Interesting case: psychopathology that remits with rest?

[stilllooking]

Hopping over from the psychology forum, as y'all seem to have more clinical case discussions.

Female patient in her 30s, seen in a PCMHI context, high-pressure professional job. Presented with depressive and anxious symptoms (much more on the depressive side, but with a lot of work-related anxiety--"pressure to work all the time, terrified of professional consequences of not working hard enough"), reported briefly taking an SNRI as a teenager for anxiety but stopping after "maybe 2-3 months" due to side effects--no other mental health history reported.

In the present, the attending PCP started an SSRI (setraline), the patient responded fairly well (reaching the low mild/high subclinical range on the PHQ), and declined psychotherapy. She also reported "making some improvements in work-life balance" concurrently with the medication. Patient tapered off SSRI after 12 months, did well for about 2 months, and then had a recurrence of severe depressive sx. Tried restarting setraline but stopped after a week due to new/worse side effects. At that point, the patient reportedly cut work back to approximately 45-50 hours a week from 70-80, reported essentially a complete resolution of symptoms, and declined any further medication (and psychotherapy). Remission seems to be continuing entirely 3 months after stopping any treatment (PHQ scores are near 0 and better than at the end of the setraline course, actually), and the patient is currently not receiving any treatment and working approx. 45-50 hours a week. She reported posthoc that during the course of SSRI treatment, residual symptom levels increase when her work hours stayed in the 60-70+ hours per week range consistently.

Based on the fact that the patient's symptoms remitted entirely when work hours were reduced and were reported to be closely correlated with that, I'm wondering if this was severe burnout instead of actual MDD?

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[tr]

MDD is multifactorial and is diagnosed when symptom and duration criteria are met. Circumstances of onset are irrelevant: It doesn't matter whether the episode was precipitated by external stressors or not. I would say in my experience it's somewhat more likely for patients to identify a precipitating stressor for depressive episodes vs not, although obviously unprecipitated episodes occur also.

I don't think there's anything very unusual about the case as described but really, if she can't tolerate her job without psychotropic medication which she otherwise would not require, I would strongly recommend she seek alternative employment.

I have reluctantly prescribed antidepressants for patients in similar situations (temporarily while continuing to urge them to change their situations), and they do seem to help somewhat, but really I think it's an awful thing to have to resort to and just a sorry dystopian commentary on daily life in the US.

 

[stilllooking]

MDD is multifactorial and is diagnosed when symptom and duration criteria are met. Circumstances of onset are irrelevant: It doesn't matter whether the episode was precipitated by external stressors or not. I would say in my experience it's somewhat more likely for patients to identify a precipitating stressor for depressive episodes vs not, although obviously unprecipitated episodes occur also.

I don't think there's anything very unusual about the case as described but really, if she can't tolerate her job without psychotropic medication which she otherwise would not require, I would strongly recommend she seek alternative employment.

I have reluctantly prescribed antidepressants for patients in similar situations (temporarily while continuing to urge them to change their situations), and they do seem to help somewhat, but really I think it's an awful thing to have to resort to and just a sorry dystopian commentary on daily life in the US.

Thanks. Alternative employment is not possible, given the patient's field (think medicine, law, etc), and she seems--by her report--to be doing well working 50 hour weeks (she actually brought in a performance eval that supports this as collateral), possibly better than she did working 80 hour weeks. I'm more just struck by how this patient went from the severe range of the PHQ to low subclinical (essentially no symptoms) simply by adjusting work hours, which makes it seem more like burnout than MDD, because I wouldn't expect that quick or total of remission in a "true" MDD case, even if you removed a precipitating stressor. It's not that the improvement occured but the speed and completeness of it that stuck out to me.

 

[tr]

Thanks. Alternative employment is not possible, given the patient's field (think medicine, law, etc), and she seems--by her report--to be doing well working 50 hour weeks (she actually brought in a performance eval that supports this as collateral), possibly better than she did working 80 hour weeks. I'm more just struck by how this patient went from the severe range of the PHQ to low subclinical (essentially no symptoms) simply by adjusting work hours, which makes it seem more like burnout than MDD, because I wouldn't expect that quick or total of remission in a "true" MDD case, even if you removed a precipitating stressor. It's not that the improvement occured but the speed and completeness of it that stuck out to me.

I guess I don't really see the distinction here. What the heck is "true MDD"? I agree that the correct attribution is likely "miserable because overworked in crappy job" but if she had 5+ symptoms for 2+ weeks, her diagnosis for the purpose of billing is MDD. Speed of recovery is irrelevant.

MDD is a symptom-checklist diagnosis that exists for the purpose of coding/billing and says nothing about underlying causality or pathophysiology. You can't bill for "burnout" so you're not going to code for that. Finis.

If you're interested in pathophysiology of psychiatric illness that's great (I am too) but taking the billing codes as your starting point isn't going to get you too far.

 

[deleted1100659]

I have reluctantly prescribed antidepressants for patients in similar situations (temporarily while continuing to urge them to change their situations), and they do seem to help somewhat, but really I think it's an awful thing to have to resort to and just a sorry dystopian commentary on daily life in the US.

I agree with this, and I do the same thing. Sometimes the job really drives most of the symptoms but even in that scenario SSRIs have had some benefit in my patients. Ideal situation is to quit and find another job, but unfortunately not always that easy.

 

[WisNeuro]

I'm not sure what is all that unusual about someone with depression reporting more symptoms of depression when they are exhausted (80 hour weeks) vs when they are working half that time. I mean, nearly half of the questions on the PHQ-9 would be adversely impacted by most people working that schedule. Throw a predisposition to depression on top of that, and there you go.

 

[aim-agm]

To add to the above, I would make sure you characterized her mood and/or anhedonia well (i.e. is she really depressed and/or anhedonic). Particularly because not all negative moods are depression. Also remember that to meet the criteria for MDD these symptoms need to be fairly severe (depressed mood most the day nearly every day; anhedonia for all or nearly all activities most of the day nearly every day).

That said, the patient was having problems either directly or indirectly because of working excessive hours. This led to development of depression. This in turn ultimately led to reducing her work hours, which improved or resolved the problems she was having. The depression resolved, its function fulfilled.

 

[clausewitz2]

I'm not sure what is all that unusual about someone with depression reporting more symptoms of depression when they are exhausted (80 hour weeks) vs when they are working half that time. I mean, nearly half of the questions on the PHQ-9 would be adversely impacted by most people working that schedule. Throw a predisposition to depression on top of that, and there you go.

I had cause to ask someone recently, "How do you think you should feel about your life when you do literally nothing other than work or sleep?"

 

[WisNeuro]

I had cause to ask someone recently, "How do you think you should feel about your life when you do literally nothing other than work or sleep?"

Yes, and I would also wonder about misinterpretation of PHQ questions without follow-up. For instance, do you actual have little to no interest in hobbies/pleasurable activities, or do you just literally have no time to engage in any other activity besides eating, working, and sleeping? PHQ can be a good starting point, but very often when you get into an actual clinical interview with the patient, the real symptom/severity count differs quite a bit from the screening instrument.

 

[deleted1100659]

Yes, and I would also wonder about misinterpretation of PHQ questions without follow-up. For instance, do you actual have little to no interest in hobbies/pleasurable activities, or do you just literally have no time to engage in any other activity besides eating, working, and sleeping? PHQ can be a good starting point, but very often when you get into an actual clinical interview with the patient, the real symptom/severity count differs quite a bit from the screening instrument.

agreed. Personally I have found it useful in patients who are poor historians/unable to really tell you if they're doing better, so sometimes showing them a dramatic reduction is scores can be a useful data point.

but at the end of the day, the clinical interview and presentation of the patient really says it all

 

[WisNeuro]

agreed. Personally I have found it useful in patients who are poor historians/unable to really tell you if they're doing better, so sometimes showing them a dramatic reduction is scores can be a useful data point.

but at the end of the day, the clinical interview and presentation of the patient really says it all

Yeah, people unfortunately put too much stock in self-report alone. In a personal example, as PTSD was my big clinical area in grad school, and through clinical work and projects through my thesis and dissertation I have done hundreds of PTSD interviews. On self report for the PCL, almost everyone presenting with symptoms endorses flashbacks (a relatively unusual symptom). In clinical interview, when what a flashback constitutes is explained, generally less than 5% endorsed it as a symptom. Clinicians take for granted that they know what the questions are asking for, but that many laypeople may misinterpret.

 

[calvnandhobbs68]

Yes, and I would also wonder about misinterpretation of PHQ questions without follow-up. For instance, do you actual have little to no interest in hobbies/pleasurable activities, or do you just literally have no time to engage in any other activity besides eating, working, and sleeping? PHQ can be a good starting point, but very often when you get into an actual clinical interview with the patient, the real symptom/severity count differs quite a bit from the screening instrument.

yep, lots of kids check off the anhedonia question and then when you ask them about it they're like "oh yeah I just don't have time to do stuff, I'd like to do it if I had time". Probably happens at least once every 1-2 weeks with me.

I use questionnaires on nearly all my patients but use to help target asking about elevated symptoms. So, if someone is giving me a 0-1 for "depressed mood", probably isn't worth it to go in depth with them about if their mood REALLY isn't depressed, but if someone gives me a 3 for anhedonia or a 3 for sleep, probably worth it to find out more about what that means.

 

[smalltownpsych]

My own experience is that effective self-care is often the best medicine for the average person‘s depressive symptoms. I am actually more surprised when I see the rapid resolution of symptoms with a medication alone. in general, stress is the trigger for mental health symptoms. Put people into distressing circumstances long enough and they will get symptoms, some people are more resilient and some are more vulnerable and the symptoms will vary depending on the individual. Some are more prone to depression, some anxiety, and some psychosis. Lack of sleep, lack of control, exposure to trauma, illnesses, major losses, relationships problems, high stress job, addiction or misuse of substances: these are some of the stressors. Address any of these and symptoms will improve. It is one reason why people get better pretty quickly in a hospital setting.

 

[tr]

It is one reason why people get better pretty quickly in a hospital setting.

Say what. Have you been on an inpatient unit lately? Just walking into there is stressful. Never mind if you actually are powerless to leave. 😳
I think of inpatient care as more of a necessary evil for safety/med titration than a beneficial 'therapeutic milieu'.

 

[calvnandhobbs68]

Say what. Have you been on an inpatient unit lately? Just walking into there is stressful. Never mind if you actually are powerless to leave. 😳
I think of inpatient care as more of a necessary evil for safety/med titration than a beneficial 'therapeutic milieu'.

Idk this is definitely the case pretty frequently on child/adolescent inpatient units (which are also much nicer than adult units frequently to be fair). Take the kid out of the interpersonal conflicts with parents/friends, out of school stressors and quite a few of the really anxious kids perk up.

 

[smalltownpsych]

Say what. Have you been on an inpatient unit lately? Just walking into there is stressful. Never mind if you actually are powerless to leave. 😳
I think of inpatient care as more of a necessary evil for safety/med titration than a beneficial 'therapeutic milieu'.

Our inpatient unit, even the adolescent, in this relatively small community is pretty calm. As far as therapeutic milieu, don't know if that really exists in hospital settings anymore, I was referring more to the removal from the external stressors.

 

[stilllooking]

Thanks for the thoughts. I did get a chance to query some of the items on the PHQ, and the symptoms endorsed were all related to work (i.e., the patient initially endorsed suicidality but in the specific context of "if I kill myself, then I won't have to work and I won't get yelled at for not working," "I can't engage in [pleasurable activities] because I know I should be working more," etc)--literally the entire interview was work focused, and the patient reported minimal/no distress in other areas (good friendships, good long-term romantic relationship, etc). As for "true" MDD, I always conceptualize MDD as being a pervasive, cross-domain issue, even accounting for the influence of triggers or the impairment being better or worse in some areas than others. Such narrowly focused symptomology, impairment, etc, seemed more in line with burnout, even if you can't bill for that.

 

[aim-agm]

Thanks for the thoughts. I did get a chance to query some of the items on the PHQ, and the symptoms endorsed were all related to work (i.e., the patient initially endorsed suicidality but in the specific context of "if I kill myself, then I won't have to work and I won't get yelled at for not working," "I can't engage in [pleasurable activities] because I know I should be working more," etc)--literally the entire interview was work focused, and the patient reported minimal/no distress in other areas (good friendships, good long-term romantic relationship, etc). As for "true" MDD, I always conceptualize MDD as being a pervasive, cross-domain issue, even accounting for the influence of triggers or the impairment being better or worse in some areas than others. Such narrowly focused symptomology, impairment, etc, seemed more in line with burnout, even if you can't bill for that.

You can call it an "Other specified stressor related disorder"

 

[calvnandhobbs68]

Thanks for the thoughts. I did get a chance to query some of the items on the PHQ, and the symptoms endorsed were all related to work (i.e., the patient initially endorsed suicidality but in the specific context of "if I kill myself, then I won't have to work and I won't get yelled at for not working," "I can't engage in [pleasurable activities] because I know I should be working more," etc)--literally the entire interview was work focused, and the patient reported minimal/no distress in other areas (good friendships, good long-term romantic relationship, etc). As for "true" MDD, I always conceptualize MDD as being a pervasive, cross-domain issue, even accounting for the influence of triggers or the impairment being better or worse in some areas than others. Such narrowly focused symptomology, impairment, etc, seemed more in line with burnout, even if you can't bill for that.

You can bill for an adjustment d/o with depressed mood. If it's clearly related to the stressor and resolves when the stressor remits, I'd tend towards an adjustment d/o.

 

[watto]

Yes, I agree with Adjustment Disorder. It makes sense to dig a little into what are the predisposing factors that allow this stressor to be so profoundly severe for the patient, and make those the target for psychotherapy. Many times, it's a difficulty allowing boundary-setting as this implies the person is "worth" having boundaries set to protect themselves. And that lack of self-worth has its own etiology.

 

[smalltownpsych]

I would think the only medication that could help you to feel better when you are working 70 to 80 hours a week would be adderall.
Also, even though the DSM is extremely limited in a lot of ways, it is a great starting point and relying on the criteria helps keep one grounded conceptually. In other words, if the actual criteria are met for MDD even if it is just the one cause, then that would still be the most appropriate dx. It sounds like that could potentially be the case given the suicidal thinking. Whether it resolves quickly due to life changes or medication changes is not part of the diagnostic differential, nor is the cause of it.

 

[sloh]

I would think the only medication that could help you to feel better when you are working 70 to 80 hours a week would be adderall.

Sounds like a splendid idea.

 

[erg923]

Our inpatient unit, even the adolescent, in this relatively small community is pretty calm. As far as therapeutic milieu, don't know if that really exists in hospital settings anymore, I was referring more to the removal from the external stressors.

I have one of those crazy Aunts...you know the Qanon type? When she group texts us my only reply at this point is "I think you should be in a smelly mental institution for the clinically goofy. Now please stop." I'm really thinking like 50s-60s rubber room stuff for her. Can we go back to this, by any chance? Maybe not for the teens though....

 

[SeniorWrangler]

The usual process is sounds like adjustment disorder-> I can’t get paid for that -> maybe MDD?

Patient’s stressors decreased and she got better without meds, res ipsa loquitur

 

[stilllooking]

I would think the only medication that could help you to feel better when you are working 70 to 80 hours a week would be adderall.
Also, even though the DSM is extremely limited in a lot of ways, it is a great starting point and relying on the criteria is a good starting point. In other words, if the actual criteria are met for MDD even if it is just the one cause, then that would still be the most appropriate dx. It sounds like that could potentially be the case given the suicidal thinking. Whether it resolves quickly due to life changes or medication changes is not part of the diagnostic differential, nor is the cause of it.

I just question the ethics/morality of giving the patient an MDD dx when it seems more in line with an adjustment disorder, being so causally linked to a specific stressor.

 

[nexus73]

Classic case of psychological claudication.

 

[Taddy Mason]

I just question the ethics/morality of giving the patient an MDD dx when it seems more in line with an adjustment disorder, being so casually linked to a specific stressor.

Part of me dies every time I have to put MDD for billing purposes for patients who clearly aren’t depressed or where depressive symptoms are clearly secondary to personality or something external. I’ve been able to find some peace of mind with “unspecified depressive disorder.” Just my two cents but I really dislike check box psychiatry and context is very often under appreciated, if not flat out ignored, when making diagnoses and can offer a lot in regard to informing treatment, prognosis, etc.

 

[calvnandhobbs68]

Part of me dies every time I have to put MDD for billing purposes for patients who clearly aren’t depressed or where depressive symptoms are clearly secondary to personality or something external. I’ve been able to find some peace of mind with “unspecified depressive disorder.” Just my two cents but I really dislike check box psychiatry and context is very often under appreciated, if not flat out ignored, when making diagnoses and can offer a lot in regard to informing treatment, prognosis, etc.

Do you guys really not get paid for billing adjustment d/o for outpatient visits? I've seen patients who had psychotherapy billed for 6 months straight for adjustment disorder. I get the classic "need a more serious diagnosis" for billing at times, but that's usually been for inpatient/higher levels of care in my experience. Even the APA gives an example of 99213 as "patient seen for adjustment disorder and referred to therapy".

 

[Taddy Mason]

Do you guys really not get paid for billing adjustment d/o for outpatient visits? I've seen patients who had psychotherapy billed for 6 months straight for adjustment disorder. I get the classic "need a more serious diagnosis" for billing at times, but that's usually been for inpatient/higher levels of care in my experience. Even the APA gives an example of 99213 as "patient seen for adjustment disorder and referred to therapy".

More so on the inpatient side in regard to billing. Outpatient it’s mainly when just inheriting patients or covering for colleagues.

 

[mistafab]

DSM is a language for physicians. We see XYZ then they have ABC. We all can agree on ABC when we see it, thats all it is.

If the patient meets criteria for MDD, then they have MDD. Not adjustment disorder. DSM doesnt care about causality.

From the perspectives view of psychiatry, which aims to say WHY things happen, then we can easily understand how a terrible work/life balance can push someone into MDD, and resolve after ameliorating that situation. Very common for ongoing stressors to be contributing to, or trigger the onset of a depressive episode.

PHQ9 and similar inventories have their own drawbacks. I do want to clarify just because the score is 26 or what have you, that doesnt mean they have MDD. MDD is a clinical diagnosis, PHQ9 is a screener and does not replace a clinical interview. OTOH it is a number and as scientists we like to track things over time, which is nice. It can also save time for providers in certain cases. But just because a PhQ9 suggests depression, I wouldn't call them MDD off the bat.

Edit: as an aside, im a bit bitter about the phq9. You get a patient with “severe depression” with high PHQ9s. turns out they are getting points for medical problems, or show up with a personality disorder. Now you have to clean up the garbage in the chart and fix the real problem.

 

[Taddy Mason]

DSM is a language for physicians. We see XYZ then they have ABC. We all can agree on ABC when we see it, thats all it is.

If the patient meets criteria for MDD, then they have MDD. Not adjustment disorder. DSM doesnt care about causality.

From the perspectives view of psychiatry, which aims to say WHY things happen, then we can easily understand how a terrible work/life balance can push someone into MDD, and resolve after ameliorating that situation. Very common for ongoing stressors to be contributing to, or trigger the onset of a depressive episode.

Which is one (of many) beefs I have with the DSM. An aortic dissection, MI, and PE can all present very similarly on subjective report of symptoms but have very different underlying etiologies, pathophysiology, and treatment. We don’t just lump them together as “chest pain disorder,” cover our bases treatment wise and call it a day. Without labs, imaging, etc. we’re pretty much left taking a more thorough history and exam to hone in on diagnosis and inform next steps - why should psychiatry be any different?

Also, medical conditions are exclusionary and the means by which an untreated sleep disorder contributes to depressive symptoms can overlap considerably with the means by which ****ty work/life balance contributes to depressive symptoms. The delineation between the latter qualifying for MDD and the former not is completely arbitrary. Similar issues with SUDs and some external stressors (e.g., bereavement, job loss) being considered exclusionary.

 

[tr]

Which is one (of many) beefs I have with the DSM. An aortic dissection, MI, and PE can all present very similarly on subjective report of symptoms but have very different underlying etiologies, pathophysiology, and treatment. We don’t just lump them together as “chest pain disorder,” cover our bases treatment wise and call it a day. Without labs, imaging, etc. we’re pretty much left taking a more thorough history and exam to hone in on diagnosis and inform next steps - why should psychiatry be any different?

Uh, that's because we don't actually know the pathophysiology for most psychiatric disorders the way we know it for MI and PE.

Researchers are working hard to fill in some of the blanks but it's definitely still a very blurry picture. Clinically we are mostly still in the 'chest pain disorder' stage of understanding.

 

[Alemo]

"Classic chest pain disorder, CPD for short! What does the evidence say are approved treatments for CPD? Here's an RCT from Smart Scientist University looking at thousands of patients with CPD. Tramelpeon is the drug of choice for this condition, works slightly better than chance! Don't worry son, millions of NIMH dollars are being spent every year to find a cure for chest pain disorder and rid the human race of this terrible scourge forever."

 

[clausewitz2]

Uh, that's because we don't actually know the pathophysiology for most psychiatric disorders the way we know it for MI and PE.

Researchers are working hard to fill in some of the blanks but it's definitely still a very blurry picture. Clinically we are mostly still in the 'chest pain disorder' stage of understanding.

Come now, we're at least at the 'pleurisy v. angina' stage, our phenomenology is at least Galenic in sophistication...

I am going to take a pessimistic stand and declare myself for mind-body supervenience, i.e. there cannot be differences between mental states without differences between neural states but mental states cannot in principle be reduced without residue to specific neural states. This has obvious negative implications for the prospect of finding 'the' pathophysiology of anything.

 

[stilllooking]

DSM is a language for physicians. We see XYZ then they have ABC. We all can agree on ABC when we see it, thats all it is.

If the patient meets criteria for MDD, then they have MDD. Not adjustment disorder. DSM doesnt care about causality.

From the perspectives view of psychiatry, which aims to say WHY things happen, then we can easily understand how a terrible work/life balance can push someone into MDD, and resolve after ameliorating that situation. Very common for ongoing stressors to be contributing to, or trigger the onset of a depressive episode.

PHQ9 and similar inventories have their own drawbacks. I do want to clarify just because the score is 26 or what have you, that doesnt mean they have MDD. MDD is a clinical diagnosis, PHQ9 is a screener and does not replace a clinical interview. OTOH it is a number and as scientists we like to track things over time, which is nice. It can also save time for providers in certain cases. But just because a PhQ9 suggests depression, I wouldn't call them MDD off the bat.

Edit: as an aside, im a bit bitter about the phq9. You get a patient with “severe depression” with high PHQ9s. turns out they are getting points for medical problems, or show up with a personality disorder. Now you have to clean up the garbage in the chart and fix the real problem.

This is really my frustration with the diagnosis/DSM in this case. This patient and a patient with endogenous, frequently relapsing MDD from young adulthood on both meet the criteria for MDD, yes, but they are two very different patients in terms of their course, arguably the etiology, the prognosis, and honestly the treatment. I know that this imperfection of the DSM is the best we have right now, but seeing this case where it is really resulting in this patient getting what is, in my clinical opinion, an overstigmatizing and questionably accurate diagnostic label is just frustrating. We know from studies of resident depression that overwork throws a sizable chunk of people into MDD-like symptoms, but labeling all of that as the same as, say, recurring longstanding MDD seems to loose much of what is actually going on clinically.

That turned into a bit of a vent, sorry.

 

[whopper]

Working 80 hours a week is enough to drive up the PHQ-9 or GAD-7 at least 5 points, likely more IMHO. IMHO, there ought to be a large database showing how many hours/week of work increases the numbers. Also see if certain professions have higher or lower numbers vs other professions. This could be the modern day equivalent of a Holmes and Rahe scale.

I've seen toxic jobs increase those scales well over 10 points.

Medication is not the only solution to treat depression or anxiety and meds don't even work that well per the STAR*D.

 

[tr]

Come now, we're at least at the 'pleurisy v. angina' stage, our phenomenology is at least Galenic in sophistication...

I am going to take a pessimistic stand and declare myself for mind-body supervenience, i.e. there cannot be differences between mental states without differences between neural states but mental states cannot in principle be reduced without residue to specific neural states. This has obvious negative implications for the prospect of finding 'the' pathophysiology of anything.

I don't think one needs to invoke metaphysics at this level. I lean towards epiphysicalism a la Immanuel Kant/Donald Hoffmann but I can't function in the world without referring to the causality of a thrombosis for the clinical appearance consistent with PE, and I see no reason why we should not one day be able to speak similarly about psychiatric illnesses.

 

[Alemo]

I don't think one needs to invoke metaphysics at this level. I lean towards epiphysicalism a la Immanuel Kant/Donald Hoffmann but I can't function in the world without referring to the causality of a thrombosis for the clinical appearance consistent with PE, and I see no reason why we should not one day be able to speak similarly about psychiatric illnesses.

Idk if I’m weird but I’m starting to near-exclusively care about this stuff (and concurrently less so about “what new drug the Carlat Report podcast told me treats ‘bipolar depression’”).

Obviously we’ve got to keep up with the algorithms (crummy as they are) to keep helping patients and rake in that sweet psychiatry coin, but unless it’s a neurobiological breakthrough or nosological shift, I just…can’t.

 

[clausewitz2]

I don't think one needs to invoke metaphysics at this level. I lean towards epiphysicalism a la Immanuel Kant/Donald Hoffmann but I can't function in the world without referring to the causality of a thrombosis for the clinical appearance consistent with PE, and I see no reason why we should not one day be able to speak similarly about psychiatric illnesses.

As Jerry Fodor once put it, nothing cramps one's causal powers like not existing. I think the ontological status of that clot in the pulmonary vasculature and the mechanistic pathways that give rise to clinical symptoms as a direct result is different from whatever particular combination of environment, genes, neurobiology, random in-utero events, etc. that ultimately leads to a particular individual having one of the many things called schizophrenia.

It would be a bit like PE being caused by a thrombosis in one case, and in another case by being overheated. In other words, I am pessimistic about even common proximal causes.

 

[clausewitz2]

Idk if I’m weird but I’m starting to near-exclusively care about this stuff (and concurrently less so about “what new drug the Carlat Report podcast told me treats ‘bipolar depression’”).

Obviously we’ve got to keep up with the algorithms (crummy as they are) to keep helping patients and rake in that sweet psychiatry coin, but unless it’s a neurobiological breakthrough or nosological shift, I just…can’t.

This means you're paying attention.

 

[smalltownpsych]

This is really my frustration with the diagnosis/DSM in this case. This patient and a patient with endogenous, frequently relapsing MDD from young adulthood on both meet the criteria for MDD, yes, but they are two very different patients in terms of their course, arguably the etiology, the prognosis, and honestly the treatment. I know that this imperfection of the DSM is the best we have right now, but seeing this case where it is really resulting in this patient getting what is, in my clinical opinion, an overstigmatizing and questionably accurate diagnostic label is just frustrating. We know from studies of resident depression that overwork throws a sizable chunk of people into MDD-like symptoms, but labeling all of that as the same as, say, recurring longstanding MDD seems to loose much of what is actually going on clinically.

That turned into a bit of a vent, sorry.

I agree with what you say and will go on rants all day long about DSM or insurance or just about anything in mental health, but wonder why MDD is more stigmatizing than Adjustment Disorder with depressed mood? To me stigma is a social-cultural thing and most people outside of our narrow field know about or even care about the distinction. In my experience society is stigmatizing and misunderstanding all of our patients regardless of diagnosis.

 

[watto]

I agree with what you say and will go on rants all day long about DSM or insurance or just about anything in mental health, but wonder why MDD is more stigmatizing than Adjustment Disorder with depressed mood? To me stigma is a social-cultural thing and most people outside of our narrow field know about or even care about the distinction. In my experience society is stigmatizing and misunderstanding all of our patients regardless of diagnosis.

It is odd that they can present exactly the same, down to suicidality, but with one, you may be seen as being extraordinarily thin-skinned.

 

[erg923]

It is odd that they can present exactly the same, down to suicidality, but with one, you may be seen as being extraordinarily thin-skinned.

Stock brokers (and many others) jump off the tops of buildings. Not all of them qualify/qualified for "MDD." Psychiatry treats symptoms, not diagnoses.

This is just how it is, no matter how many people/psychiatrists may want it to be otherwise.

 

[Taddy Mason]

Uh, that's because we don't actually know the pathophysiology for most psychiatric disorders the way we know it for MI and PE.

Researchers are working hard to fill in some of the blanks but it's definitely still a very blurry picture. Clinically we are mostly still in the 'chest pain disorder' stage of understanding.

I’m acutely aware of that. But lumping persistently low mood states that are autonomous v. reactive, or manifest after a prolonged stressor v. an acute stressor, or significant stressor v. more minor stressor, etc. into one broad category does a disservice to working towards filling in those blanks - I have a hard time believing that they remain homogeneous at more granular levels. Also, with our current level of understanding delineating those details can meaningfully inform prognosis and treatment more so than the label of MDD.

 

[smalltownpsych]

I’m acutely aware of that. But lumping persistently low mood states that are autonomous v. reactive, or manifest after a prolonged stressor v. an acute stressor, or significant stressor v. more minor stressor, etc. into one broad category does a disservice to working towards filling in those blanks - I have a hard time believing that they remain homogeneous at more granular levels. Also, with our current level of understanding delineating those details can meaningfully inform prognosis and treatment more so than the label of MDD.

That is looking at it too rationally and as though you are an actual medical doctor trying to help your patients address a complex bio-psycho-social problem. It is a lot easier to market that there is a condition called Major Depressive Disorder that tens of millions of people in the US have and we have pharmaceutical agents that will manage it. Lot more money in the latter too. Maybe my cynical side is showing.

 

[clausewitz2]

I’m acutely aware of that. But lumping persistently low mood states that are autonomous v. reactive, or manifest after a prolonged stressor v. an acute stressor, or significant stressor v. more minor stressor, etc. into one broad category does a disservice to working towards filling in those blanks - I have a hard time believing that they remain homogeneous at more granular levels. Also, with our current level of understanding delineating those details can meaningfully inform prognosis and treatment more so than the label of MDD.

This is even avoiding the people who fail the dexamethasone suppression test v. those who don't; this line of research died in its infancy because when you consider all of them as having one "MDD" construct you of course can't make heads or tails of it but the people who fail this test do not seem to be the same in a number of ways as the average person who does.

Geigy initially was very resistant to the idea of impiramine being marketed as an anti-depressant because they didn't feel like depression was a common enough thing to be a sustainable market. They wanted their own version of Thorazine and hoped imipramine would be it. Roland Kuhn ends up discovering the fact that it's useless for his chronic schizophrenic inpatients but it did seem to make them way more interested in doing things, less withdrawn, and happier seeming. Roland Kuhn presents this at a conference and captures the imagination of some American colleagues. Donald Klein and Max Fink had to beg Geigy to let them test this more formally and they reluctantly agreed to send a supply. They start a pilot study, thinking they might have a "supercocaine" on their hands, but no, the "anhedonic, anorexic, insomniac patients" they gave it to started sleeping better, eating better, and after a few weeks had an experience of radical transformation, one of them commenting that "the veil has been lifted".

When they talked about depression in those days, they obviously meant something with only limited overlap with the majority of people who get slapped with an MDD label these days, I think it is fair to say.

 

[Taddy Mason]

When they talked about depression in those days, they obviously meant something with only limited overlap with the majority of people who get slapped with an MDD label these days, I think it is fair to say.

While of one of the aims of the DSM was to make our diagnoses more “reliable” the arbitrary lumping of neurotic depression with the what was considered unipolar depression at the time into MDD to appease the psychoanalytic powers that were, was more of a step back than a step forward.