Medicalizing unhappiness?

[Miklos]

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I recently read an opinion piece by Theodore Dalrymple (a pseudonym for the British social critic and now retired psychiatrist, Anthony Daniels) and found the part below very interesting.

Yesterday, for example, a 21-year-old woman consulted me, claiming to be depressed. She had swallowed an overdose of her antidepressants and then called an ambulance.

There is something to be said here about the word "depression," which has almost entirely eliminated the word and even the concept of unhappiness from modern life. Of the thousands of patients I have seen, only two or three have ever claimed to be unhappy: all the rest have said that they were depressed. This semantic shift is deeply significant, for it implies that dissatisfaction with life is itself pathological, a medical condition, which it is the responsibility of the doctor to alleviate by medical means. Everyone has a right to health; depression is unhealthy; therefore everyone has a right to be happy (the opposite of being depressed). This idea in turn implies that one's state of mind, or one's mood, is or should be independent of the way that one lives one's life, a belief that must deprive human existence of all meaning, radically disconnecting reward from conduct.

A ridiculous pas de deux between doctor and patient ensues: the patient pretends to be ill, and the doctor pretends to cure him. In the process, the patient is willfully blinded to the conduct that inevitably causes his misery in the first place. I have therefore come to see that one of the most important tasks of the doctor today is the disavowal of his own power and responsibility. The patient's notion that he is ill stands in the way of his understanding of the situation, without which moral change cannot take place. The doctor who pretends to treat is an obstacle to this change, blinding rather than enlightening.

The patient who he continues to describe in the piece, appears to me to be a borderline.

Regardless, I think that he raises two very interesting questions about the practice of psychiatry in general. I'd be interesting in your opinion of the following based on his observations.

• Are we medicalizing unhappiness by (unnecessarily) reaching for the prescription pad?
• In withholding judgement on the choices of our patients are we doing them a disservice?

 

[Poety]

I recently read an opinion piece by Theodore Dalrymple (a pseudonym for the British social critic and now retired psychiatrist, Anthony Daniels) and found the part below very interesting.



The patient who he continues to describe in the piece, appears to me to be a borderline.

Regardless, I think that he raises two very interesting questions about the practice of psychiatry in general. I'd be interesting in your opinion of the following based on his observations.

• Are we medicalizing unhappiness by (unnecessarily) reaching for the prescription pad?
• In withholding judgement on the choices of our patients are we doing them a disservice?

There is something to say for those that are just melancholic personalities. I know this first hand as I have plenty of close friends who are just this. I do however, also have experience with those that are truly "depressed". In my personal (NOT PROFESSIONAL) experience (because I can actually SEE what IS happening as opposed to just being subject to the 15 minute med checks with patients) is that a truly depressed person does appear to benefit significantly with medication. I will swear by this until the day I die.

If on the other hand you treat the melancholy personality (i.e. plenty of my friends in med school and/or my ever dramatic writer friends) they seem to be almost resistant to the treatment, needing a multitude of different therapies before one actually works, and even then, its questionable on how significant this impact is.

Now, with that being said, I'm not at all implying that meds don't need to be tweaked, etc etc, but I am saying that I have witnessed, with my own eyes, on 4 different occassions, people that would actually fit the DSMIV criteria for depression to a tee - literally LIFTED out of their bondage and were able to live again after starting therapy. They're able to see things from a better and more positive point of view, they're able to work without being late, they are able to once again enjoy the fruits of their labor. I will say, I was in awe to see this and it truly is a beautiful thing- which ofcourse makes me love psychiatry even more.

Now if you ask me are we overprescribing and overdiagnosing depression - absolultely. Do I think meds are just thrown out willy nilly without thought to the consequences of putting a patient on them? Absolutely. What is most frightening is that it seems a lot of docs are so willing to prescribe anti-depressants as they feel they are so "benign" when in actuality, they are NOT benign medications.

I happen to be of the slant that is all for psychotherapy/counseling/cbt and the like, so I believe medications need to be used in conjunction with the above. By doing this, I don't believe we withold the options for our patients and in turn, end up learning more about what is the MOST appropriate therapy for them.

I guess I would say that depression has definitely began to rear its ugly head with the stressors we as a society have incorporated into our daily lives. However, I agree its being overprescribed when in fact, a little CBT and introspection may work a lot better for a whole lot of people. Unfortunately though, we have speeded up so fast that most people just want the little pill to fix it all - sometimes perhaps its too painful for them to really explore whats going on inside, so you end up with the anxiety ridden patient becoming overwhelmed and ultimately showing up in your office complaining of depression - go figure.

I don't know - these are just my opinions and I'm but a lowly 4th year - I still have so much to learn! 🙂

 

[LM02]

Interestingly, research suggests that Negative Affect and Positive Affect are not opposite ends of a spectrum. Rather, factor analysis has shown that Negative Affect and Positive Affect are largely independent (though slightly negatively correlated) constructs - you can be high or low on NA. But low NA does not equal high PA.

Similarly, (IMO) the opposite of depression is not happiness. Rather, the opposite of depression is not being depressed. As an empirically-driven clinical psychologist, I often work with my patients to establish this distinction. Taking Prozac is not going to "make them happy." But it might help them feel non-depressed. Happiness is an entirely different ballpark. 😉

 

[Poety]

Interestingly, research suggests that Negative Affect and Positive Affect are not opposite ends of a spectrum. Rather, factor analysis has shown that Negative Affect and Positive Affect are largely independent (though slightly negatively correlated) constructs - you can be high or low on NA. But low NA does not equal high PA.

Similarly, (IMO) the opposite of depression is not happiness. The opposite of depression is not being depressed. As an empirically-driven clinical psychologist, I often work with my patients to establish this distinction. Taking Prozac is not going to "make them happy." But it might help them feel non-depressed. Happiness is an entirely different ballpark. 😉

Hi LM, I thought that research suggested that having a negative/pessimistic affect actually contributes to the development in depression? Does this no longer hold any credence?

I do however agree that happiness does not equate not being depressed.... they are completely different entities entirely in my book 🙂

 

[LM02]

Hi LM, I thought that research suggested that having a negative/pessimistic affect actually contributes to the development in depression? Does this no longer hold any credence?

No, you're right. That's the model - formerly called the Tripartite Model, it has since been revised and is now called the Integrative Hierarchical Model. Basically, it suggests that the unique combination of high NA and low PA predict depression. But that doesn't mean that they're opposites on the same spectrum - in other words, they co-occur in people who are depressed.

Re: a pessimistic attitude - that is a cognitive variable that is more proximal to depression. In other words, someone who is high NA is also likely to have a negative cognitive style that may increase vulnerability to a depressive episode.

However, I brought all of this up in my original post to illustrate the research behind the thinking that happiness is not, in fact, the opposite of depression. For example, among non-depressed individuals, you can have someone who is low NA but may not necessarily be high PA. Does that make sense?

Unlike a more medical model categorical approach, this is a more continuous-based approach to understanding vulnerability to psychopathology - which actually happens to be the direction in which DSM-V is going...

(but that's getting way off-topic for this post!).

 

[Poety]

No, you're right. That's the model - formerly called the Tripartite Model, it has since been revised and is now called the Integrative Hierarchical Model. Basically, it suggests that the unique combination of high NA and low PA predict depression. But that doesn't mean that they're opposites on the same spectrum - in other words, they co-occur in people who are depressed.

Re: a pessimistic attitude - that is a cognitive variable that is more proximal to depression. In other words, someone who is high NA is also likely to have a negative cognitive style that may increase vulnerability to a depressive episode.

However, I brought all of this up in my original post to illustrate the research behind the thinking that happiness is not, in fact, the opposite of depression. For example, among non-depressed individuals, you can have someone who is low NA but may not necessarily be high PA. Does that make sense?

Unlike a more medical model categorical approach, this is a more continuous-based approach to understanding vulnerability to psychopathology - which actually happens to be the direction in which DSM-V is going...

(but that's getting way off-topic for this post!).

Actually I love this discussion, go on! We're the only two posting in here anyway haha

I'm applying to res this year and I really do pray I get in somewhere thats big on psychotherapy. I would hate to lose the foundation for all of this by being in a mostly psychopharm focused program.

So this model, I'm fascinated - does it also imply anthying regarding resistance to depression - i.e. I understand that having a high NA with a low PA predict a propensity toward depression, but can alternatively a high PA with low PA be a protective mechanism against it? And also, what about a high PA/high NA, although I imagine that would be more of a bipolar spectrum.

Thanks for sharing your knowledge with me by the way 🙂

 

[watto]

Psychiatry isn't about making people happy--I always find myself coming back to this quote from Dr. Drew (love love love him), who wrote in his book "Cracked" --

"Mental health is defined by one's ability to be fully present and integrated in reality. Of course, that reality might not always be happy. There might be negative experiences. In fact, there will be negative experiences, days that are downright crappy, moments or even years so painful you'll ask why such **** is happening to you. But if you are mentally healthy, you will be able to tolerate such experiences, regulate your emotions. And in the end you will be nourished by something more real than merely 'feeling good."

 

[Poety]

Psychiatry isn't about making people happy--I always find myself coming back to this quote from Dr. Drew (love love love him), who wrote in his book "Cracked" --

"Mental health is defined by one's ability to be fully present and integrated in reality. Of course, that reality might not always be happy. There might be negative experiences. In fact, there will be negative experiences, days that are downright crappy, moments or even years so painful you'll ask why such **** is happening to you. But if you are mentally healthy, you will be able to tolerate such experiences, regulate your emotions. And in the end you will be nourished by something more real than merely 'feeling good."

Great addition to the thread 🙂

 

[50960]

This is a great thread.... 😀

 

[mosche]

Based on what I'm hearing, the OPs article has it right! There does seem to be a paradigm shift -- if only semantically -- from the idea that depression is a deeply seeded mental illness, to the idea that depression is just dissatisfaction with life.

Poety, you mentioned in your original post that your med. school compatriots have been perscribed numerous drugs, and those drugs have been tweaked with "questionable" success. To me that seems to be a wholesale agreement with the original article. Unfortunately, however, I think that physicians all too often want the quick-fix as well. I mean why wouldn't they? After all, failure to provide a quick-fix is proof (at least in gossip circles) that said physician is ineffective.

Patient[I]:"Doc, my wife just ran away with my best friend. I'm really depressed."[/I]
Doctor[/B[I]]:"Okay, take medication and you'll feel much better."[/I]
Wow! He's such a great doctor--I felt depressed and he gave me a miracle drug!

In this example, why would the patient not feel "depressed"? Well, he may not be--he may just be unhappy. Unfortunately, the failure to clarify the meaning of the term actually reiterated the patient's misunderstanding of the word DEPRESSION. Thus the semantic argument is entrenched.

LM02, you made a valid point when you stated that depression and happiness are not antonymns. Happiness and unhappiness are antonymns. If a patient presents with supposed "depression" and expects happiness, what they are really saying is that they are UNhappy -- NOT depressed per se. Now unhappiness may be a component of depression; however, in my humble unskilled opinion, happiness seems to suggest that there is something that the individual can do -- absent medication -- to help themselves.

 

[Poety]

Based on what I'm hearing, the OPs article has it right! There does seem to be a paradigm shift -- if only semantically -- from the idea that depression is a deeply seeded mental illness, to the idea that depression is just dissatisfaction with life.

Poety, you mentioned in your original post that your med. school compatriots have been perscribed numerous drugs, and those drugs have been tweaked with "questionable" success. To me that seems to be a wholesale agreement with the original article. Unfortunately, however, I think that physicians all too often want the quick-fix as well. I mean why wouldn't they? After all, failure to provide a quick-fix is proof (at least in gossip circles) that said physician is ineffective.

Patient[I]:"Doc, my wife just ran away with my best friend. I'm really depressed."[/I]
Doctor[/B[I]]:"Okay, take medication and you'll feel much better."[/I]
Wow! He's such a great doctor--I felt depressed and he gave me a miracle drug!

In this example, why would the patient not feel "depressed"? Well, he may not be--he may just be unhappy. Unfortunately, the failure to clarify the meaning of the term actually reiterated the patient's misunderstanding of the word DEPRESSION. Thus the semantic argument is entrenched.

LM02, you made a valid point when you stated that depression and happiness are not antonymns. Happiness and unhappiness are antonymns. If a patient presents with supposed "depression" and expects happiness, what they are really saying is that they are UNhappy -- NOT depressed per se. Now unhappiness may be a component of depression; however, in my humble unskilled opinion, happiness seems to suggest that there is something that the individual can do -- absent medication -- to help themselves.

So true Mosche, and it really is boggling. How should we as future psychiatrists address the issue of depression vs. unhappiness. In reality, we're not here to bring happiness to people but to actually help restore functioning - so how would people suggest telling people that we cannot merely give them the little pill to make it all better - without a huge backlash on the psychiatric field in general?

Thoughts?

 

[mosche]

You're correct!

I think that it's akin to informing a parent that: little Johnny doesn't need medication, he needs discipline, little Johnny doesn't need medication, he needs parental involvement, etc.... What's unfortunate is that those same kids -- many of whom are just normal kids -- will grow up convinced that they have a mental illness, and will use that excuse to justify every negative emotion or experience that makes them UNhappy! Thus, when they are unhappy, it's beyond their control -- they bear no personal responsibility for their actions, therefore they ought to feel no sense of accountability, remorse, nor any obligation to modify their behavior (unless there is pill that makes it easy). At some point, those who are victimized by these undisciplined individuals will begin to blame the psychiatrists who have encouraged such behavior/thinking. When that happens, psychiatrists will be viewed as the medical professional equivalents of ambulance chasing lawyers who will do ANYTHING for a buck.

 

[Poety]

You're correct!

I think that it's akin to informing a parent that: little Johnny doesn't need medication, he needs discipline, little Johnny doesn't need medication, he needs parental involvement, etc.... What's unfortunate is that those same kids -- many of whom are just normal kids -- will grow up convinced that they have a mental illness, and will use that excuse to justify every negative emotion or experience that makes them UNhappy! Thus, when they are unhappy, it's beyond their control -- they bear no personal responsibility for their actions, therefore they ought to feel no sense of accountability, remorse, nor any obligation to modify their behavior (unless there is pill that makes it easy). At some point, those who are victimized by these undisciplined individuals will begin to blame the psychiatrists who have encouraged such behavior/thinking. When that happens, psychiatrists will be viewed as the medical professional equivalents of ambulance chasing lawyers who will do ANYTHING for a buck.

AMEN! and have you done a child psych rotation yet? OY - there were times my attending and I wanted to SLAP these parents, its AMAZING how some people are with their kids isn't it? Its not even just the matter of discipline, some of the neglect, abuse, and all around dysfunctionality - you wonder if these kids have a chance.

So sad. You need to get 6 point verification and practically level 1 clearance to get a DRIVER'S license, but ANYONE can be a parent - what a shame.

 

[Miklos]

Thanks for the replies, they've given me some things to think about.

For instance, the models mentioned by LM02 do not seem to account for the moods of some of my patients. Though, the unstable affects of boderlines might better be explained by such a model, I just don't see most "normal" people experiencing emotions in that way. In addition, considering depression a completely separate entity, though a very attractive solution, I think has its own problems (for instance, having seen a fair number of undiagnosed bipolars "flip" on unopposed SSRI therapy.) Therefore, a straight line model makes more sense to me. Also, I'm a bit skeptical when it comes to factor analysis.

Regarding the use of anti-depressants, I worry (like mosche above) that it can play into societal notions about people simply wanting a quick fix in the form of a pill. I also wonder if psychiatry is especially vulnerable to reaching for the prescription pad in such an instance, as many of our patients are referred to us by PCPs who presumably have already unsuccessfully tried SSRIs. It is here that I fear that we are often are not able to take a step back and see the whole picture (for various reasons), but in our hurry to help, we start cycling through our formidable arsenal of psychotropics, when that approach may not be necessary.

Might it be a little like prescribing antibiotics for viral illnesses?

Psychiatrist to a patient: "Hey, wait a minute... you might not need another anti-depressant, but you should consider changing some of the things you do."

That might go over like a lead brick with some patients.

 

[LM02]

Thanks for the replies, they've given me some things to think about.

For instance, the models mentioned by LM02 do not seem to account for the moods of some of my patients. Though, the unstable affects of boderlines might better be explained by such a model, I just don't see most "normal" people experiencing emotions in that way. In addition, considering depression a completely separate entity, though a very attractive solution, I think has its own problems (for instance, having seen a fair number of undiagnosed bipolars "flip" on unopposed SSRI therapy.) Therefore, a straight line model makes more sense to me. Also, I'm a bit skeptical when it comes to factor analysis.

Actually, the emerging evidence suggests that depression and mania are not opposite ends of a spectrum. Rather, most experts are now arguing that bipolar and unipolar depression actually represent similar phenomena. What distinguishes the two is that people with "bipolar depression" also have increased vulnerability to mania - almost like some people with unipolar depression may also be prone to comorbid anxiety disorders. This is a very new idea, but one that has considerable research support. For some references, I would read:

Schweitzer et al. (2005). Should bipolar disorder be viewed as manic disorder? Implications for bipolar depression. Bipolar Disorders, 7, 418-423.

Cuellar et al. (2005). Distinctions between bipolar and unipolar depression. Clinical Psychology Review, 25, 307-339.


The Tripartite Model and Revised Integrative Hierarchical Model are specifically models of the shared vs. distinct features of depression and anxiety. They are relatively silent when it comes to other forms of psychopathology.

But, as far as the models go, they present normal human traits on a continuum - for example, at any point in time, we all fall somewhere on the Negative Affect spectrum (from very negative to absent). And perhaps one of the most consistent literatures is that supporting the basic factor structure of personality - Neuroticism, Extraversion, Openness, (and some argue - Conscientiousness & Agreeableness). Essentially, Neuroticism is strongly correlated with Negative Affect and Extraversion is strongly correlated with Positive Affect. We all fall somewhere on the Neuroticism and Extraversion spectra. However, you often find extreme scores among individuals who present with psychopathology.

We know how some of these constructs work in Depressive and Anxiety Disorders, and are just now starting to better understand their relationship to other disorders. For example, there is some evidence that people with bipolar disorder score outside the normal range on Openness (which isn't terribly surprising).

As I referenced above, this literature is going to be very influential in the development of DSM-V. I have spoken with some individuals who are on the DSM committees, and they have suggested that the DSM definitions of depression and anxiety are going to look very different.

 

[mosche]

Miklos and LM02, I'm finding this thread to be one of the most enlightening threads that I've read in this forum. Thank you both for your insights.

Others?

 

[mosche]

Miklos and LM02, I'm finding this thread to be one of the most enlightening threads that I've read in this forum. Thank you both for your insights.

Others?

And also Poety, Psisci, and Watto: Thank you, too! I didn't want anyone to think that their insights weren't appreciated, it's just that the other two had responded most recently.

This must be how people in Hollywood become depressed/unhappy -- they worry too much about who they forgot to "Thank" at the most recent award show 😛 !!

 

[Anasazi23]

Miklos and LM02, I'm finding this thread to be one of the most enlightening threads that I've read in this forum. Thank you both for your insights.

Others?

I don't find that a lot of this pontification will change treatment drastically. Psychological theory is just that - interesting, but theoretical. Factor analysis is not a substitute for clinically observable phenomena. Psychiatrists will still operate on clinically observable symptom complexes, and treat accordingly...not necessarily according to DSM criteria, but by targeting these symptom complexes and prescribing medications which, combined with the complete patient picture, alleviate these symptoms.

Psychiatry, in some ways, is not like other branches of medicine. It is not as easy as reading the practice guidelines for hypertension and operating cookbook style. Black boxes warnings, history of "flips," and lots of other non-DSM phenomena will still factor largely in psychiatrists' treatment decisions.

Overall, however. I completely agree with the "medicalizing of unhappiness" phenomena. I have two patients I'm caring for now...one as an outpatient, and one inpatient, that exemplify this perfectly. Notice that I said one of the patients is an INpatient. Yes, you can be admitted nowadays for being unhappy...but not necessarily depressed. Quick malingering screening questions are equivacal or worse in this patient, yet he still there. In this ever-entitled society, it seems that everyone appears entitled to obtain unabashed happiness. This, as we know, is largely impossible - especially for some with more with so-called "depressed personality," or "depressives." These patients, also not in existence in the DSM, are difficult to treat, and typify the limitations of the DSM and dozens of other clinically observable but non-acknowledged psychiatric phenomena.

Moving borderline personality from axis II to axis I with the intent of reducing hurt feelings in patients and their families, along with other such artificial political doings accomplish little in the scheme of psychiatric treatment, but at least make for interesting historical discussion. I still use terms, and find them most often the most descriptive, from my original copy of DSM I. Then, more phenomenological descriptions of psychiatric illness were to be found. While I support and look forward to psychiatry advancing the neurosciences and psychiatric sciences towards its inevitable growth, the casting aside of 'real world' diagnostic structure toward the favor of manipulated and corrected statistics is somewhat worrisome. Either way, it will be interesting to see how it pans out.

 

[Poety]

I don't find that a lot of this pontification will change treatment drastically. Psychological theory is just that - interesting, but theoretical. Factor analysis is not a substitute for clinically observable phenomena. Psychiatrists will still operate on clinically observable symptom complexes, and treat accordingly...not necessarily according to DSM criteria, but by targeting these symptom complexes and prescribing medications which, combined with the complete patient picture, alleviate these symptoms.

Psychiatry, in some ways, is not like other branches of medicine. It is not as easy as reading the practice guidelines for hypertension and operating cookbook style. Black boxes warnings, history of "flips," and lots of other non-DSM phenomena will still factor largely in psychiatrists' treatment decisions.

Hi Sazi, I actually disagree, I think its our choice as to whether or not we decide to approach the patient with a predominantly psychopharm treatment - but I'm a big psychoanalysis, CBT person so there ya go 🙂 I think getting to know my patient a bit better would help me decide whether or not I'd want to prescribe - I hope I don't become just a pill pusher yuck!

 

[Anasazi23]

Hi Sazi, I actually disagree, I think its our choice as to whether or not we decide to approach the patient with a predominantly psychopharm treatment - but I'm a big psychoanalysis, CBT person so there ya go 🙂 I think getting to know my patient a bit better would help me decide whether or not I'd want to prescribe - I hope I don't become just a pill pusher yuck!

It sounds like you're actually agreeing with what I'm saying. I probably was not clear. I've been on call too much lately. I wouldn't be surprised if I'm less coherent.

The pill-pusher mantra of non-psychiatrists is old and tired, as you'll see in residency...and frankly - overdone. If you're interested in practicing psychoanalysis, for example, you'll appreciate the phenomenological approach to the patient, and be what our forefathers in psychiatry were: masters at descriptive psychopathology and case formulation. By gaining at least some of these skills, you'll be able to integrate your biological, pharmacological, and neuroscientific training in your approach to the patient, and may either decide to prescribe or not prescribe medications.

If you practice CBT, there's nothing to keep you from prescribing a medication to help alleviate symptoms so that the person can quickly return to work while waiting the (often weeks) for CBT to "kick in."

Even if you are a psychoanalyst, you will be required to treat certain conditions (psychiatric and non) with medications. To do otherwise would be unethical and not the standard of care. Psychiatry doesn't fit well into the reductionist model. It's just too diverse, and there's too much we don't know about the pathogenesis of psychiatric disease states to boil down mood disorders into affect continuims and the like. The emerging genetic research will be very useful in the near future.

 

[Poety]

It sounds like you're actually agreeing with what I'm saying. I probably was not clear. I've been on call too much lately. I wouldn't be surprised if I'm less coherent.

The pill-pusher mantra of non-psychiatrists is old and tired, as you'll see in residency...and frankly - overdone. If you're interested in practicing psychoanalysis, for example, you'll appreciate the phenomenological approach to the patient, and be what our forefathers in psychiatry were: masters at descriptive psychopathology and case formulation. By gaining at least some of these skills, you'll be able to integrate your biological, pharmacological, and neuroscientific training in your approach to the patient, and may either decide to prescribe or not prescribe medications.

If you practice CBT, there's nothing to keep you from prescribing a medication to help alleviate symptoms so that the person can quickly return to work while waiting the (often weeks) for CBT to "kick in."

Even if you are a psychoanalyst, you will be required to treat certain conditions (psychiatric and non) with medications. To do otherwise would be unethical and not the standard of care. Psychiatry doesn't fit well into the reductionist model. It's just too diverse, and there's too much we don't know about the pathogenesis of psychiatric disease states to boil down mood disorders into affect continuims and the like. The emerging genetic research will be very useful in the near future.

OHHH NOW I SEE WHAT YOU ARE SAYING - you're RIGHT I agree 100% with all of what you said - although I'm definitely pro psychotherapy - I AM also pro meds in the right setting - so we are on the same page 🙂 I was confused thanks for straightening that out 🙂

 

[LM02]

I don't find that a lot of this pontification will change treatment drastically.

Actually, I agree. At the end of the day, we're in a position where we can only treat Sx. But that doesn't mean that it's not worth our time to increase our understanding of basic processes in psychopathology. Ultimately, it will be research that informs this knowledge, and this knowledge will lead to more targeted interventions.

Psychological theory is just that - interesting, but theoretical.

Actually, this is true for all models of psychopathology - social, psychological and biological. And at this point in time, all we have are conceptual models - some have more empirical support, whereas others have more limited support. With few exceptions, there is no known clear etiology for most of the disorders we treat.

Psychiatrists will still operate on clinically observable symptom complexes, and treat accordingly...not necessarily according to DSM criteria, but by targeting these symptom complexes and prescribing medications which, combined with the complete patient picture, alleviate these symptoms.

Agreed. See above.

... for some with more with so-called "depressed personality," or "depressives." These patients, also not in existence in the DSM, are difficult to treat, and typify the limitations of the DSM and dozens of other clinically observable but non-acknowledged psychiatric phenomena.

Exactly, this highlights the limitations of using a categorical vs. spectrum-based model of psychopathology. Those "depressives" are more easily operationalized on a continuum of depressive Sx. And I further agree with the notion that we shouldn't underestimate the functional impairment that goes along with these subthreshold presentations. So do we stick with a categorical system that continues to leave some of our patients in this diagnostic no-mans-land? The phenomena we treat are more subtle than previously conceptualized (although, arguably, in inpatient and partial hospital settings, you're seeing the not-so-subtle end of that spectrum). 🙂

Moving borderline personality from axis II to axis I with the intent of reducing hurt feelings in patients and their families, along with other such artificial political doings accomplish little in the scheme of psychiatric treatment, but at least make for interesting historical discussion.

Agreed. And from what I understand, it's not going to happen. In fact, my understanding is that there is a big push to completely eliminate the current Multiaxial Assessment in favor of something that will look quite different.

 

[mosche]

It sounds like you're actually agreeing with what I'm saying. I probably was not clear. I've been on call too much lately. I wouldn't be surprised if I'm less coherent.

The pill-pusher mantra of non-psychiatrists is old and tired, as you'll see in residency...and frankly - overdone. If you're interested in practicing psychoanalysis, for example, you'll appreciate the phenomenological approach to the patient, and be what our forefathers in psychiatry were: masters at descriptive psychopathology and case formulation. By gaining at least some of these skills, you'll be able to integrate your biological, pharmacological, and neuroscientific training in your approach to the patient, and may either decide to prescribe or not prescribe medications.

If you practice CBT, there's nothing to keep you from prescribing a medication to help alleviate symptoms so that the person can quickly return to work while waiting the (often weeks) for CBT to "kick in."

Even if you are a psychoanalyst, you will be required to treat certain conditions (psychiatric and non) with medications. To do otherwise would be unethical and not the standard of care. Psychiatry doesn't fit well into the reductionist model. It's just too diverse, and there's too much we don't know about the pathogenesis of psychiatric disease states to boil down mood disorders into affect continuims and the like. The emerging genetic research will be very useful in the near future.

My issue is NOT just with the pill pushing per se, it's with the patient's misunderstanding of the word "depression". When society misuses a medical term and then the misuse of the term is entrenced by a psychiatrist, the patient -- who has pseudo-knowledge of medicine -- expects medication for depression. Unfortunately, the psychiatrist has painted herself/himself into a corner: after all, they admitted that the patient was "depressed". Had they used the term UNhappy, the true meaning of "depression" could have been clarified as opposed to entrenched.

BTW, as an aside, I love the word "pontification"! 😍 I do admit, however, that I'm only a novice!

 

[PublicHealth]

This thread is missing an important article:

http://www.journals.apa.org/prevention/volume1/pre0010002a.html

 

[Poety]

This thread is missing an important article:

http://www.journals.apa.org/prevention/volume1/pre0010002a.html

Nice article, just a thought, could essentially all the placebo effects then be considered as a result of treating "unhappiness" as opposed to depression? I think I'm hitting on the point of my first post in this thread 😕

 

[Miklos]

Nice article, just a thought, could essentially all the placebo effects then be considered as a result of treating "unhappiness" as opposed to depression?

Bingo.

(Though that's not to say that I don't think that clinical depression doesn't exist or that psychopharmacology is ineffective/inappropriate in those cases. However, DSM criteria, as Anasazi points out aren't the be all, end all.)

 

[Poety]

Bingo.

(Though that's not to say that I don't think that clinical depression doesn't exist or that psychopharmacology is ineffective/inappropriate in those cases. However, DSM criteria, as Anasazi points out aren't the be all, end all.)

Especially when considering the personality d/o that tend to learn how the system works, and subsequently say all the right things to get what they are seeking - I definitely think our current system is a bit flawed.

 

[Anasazi23]

My issue is NOT just with the pill pushing per se, it's with the patient's misunderstanding of the word "depression". When society misuses a medical term and then the misuse of the term is entrenced by a psychiatrist, the patient -- who has pseudo-knowledge of medicine -- expects medication for depression.

I agree with you. I struggle with my some of my outpatients, in that they claim to be "depressed and anxious," but are clearly reacting to life events that naturally should evoke those responses.

Unfortunately, the psychiatrist has painted herself/himself into a corner: after all, they admitted that the patient was "depressed". Had they used the term UNhappy, the true meaning of "depression" could have been clarified as opposed to entrenched.

I also agree with this. Someone above mentioned the reaction to a doctor that does NOT prescribe an antibiotic when the patient went through the trouble to take a day off of work, show up to the doctor's office, and report their viral illness symptoms (for which an abx will do nothing). Unfortunately, medicine is a business, and we have customers to please. This can and does put us in awkward positions when patients ask for "something for anxiety."

BTW, as an aside, I love the word "pontification"! 😍 I do admit, however, that I'm only a novice!

Please don't think I was referring to you...just our general discussions about these amorphous topics in general. We all do it. 🙂

 

[mosche]

I agree with you. I struggle with my some of my outpatients, in that they claim to be "depressed and anxious," but are clearly reacting to life events that naturally should evoke those responses.


I also agree with this. Someone above mentioned the reaction to a doctor that does NOT prescribe an antibiotic when the patient went through the trouble to take a day off of work, show up to the doctor's office, and report their viral illness symptoms (for which an abx will do nothing). Unfortunately, medicine is a business, and we have customers to please. This can and does put us in awkward positions when patients ask for "something for anxiety."


Please don't think I was referring to you...just our general discussions about these amorphous topics in general. We all do it. 🙂

I didn't take it personally at all -- I just really think that the word is a great word! 👍