A commenter on my post about screening makes an argument in favor of screening and by implication medication for those who would not otherwise seek treatment. As you might guess, I disagreed. Then today Neuroskeptic posted about yet another study showing that antidepressants do not work for mild depression. That study is not news. But he goes on to talk about how we got here in terms of changes in how depression is diagnosed.
" in fact, it's not just not news, it's positively ancient. 50 years ago, at the dawn of the antidepressant era, it was commonly said that most antidepressants don't work in everyone with "depression", they work best in people with endogenous depression, and less well, or not at all, in those with "neurotic" or "reactive" depressions...
"Endogenous" is not strictly the same as "severe", however, in practice, these two concepts have never really been clearly seperated, and they're largely equivalent today, because the leading measure of "severity", the Hamilton Scale, measures symptoms, and arguably these symptoms are mostly (though not entirely) the symptoms of the old concept of endogenous depression. The Hamilton Scale was formulated in 1960 when modern concepts of "minor depressive disorder" and "major depressive disorder" were unknown."
In other words, along the way we lost the ability, using the DSM, to make a distinction that was once made about reactive or neurotic depression. So today we see people whose physicians, usually primary care but not infrequently psychiatrists as well, prescribe medication for grief and other distressing but normal experiences of life.
He goes on:
"Prozac and the other SSRIs changed the game completely. They're much less toxic, the side effects are milder, and you can eat as much cheese as you want. So it's very easy to prescribe an SSRI - maybe it won't work, but it can't hurt, so why not try it...?
As a result, I think, the concept of "depression" broadened. Before Prozac, depression was inherently serious, because the treatments were serious. After Prozac, it didn't have to be. Drug company marketing no doubt helped this process along, but marketing has to have something to work with. Over the past 25 years, terms like "endogenous", "neurotic" etc. largely disappeared from the literature, replaced by the single construct of "Major Depression"."
And only the dinosaurs like me, who trained pre-SSRI, remember the old categories.
The likelihood of a depression screening turning up someone with an endogenous or true major depression is small. Because they will have been identified by someone or themselves beforehand. And if they refuse treatment? Some people do. That is still their right.
Then I read about an effort being undertaken by practicing psychologists to educate the public about issues about psychotropic drugs, a small but one hopes potentially successful effort to have a counter to the massive marketing done by Big Pharma pushing antidepressants and atypical antipsychotics. The campaign, Truth in Drugs, is being undertaken by NAPPP (National Public Awareness Campaign For Practice). It could be that things are beginning to change. Maybe.