Drugs, Diagnosis, and Despair

On Depression: Drugs, Diagnosis, and Despair in the Modern World - Nassir Ghaemi

What's the angle?
   Ghaemi is a practicing psychiatrist and researcher, also very well read in the western humanistic tradition. I really enjoyed all the history of psychology and medicine he included. His chapter on Hippocrates was one of my favorites, as was his chapter on Lester Havens, his teacher. 
   On the other hand, his "clinical picture" of post-modernism was vague, watery, a straw-man, so his arguments against it didn't go over well; like a grumpy old-man.

What is depression?
   Ghaemi would like for the mental health field to make a distinction between depression disease - whose hallmark is recurrence - and depression non-disease - perhaps resuscitating "neurotic depression" as an apt term. He doesn't draw a hard and fast line between the two - there must be overlap; but his goal is to distinguish, as far as possible, between biologically based depression and psychologically based depression.
   For depression disease, he identifies genetics and early life environment as the "first" causes (the things that make the disease possible) and adverse experiences or events as the "efficient" causes (the things that trigger the disease).

How do you treat depression?

1. Medicine
   Dr Ghaemi, like many of the authors I've read, think that anti-depressants are being overprescribed, but in principle he is in favor of medicating diseases. The key is accurate nosology, and Ghaemi thinks that the DSM has lumped too much into Major Depressive Disorder. He lays out some good rules of thumb (rule of thumbs?)

• As to diseases, make a habit of two things - to help, or at least to do no harm -Hippocrates. Is the disease curable? help. incurable? do no harm. self-limiting? do no harm. "...a Hippocratic approach would avoid medications as much as possible, except where we can clearly help the natural process of healing and with great attention to side effect."
• Osler's Rule: Treat diseases, not symptoms. "if we reject disease-oriented medicine, we are left at the mercy of social forces tending toward overmedication: patients themselves; the pharmaceutical industry; and doctors' own economic interest."
• Holmes's Rule: All medications are guilty until proven innocent. Medications "need not be proven harmful; they do need to be proven safe and effective."
• Use a diagnostic hierarchy: "certain diagnoses should not be made if other diagnoses are present...mood illnesses can produce not only depression and mania but almost any psychiatric symptom."

2. Psychotherapy
   Ghaemi reminds us that not too long ago psychiatrists primarily practiced psychotherapy. Freud and Kraepelin were the founding tree trunk, and various disciples and heretics branched out with theories and therapies. Ghaemi practices psychotherapy quite a bit, and his chapters on "guides" include many in the "existential" psychotherapeutic tradition.

• Victor Frankl: an abnormal reaction to an abnormal circumstance is normal.
• We must learn to suffer. "We must try to reduce needless evil and horrible suffering where possible, but we also need to learn, not only to accept, but to benefit from, whatever suffering remains.
• Rollo May: the therapist enters the circle of the patient's existence wherever the patient happens to be...Usually, the patient comes with a problem...Whatever the problem is, May teaches that the existential therapist meets it first as a person's experience, not as pathology, nor in any other theoretical way.
• Angst and the awareness of death
• Nudging the patient toward the "I am" experience
• Leston Havens: "soundings," probing comments rather than questions
• "motor empathy," using non-verbal communication to empathize
• hold opposing theories in your head at once
• therapy is "successive acts of liberation, not moving speeches or penetrating insights"
•  "I judge the success of psychotherapy in two ways. Does the patient's appearance change? Does he get new friends?"
• the therapeutic alliance; he was convinced that this relationship was the key treatment

 


notes

• depression a sign that we are at a dead end
• using depression to help understand normal problems
• I think the old term (neurotic) - now discarded for the fancier terms "dysthymia" and "generalized anxiety disorder" - was more true to reality
• depression disease vs non-disease
• recurrence key aspect of disease
• "first cause" - genetics (additive, not Mendelian) and early life environment
• "efficient cause" - life events as triggers
• mental health clinicians should be biased against common sense, because anything that comes their way has already failed to respond to it
• depression expressed as psychic vs physical pain, in diff cultures
• disease process vs clinical picture
• the feeling comes first, the rationalization comes later
• in usa, psychiatrists prescribe meds to 82 percent of patients
• psychiatric drugs second most profitable class (cardiology 1st)
• hippocrates - nature wants to heal, physician should aid nature,
• galen - illness is lack of humoral balance, always intervene
• Osler's Rule - treat diseases, not symptoms
• Holme's Rule - all medications are guilty until proven innocent
• recent study: half of people diagnosable with mental illness not in treatment, and half of people in treatment not diagnosable
• history of DSM and depression
• Frankl - an abnormal reaction to an abnormal circumstance is normal
• learn to suffer
• Havens - goal of therapy is "successive acts of liberation"
• Havens - work with comments, empathy, rather than questions
• Havens - "just as conventions and expectations can fix a lethal straitjacket on individual differences, so standards of health on the basis of admirable traits ignore the way human situations an call up the need for the most bizarre qualities"
• "norm" - what is typical in a group
• "normal" - absence of pathological
• "ideal" - theoretical standard
• Havens - "hold your formulations lightly, and let your imaginations grow, remembering that all formulations used to be imagination"