Jung At Heart

The other day I ran across an article in Scientific American that seems to fit my own musings on the issue of meaning in symptoms. In this article the authors suggest that "depression is not a malfunction, but a mental adaptation that brings certain cognitive advantages", quite in line with my ongoing interest in meaning. 

That cognitive advantage is the tendency among those suffering from depression to dwell on problems by thinking intensely at length about them. 

"Many other symptoms of depression make sense in light of the idea that analysis must be uninterrupted. The desire for social isolation, for instance, helps the depressed person avoid situations that would require thinking about other things. Similarly, the inability to derive pleasure from sex or other activities prevents the depressed person from engaging in activities that could distract him or her from the problem. Even the loss of appetite often seen in depression could be viewed as promoting analysis because chewing and other oral activity interferes with the brain’s ability to process information.

But is there any evidence that depression is useful in analyzing complex problems? For one thing, if depressive rumination were harmful, as most clinicians and researchers assume, then bouts of depression should be slower to resolve when people are given interventions that encourage rumination, such as having them write about their strongest thoughts and feelings. However, the opposite appears to be true. Several studies have found that expressive writing promotes quicker resolution of depression, and they suggest that this is because depressed people gain insight into their problems."

They conclude:

"depression is nature’s way of telling you that you’ve got complex social problems that the mind is intent on solving. Therapies should try to encourage depressive rumination rather than try to stop it, and they should focus on trying to help people solve the problems that trigger their bouts of depression. (There are several effective therapies that focus on just this.) It is also essential, in instances where there is resistance to discussing ruminations, that the therapist try to identify and dismantle those barriers.

When one considers all the evidence, depression seems less like a disorder where the brain is operating in a haphazard way, or malfunctioning. Instead, depression seems more like the vertebrate eye—an intricate, highly organized piece of machinery that performs a specific function."

Now this idea that depression is a positive adaptation is a radical one in a time when antidepressant use is still growing, having doubled between 1996 and 2005. Rather than seeing any advantage to depression, any meaning, the push is to medicate the symptoms away. In today's NY Times, we read --

"news of an uptick in antidepressant sales despite -- or perhaps because of -- the recession was just plain depressing.

Helplessness, pessimism and persistent sadness -- the main symptoms of depression -- didn't seem to abate as the economy crumbled. About 164 million antidepressant prescriptions were written in 2008, 4 million more than in 2007, according to IMS Health, a health-care information and consulting company.

Antidepressants were the third most prescribed type of drug in 2008, hitting $9.6 billion in sales, up from $9.4 billion the year before."

And never mind this almost toss away conclusion to the article:

The most important benefit that antidepressants can provide, of course, is to those taking the medications. While the salutary effects are just the relief that some people need, a few skeptics have theorized that the pills may change a person's mind-set too much.

Nearly a decade ago, Randolph Nesse, a professor of psychiatry at the University of Michigan, suggested that investors numbed by antidepressants would take risky bets and make bad decisions.

They may "become far less cautious than they were before, worrying too little about real dangers," he wrote. He predicted that, as more people turned to prescription medications, the collective effect would cause a Wall Street bubble to grow and burst."

Remember the cognitive advantage of depression -- that it disposes to analytical thinking? Isn't that the kind of thinking that investors and those in the financial industry need? Is it such a good idea to medicate away their ruminations?*

Philip Dawdy pointed me to this last piece, which is of a piece with those I have just cited, at least for me. Titled "I'm One of Those Moms on Meds", she begins by relating a stressful interaction with her three kids in which she yells a lot. And then the next day feels remorseful about her yelling. Discovering from another mother that 2/3rds of the moms she knew were on antidepressants and how calm and level it made them all, she decides to ask her own doctor for a prescription. Nowhere in the article does she indicate that she actually suffers from depression. She yells at her kids, wishes her husband weren't out of town so often, and finds the whirl of running a household stressful, but these do not signify depression. She knows that --

"My doctor said he prescribes mood-enhancing medications about 10 times a week. He showed me a diagram of the brain and how certain medications can restore the balance of serotonin, a natural substance in the brain, which helps improve certain mood problems.

My friend called her doctor to make an appointment and talk about going on Paxil. The nurse said she would just call the script into the pharmacy. No appointment necessary.

These meds are probably overused and too easy to get. I wasn't suffering from depression, which is a very serious problem. Medication has proven to change and save lives of depressed people. I was anxious. I was having meltdowns way too often."

Whatever possessed her doctor to write the prescription for her, given that she has none of the indications for its use? What kept him from suggesting she consider changing how she deals with the kids, carve out more time for herself, try exercise, writing in a journal or even therapy? Chances are he wanted to do *something* for her and writing a prescription was easy and quick and codable for reimbursement. And he may well have known that if he didn't do it, she would find someone who would.

She concludes:

"Maybe moms like me should do more yoga, cut back our responsibilities, see a therapist, exercise more, put duct tape over our mouths every day after 5 p.m. Maybe we should do anything to avoid relying on drugs to become calmer, happier people. For a year I kept thinking I wouldn't feel so stressed out after I met a certain deadline, after school was out, after my youngest quit waking up in the night, after I organized my office, after we went on vacation and once I got to sleep as late as I wanted.

But unlike Hannah/Miley I only have one world. And I don't want to spend it waiting for something to be over. I want to enjoy every minute of it as much as I can."

She knows that there are other solutions, probably better ones, but they wouldn't be as quick and they would require effort on her part and impose changes on her family. But if she takes a pill, then the problem is all hers, no one has to do anything different. It is eerily similar to the rush to Valium, Librium, Miltown, and Equanil tranquilizers in the 50's and 60's, the climate that led to Betty Friedan's book, The Feminine Mystique. Happy pills are not new, nor are the conditions that drive women to seek them. Happiness has become defined as the norm and if it cannot be found without drugs, then the drugs that produce it should be taken. But this version of happiness is one we get from the commercials for the drugs themselves, where the sad stressed person becomes smiling and happy, complete with happy dog next to her after taking the antidepressant. Nowhere is it asked if that is what it means to be happy or what happiness is.

I agree with Dawdy who concludes:

"I know these are deeply-trying times in America (and elsewhere, too, of course). They are for me, too. But turning to a class of drugs known to be dangerous in some cases and with a dizzying host of side effects in many cases doesn't strike me as an intelligent way to operate as a culture. And to write about it all so blithely...well, you just don't know what to say.

Yoga, yes. Prozac, no."

*Before someone accuses me of not understanding that severe depression is is incapacitating, please be aware I am not suggesting that those who suffer from *major* depression should not be treated and most probably with medication. But the majority of those millions of antidepressant prescriptions were not written for people with major depression and it is those millions of other people I am thinking about here.

Stephen Diamond, in his Psychology Today bloghas been writing for some time about anger and his support for inclusion in the upcoming DSM V a new diagnostic category for embitterment:

Posttraumatic Embitterment Disorder (PTED) was first proposed by German psychiatrist Dr. Michael Linden in 2003, based on his clinical work with troubled immigrants from East Germany following the fall of the Berlin Wall. That profound cultural change proved to be quite traumatic for those whose lives were directly affected by it, and the repercussions of this life-changing event--seen almost universally by the rest of the world as a positive development--was felt for years. We in this country are going through some significant social changes of our own. As Linden (2003) observes, some of the debilitating emotional symptoms of those patients meeting his proposed diagnostic criteria for PTED include chronic feelings of injustice, victimhood, helplessness, hopelessness, powerlessness, self-recrimination, aggression, anger, rage, resentment and, of course, embitterment. Such individuals feel they have lost control of their lives and their destiny. The values and structure that once provided a stable sense of self, meaning, purpose and personal or professional identity have been lost or eroded. The old life has been altered irrevocably. The new life has not yet been established, leaving the person in a state of existential limbo.

And he relates the eruptions of anger and hatred surrounding the debates now occurring around health care reform and other changes which some are protesting. Now I agree that the level of rage and bitterness being expressed and the potential for violence concerns me greatly; in fact to me this situation feels volatile and potentially dangerous on a level I have not felt since tremendous summer tensions in the 60's and early 70's. But I have reservations about applying a psychiatric label to reactions to societal changes. As a Jungian I am drawn more to considering meaning here -- what does it mean that these mobs have appeared? What is the meaning in this response to a message that one side sees as holding promise, the other as threatening loss?

When how you view the response to change depends on a political viewpoint, then tagging one side as psychiatrically disordered becomes as much a political response as a clinical one. I support the change in our health insurance program and reform in health care delivery. So, to me, the rage and bitterness being expressed by those who do not seems "disordered." But so was the so-called "Brooks Brothers mob" of the the election of 2000. And that mob was a created one, created to disrupt the efforts to recount the vote. It was created to support a particular political position. 

It has long been a tool in the political toolkit to enflame the passions of people who feel embittered, left behind, not listened to. The Bolsheviks used it as did Hitler, Mussolini,  Huey Long, George Wallace, Lewis Farrakhan. It is a tool being used today as well by a group of politicians and groups on the right who are attempting to gain political advantage. And they are successfully promoting "change" as a threat to the way of life that their constituents desire.

But if I were on the other side in this debate, I might well see the responses of these mobs as a sane and sensible response to conditions that threaten my way of life. Where I stand on the issue determines my view of the responses. Identification of a disorder should not, it seems to me, be so susceptible to political point of view. 

And if we looked at more of the categories in the current DSM and those being proposed, might we not find others that also seem more about a particular point of view than on the existence of a disorder? That was the case with homosexuality after all. 

Regular readers, you know I write often about the mess issues clustering around diagnosis and the DSM. And in the past couple of weeks, I have run across several articles and ads that have continued my questioning about the diagnostic enterprise.

For a number of weeks now, if you watch much television, you likely have seen Brooke Shields talking about Latisse, which purports to make eyelashes longer and thicker. Only instead of being a new kind of mascara, it is actually a prescription medication applied to the eyelid. Now that is a first in my experience -- an ad for a prescription only cosmetic. And in the ad, we hear the term "inadequate lashes", implying a disorder. Which of course sets up the consumer believing her lashes to be too thin or shorter than she would like to now believe her "condition" has a name -- inadequate lashes. As noted by Rob Walker in the NY Times,

"When it sinks in that this is something you need a doctor to obtain, it’s oddly reassuring. Inadequate eyelashes aren’t simply a matter of looks; they’re a problem serious enough that the F.D.A. itself had to be brought in to sign off on a treatment, right? Clearly the logic I’ve just suggested is wrongheaded: the Food and Drug Administration doesn’t offer opinions about what needs treating; it evaluates drugs containing certain ingredients that require approval.But we don’t always evaluate sales pitches with perfect logic. (Well, you do, I’m sure, but you probably know somebody who doesn’t.) And in any case, Allergan isn’t making a disease-related claim about Latisse but rather positioning it, like Botox, as part of what the company calls a “science of rejuvenation.”

John Mack, who publishes the e-newsletter Pharma Marketing News, notes that some critics of contemporary medicine complain of disease mongering — the conversion of what used to be routine dissatisfactions of life into medical conditions, often treatable with drugs. But he agrees that Latisse, like Botox, makes no pretense of addressing a medical condition, just a cosmetic one. What he wonders about are consumers who hear “F.D.A. approved” as meaning “completely safe.” The ad mentions potential side effects like itching and redness and that if Latisse comes into regular contact with the eye there is “potential for increased brown iris pigmentation, which is likely permanent.” The latter had Mack somewhat jokingly fretting on his blog about whether Shields’s baby blues might turn brown. His real point: “Many people don’t read the side effects.”

Hypotrichosis aside, then, Latisse isn’t disease mongering. But is it inadequacy mongering? Defining eyelash adequacy is largely subjective. And if Brooke Shields — who, after all, is basically great-looking for a living — didn’t have adequate eyelashes, who does? Grant says that this is a matter for a patient and a doctor to discuss. He also notes that mascara is a billion-dollar business in the United States.

“Let’s just put it this way,” he says. “There is a very large demand for eyelash enhancement. Eyelashes are a very important part of a woman’s beauty regimen.” Any given individual’s eyelashes may not look inadequate to other people, he allows, but that person still “may feel they are inadequate.” And that, perhaps, is all it takes."

Now, consider these data points:

1. BBC News reports GPs have difficulty spotting depression among their patients, a review of research suggests.

"The researchers, who examined a total of 41 trials, found GPs were able to recognise only about half of people who had clinical depression.

For a typical GP trying to spot depression in an urban practice and seeing 100 cases over two days, there would be 20 true cases of depression.

The GP would correctly diagnose 10 people as depressed but miss about the same number with depression.

Of the remaining 80 non-depressed patients, the GP would be likely to over-diagnose 15 people, and correctly reassure the other 65."

It seems unlikely that US primary care physicians are any more accurate than their British counterparts. And, considering that a large percentage of the prescriptions for antidepressants are written by primary care physicians, we might guess that there are many people given such prescriptions who don't need them and some who do not receive them, or referral to treatment, who do need them.

2. Neuroskeptic, reviewing a study showing St. John's Wort is effective in treating depression, in Germany, concludes"

"The case of St John's Wort also highlights the weaknesses of our current diagnostic systems for depression. According to DSM-IV someone who feels miserable, cries a lot and comfort-eats icecream has the same disorder - "major depression" - as someone who is unable to eat or sleep with severe melancholic symptoms. The concept is so broad as to encompass a huge range of problems, and doctors in different cultures may apply the word "depression" very differently."

How do we know that professionals within the US, coming from differing cultural backgrounds do not also apply the word "depression" differently? The answer? We don't know. No one has looked to see.

3. From Science Daily:

"research involved the study of 82 psychiatric outpatients who reported that they received a previous diagnosis of bipolar disorder that was not later confirmed through the use of the SCID. The diagnoses in these patients were compared to 528 patients who were not previously diagnosed with bipolar disorder. The study was conducted between May 2001 and March 2005.

Zimmerman, who is also an associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, says, "In our study, one quarter of the patients over-diagnosed with bipolar disorder met DSM-IV criteria for borderline personality disorder. Looking at these results another way, nearly 40 percent (20 of 52) of patients diagnosed with DSM-IV borderline personality disorder had been over-diagnosed with bipolar disorder."

The results of the study also indicate that patients who had been over-diagnosed with bipolar disorder were more frequently diagnosed with major depressive disorder, antisocial personality disorder, posttraumatic stress disorder and eating and impulse disorders.

Zimmerman and colleagues note that "we hypothesize that in patients with mood instability, physicians are inclined to diagnose a potentially medication-responsive disorder such as bipolar disorder rather than a disorder such as borderline personality disorder that is less medication-responsive." (text made bold by me)

So even without the concerns being voiced about the process being used to develop the DSM V -- and I will talk more about them soon -- here we can see that the existing system is fraught with problems due to examiner bias, cultural differences, and professional expectations. With these kinds of variance in diagnosis and lack of reliability, I find it hard to have much faith in reported incidence of depression, bipolar illness and other commonly known psychiatric problems. What we see in these incidence figures is how frequently these diagnoses are applied, not how many people actually suffer from these problems.

Also reported all over the news in the last few days is that the number of Americans prescribed antidepressants doubled in the period from 1996 - 2005 while the number of those receiving psychotherapy fell in the same period. The majority of the prescriptions, on the order of 80%, were written by physicians who are not psychiatrists. 

None of this is good news.