{"id":24540,"date":"2012-06-17T15:29:50","date_gmt":"2012-06-17T19:29:50","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=24540"},"modified":"2012-06-17T22:27:10","modified_gmt":"2012-06-18T02:27:10","slug":"a-minority-report-ii","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2012\/06\/17\/a-minority-report-ii\/","title":{"rendered":"a minority report II…"},"content":{"rendered":"
I think what I’m talking about here is the biggest of deals. The topic is about a debate in psychiatry that happened well over a quarter of a century ago, one that really has never been resolved – it just faded away before its time. It has to do with the nature of depressive illness. Part of the problem, it seems to me, was in something like a confusion of tongues<\/font><\/strong><\/em> [to borrow a term from Sandor Ferenczi from another debate long before<\/em>]. There had been any number of terms applied trying to categorize depressed patients. Dr. Spitzer listed some of them in his 1978 article about his Research Diagnostic Criteria<\/font><\/strong>…<\/div>\n
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…but there were others: Endogenomorphic, Melancholia, Spectrum, Existential, Neurotic, Anaclytic, Situational, Reactive, Unipolar, Bipolar, etc. I’m going to claim the divine right of a non-expert and simplify things down to two terms – melancholic<\/font><\/strong> and neurotic<\/font><\/strong> [but apples <\/strong><\/font>and oranges <\/strong><\/font>would do], and say that in my mind, the former implies biology<\/em> and the latter implies biography <\/em>[but even that’s optional]. Both the DSM and DSM-II made a distinction but didn’t do much of a job describing them, particularly the latter – just throwing in some dynamics from Freud’s 1916 Mourning and Melancholia<\/em>. In the articles in my last post, Dr. George Winokur did a much better job of discussing the clinical picture describing patients with significant ongoing personality problems who have periodic depressive illness that can be profound and sometimes fatal. He presented us with a criteria set:<\/div>\n
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I don’t know how Dr. Winokur factored in the family history of Alcoholism. I’d change that to "comes from a Dysfunctional Family<\/em>," though I don’t know if that’s what he was getting at. That would certainly fit the many such patients that I’ve seen. But that small point aside, he seems to have had his finger firmly on the pulse of things. Winokur even opened his paper with a route to escape the taint of a psychodynamic explanation…<\/div>\n
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The term neurotic-reactive depression need not imply etiology. It easily can be defined on the basis of phenomenological factors. D’Elia et al defined it as "a reaction to external events or … an acute breakdown in persons with gross personality disorders of a neurotic nature [patients with unstable personalities and a tendency to react with depressive, anxious, or psychosomatic symptoms under the influence of stress in relatively ordinary life situations]." The authors pointed out that these patients’ characteristics would correspond to the diagnosis of reactive-neurotic depressive reaction in the World Health Organization manual. This definition is notable because it is irrelevant to the presumption of a dynamic etiology. In fact, it is similar to the definition used throughout most of the lifetime of the neurotic-reactive concept. Only recently has the concept assumed an etiologic meaning and mainly in the United States. The European literature dealt with the diagnosis on a phenomenological rather than a dynamic-interpretive basis. Because the term has had multiple meanings in recent years, agreement on diagnosis is difficult to achieve. If the criteria are limited to a significant depressive syndrome in a person who has a lifelong history of a stormy lifestyle and personality problems, the reliability should improve [in The Validity of Neurotic-Reactive Depression<\/font><\/strong>, 1985].<\/sup> <\/div>\n<\/blockquote>\n
…but even when Dr. Winokur [and others] handed Dr. Spitzer this ready-made solution\/compromise on a silver plate, he didn’t budge. The DSM-IIIR was unchanged – the same unitary Major Depressive Disorder<\/font><\/strong> as before – and it persisted into the DSM-IV. It’s still going to be there in the DSM-5. So in spite of seemingly clear delineations for the syndromes of melancholic depression and neurotic depression, they have remained in the same category now for 32 years.<\/div>\n

There is a further not-so-subtle point to be made about the patients considered in arriving at the depressive diagnosis that ended up in the DSM-III. They were in-patients<\/font><\/strong><\/em>, admitted to psychiatric hospitals because of depressive episodes that were show-stoppers. In Dr. Spitzer’s meta-analysis of diagnostic reliability in 1974, he reviewed studies primarily done on in-patients<\/font><\/strong><\/em>. Most studies of melancholic depression [including those people with depressions that occurred in the course  of a Manic-Depressive Illness] were done on in-patients<\/font><\/strong><\/em>. Dr. Winokur’s studies of Neurotic Depressions were conducted by reviewing hospital charts – in-patients<\/font><\/strong><\/em>:<\/p>\n

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Certainly the choice of hospitalization was more available in those days, but still, these were very ill people – not the walking wounded. And if you read Dr. Winokur’s criteria above, he’s hardly describing prime psychotherapy or even biological treatment candidates. They are demanding, externalizing people who become severely depressed when their maladaptive ways of being in the world inevitably fail. Treatment is often more in the range of what medical doctors call palliative, and mental health clinicians might call crisis intervention. Successful and definitive treatment is not guaranteed, no matter the modality. This is the stuff of "nervous breakdowns" in a former time.<\/p>\n

The majority of people with a diagnosis of Major Depressive Disorder <\/font><\/strong>in today’s world fit neither category. They are help-seeking out-patients whose dysphoria is real and interfering with their lives in significant ways, but their ill-ness<\/em> is not in the show-stopper range. The older term Depressive Neurosis [stripped of the etiologic implications] did seem to refer to these patients. Dr. Spitzer’s early Research Diagnostic Criteria<\/font><\/strong> [first figure above] had a category for them – Minor Depressive Disorder<\/font><\/strong>. The term was doomed from the start because if they’re your symptoms, they’re not Minor<\/font><\/strong>. And if they’re Minor<\/font><\/strong>, your insurance carrier is not interested in paying for much in the way of treatment.<\/p>\n

So there’s a further confusion of tongues<\/font><\/strong> that complicates the current psychiatric diagnostic system. Not only is the category Major Depressive Disorder <\/font><\/strong>a heterogeneous mixture of severe depressions, it’s widely used to describe a group of depressed people who were not included in the cohort used to define the diagnostic category itself. And while they were not used to validate the diagnosis, they make up the majority of the patients that are included in the numerous clinical trials of treatments, primarily medication treatments. They are neither patients who likely have a biologically colored propensity to melancholia nor those with  severe personality disorder who periodically have show-stopping depressive episodes. <\/p>\n

The reason you don’t see people like me who spent their days working with depressed, help-seeking out-patients signing on to committees in charge of diagnostic classifications is that we wouldn’t know where to start. Every case is different. A surprising number are people with soft disabilities: learning problems, attentional problems, visual difficulties not diagnosed early – people who have succeeded against a gradient that left its mark. Equally surprising are the number with unseen and unacknowledged traumatic experience lurking in the background discoloring living. Then there are idiosyncratic characterologic ways of being that were adaptive in an earlier dysfunctional environment, but lead to repeated misery in the adult arena. Some have distorted templates for interpersonal experience that make authentic relatedness a near impossibility. One could fill this page, this blog, maybe this Internet with the ways endowment, experience, and human-ness can tie knots in the complex systems required to live comfortably in the world. We will never have  a diagnostic system to cover all of those bases nor a healthcare policy that can provide relief from all of those knots. What we could expect, however, is a precise diagnostic system that does not include people in inappropriate categories [like Major Depressive Disorder<\/font><\/strong>] that make them an unwitting and inappropriate market for expensive medications that won’t help [and may potentially harm]. It’s a predatory diagnostic category as it stands.<\/p>\n

Dr. Allen Frances is completely correct in saying that the diagnostic system in mental health is rife with opportunities for untoward influence and unintended consequences. In the absence of the longed for biological markers, things are hard enough already, but the addition of industry influence, third party payers, ideological differences among specialties, and the scope of the task at hand, even the best of efforts is bound to need constant vigilance and a willingness to revise and retool frequently. From my perspective, the category Major Depressive Disorder<\/font><\/strong> has been the one most in need of a thorough overhaul from its birth. It appears that it has survived now three revisions untouched, perhaps because no-one can think of a better way to deal with depression. But frankly, I can think of little worse than what we have now. One very real possibility is that the recent DSM-5 Field Trials were actually accurate [kappa = 0.32 in adults and 0.29 in children]. It is not only an overly inclusive and an invalid category as we’ve suspected, but it can’t even be reliably diagnosed. It is certainly not a category for any kind of reliable research [and never has been].<\/p>\n

The problem of overdiagnosis and overmedication was not apparent in 1988 [DSM-IIIR]. I’m not even sure it was that obvious in 1994 [DSM-IV]. But it’s sure clear as a bell right now and has been for a while. As much criticism as the DSM-5 has received in other areas, to my mind those things are small potatoes compared to their failure to tackle the task of revising the categories that address depressive illnesses – particularly Major Depressive Disorder<\/font><\/strong>. It’s the mote in the eye of the DSM…<\/div>\n","protected":false},"excerpt":{"rendered":"

I think what I’m talking about here is the biggest of deals. The topic is about a debate in psychiatry that happened well over a quarter of a century ago, one that really has never been resolved – it just faded away before its time. It has to do with the nature of depressive illness. […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-24540","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/24540","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=24540"}],"version-history":[{"count":57,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/24540\/revisions"}],"predecessor-version":[{"id":24614,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/24540\/revisions\/24614"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=24540"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=24540"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=24540"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}