses…
            296.1 Manic-depressive illness, manic type…
            296.2 Manic-depressive illness, depressed type…
            296.3 Manic-depressive illness, circular type…
                  296.33 Manic-depressive illness, circular type, manic
                  296.34 Manic-depressive illness, circular type, depressed
            296.8 Other major affective disorder…
      298.0 Psychotic depressive reaction…
IV. NEUROSES [300]
      300 Neuroses
            300.4 Depressive neurosis<\/font><\/strong><\/sup><\/div>\n<\/td>\n<\/tr>\n<\/table>\n

There was something comforting about those systems. The task was clear. With a depressed person, the diagnostic dilemma was categorical. It was like my medical mind?<\/em> [Severe shortness of breath. Heart Disease? Lung Disease?][Severe Depression.  Major Affective Disorder? Depressive Neurosis?]. It directed what came next. Neither category was quite right: in the first group, what about a person with Melancholia with no previous episodes? in the second, neither Depressive reaction <\/font><\/strong> nor Depressive neurosis<\/font><\/strong> quite fit the bill, as there are a sea of ways that life, the mind, and the personality can weave together in a given depression – certainly not all covered by the definitions or mechanisms in the DSM code books. But still, there was a categorical separation that helped me think about the case in front of me. I never had that from the DSM-III, so I never paid a lot of attention to it. Major Depressive Disorder didn’t move me anywhere in my understanding of a case.<\/p>\n

But that’s not what Robert Spitzer had that in mind.  He had a couple of things to work with. He had resident John Feighner’s simple and naive classification with its adherence to descriptive criteria, and he needed to get rid of the categories defined by psychoanalytic mental mechanisms like Depressive Neurosis. When it came to Depression, he had to deal with the kinds of depressive illness. When John Feighner<\/font><\/strong><\/a><\/u> did his classification [1972], he simply classified discrete illnesses, episodes, and didn’t even bother with diseases like Manic-Depressive Illness [though that was a big topic in St. Louis]:<\/p>\n