Sunday, April 29, 2007

Down in the dumps in the penny press!


An article in the latest issue of Harper's couldn't help but attract our attention here at Stevereads. It's by Gary Greenberg, and it's called 'Manufacturing Depression.'

Greenberg is a practicing psychotherapist, and for the purposes of preparing his article, he gets himself qualified for Massachusetts General Hospital's Depression Clinical and Research Program. The qualification is based on his showing at least two out of the nine symptoms for Minor Depression listed in the latest DSM of the American Psychiatric Association.

Just so we're all completely clear on what we're talking about here, let's list the symptoms that qualify you for this disease:

1. Sadness
2. Diminished Pleasure
3. Weight loss or gain
4. Trouble sleeping
5. Fatigue
6. Malaise
6. Guilt
7. Diminished concentration
8. Recurrent thoughts of death

A minimum of two of these symptoms will get you well on your way to being diagnosed with Minor Depression, a 'condition' which the DSM currently considers 'provisional' - meaning it lacks "the five-digit code that allows doctors to bill insurance companies for treatment." Greenberg's fairly obvious implication is that this approval is only a matter of time. In fact, the implication of Greenberg's entire article is that the gigantic amount of money involved in the medical and pharmacuetical world not only influences but dictates what constitutes medicable mental illness.

Here's Greenberg on the whole subject:

"In this nondescript office building beside the towers and pavilions of Massachusetts General Hospital in Boston, these dedicated people do research that determines whether drugs work - which is to say, whether drugs will come to market as government-sanctioned cures. In the process, they turn complaint into illness, and illness into diagnosis, the secret knowledge of what ails us, what we must do to cure it, and who we will be when we get better. This is the heart of the magic factory, the place where medicine is infused with the miracles of science, and I've come to see how it's done."

Once he's described his symptoms to the doctors involved in the study, they classify him not with Minor Depression but with minor Major Depression, which qualifies him for all kinds of drugs - or placebos, depending on which he's given (which is something even the doctors involved don't seem to inside info on).

And that's the crux of the whole article: placebos. Here's Greenberg again:

"In fact, in more than half the clinical trials used to approve the six leading antidepressants, the drugs failed to outperform the placebos, and when it came time to decide on Celexa, an FDA bureaucrat wondered on paper whether the results were too weak to be clinically significant, only to be reminded that all the other antidepressants had been approved on equally weak evidence."

Greenberg adds a footnote to this that deserves quotation too:

"The advantage of antidepressants over placebos in those trials was an average of two points on the HAM-D, a result that could have been achieved if the patient ate and slept better. The average improvement in antidepressant clinical trials is just over ten points, which means, according to Irving Kirsch, a University of Connecticut psychologist, that nearly 80 percent of the drug effect is actually a placebo effect."

That's pause-inducing stuff. Assuming Greenberg doesn't have any hidden agenda, assuming that unnamed FDA bureaucrat in his private communique doesn't have any hidden agenda, that's pause-inducing stuff.

We here at Stevereads have a long personal history with Clinical Depression ('major' or 'minor' it doesn't matter - if Greenberg's article says anything, it says that) - not personally, but through many, many friends. They span the spectrum of all humanity, these friends and friends of friends: from teenaged girls whose hormonal hurricanes ought to disqualify them from any drugs whatsoever, right up to the father of a former friend, whose basso profundo backporch wisdom was, his son averred, from time to time utterly halted by clouds of black depression.

We've seen co-workers simply stop showing up for work, thereby sacrificing their position. We've seen grown adults squander entire days, entire days, spooning themselves ice cream and watching old reruns on TV in the dark. We've seen fully functioning adults with good jobs and good families break down in uncontrollable tears with no visible provocation.

In all this time, that former friend's sagacious father has been our single and only cautionary tale, and even in that case, there's some cause for concern. And with everybody else we've ever known who claimed to be suffering from 'clinical depression,' the problem runs unsolvably deeper.

The problem is those placebo results. If placebos are out-performing drugs on a regular basis, there's one conclusion that becomes utterly inescapable: something's going on that ISN'T MEDICAL. If all those patients taking placebos were being treated for neck tumors, the placebos would have their normally-negligible effect on the final data. Again, if the placebos are regularly out-performing the medicine, the patients involved AREN'T SUFFERING FROM A MEDICAL CONDITION.

In 2007, saying something like that is equivalent to insisting that the sun revolves around the Earth, but nevertheless. Nevertheless, sugar pills don't reduce tumor growth.

The very hint of this suggestion causes hackles to rise ferociously everywhere, we've found. People are fierce in what they've seen in friends in loved ones - or what they've felt themselves. Time and time again, we've heard of the 'miraculous' effect antidepressants seem to have on those who need them: panic attacks finally controlled, chaotic thoughts finally subdued, wandering listlessness finally banished.

Normalcy, but not exactly. The crabgrass is eliminated from the lawn, yes, but so too are the grasses and flowers. The desperate lows are eliminated (or at least ameliorated) by drugs, but so too are the personal reservoirs of nerve and clutched-at optimism that allow the vast numbers of non-medicated to deal with life's setbacks and disappointments and unfairnesses.

There's a horrible-feeling moment that comes to everybody eventually. Most people slam into it directly after they graduate from college and realize they are now expected to deal with every single one of life's cold demands entirely on their own, outside the umbrella of their parents. But of course the moment can occur at any time in young adulthood; the point is, there comes a moment when every person in the West (needless to say, 'clinical depression' is, in terminology and manifestation, almost entirely absent from the East or Middle East) realizes on some level that they CAN'T GO BACK. They can never return to the time in their lives before they stood bare before bill-collectors, landlords, angry employers. Anybody who's ever stared at a bill they can't possibly pay has yearned to return to that carefree time (even, it should be pointed out, if they've never in fact experienced it before).

And it's more than that. Look at that list of so-called symptoms again: who HASN'T felt at least two of those conditions every day of their lives?
Or three? Even persistently? We've been told, by those personally involved, that 'clinical depression' feels different from this, feels different from simply feeling these things: that sufferers feel these feelings have utterly taken control of their lives - that such feelings aren't just temporary weather but seem permanent and unopposable. We have nothing but sympathy for the afflicted and their friends and loved ones, but we humbly suggest that the bathos of their plight has been buttressed over the past thirty years by the medical, psychiatric, and especially pharmacuetical concerns operative in this country and abroad - concerns that have learned, to the cynical health of their bottom lines, that offering people pricey medical RELIEF from the fact that life doesn't always leave its denizens feeling absolutely, resolutely and at all times happy and content is an extremely lucrative endeavor. But we reserve the right to at least CONSIDER the possibility that people so inclined will grasp at the so-called history, the so-called medical credibility of having a name and documentation and the appearance of clinical viability to make what they feel less ... debatable? blameful? shameful? ... to others and to themselves. We reserve the right at least to WONDER if those afflicted might, just might, feel slightly better saying 'I have clinical depression and don't feel like getting out of bed' than simply 'I don't feel like getting out of bed.'

It's a sad subject either way, but we can't help but wonder what doctors a century from now will make of so-called clinical depression. We can't help but wonder what you, our loyal readers, have to say on the subject. But we'll give the last word to Greenberg, since he opened this particular can of worms:

"I am already deflated when I arrive for my last interview. Of course, there's no place in the HAM-D to express this, to talk about the immeasurable loss that I think we all suffer as science turns to scientism, as bright and ambitious people devote their lives to erasing selfhood in order to cure it of its discontents."

7 comments:

beepy said...

Ok, I'm going to come in from the depths to wade through these muddy shallows. Mostly because I find it impossible to keep my big yap shut.

Have they not done studies which show differences in the brain chemistry between a depressed person and a "normal" person? Something about seratonin? Granted it's all a chicken vs. egg thing. Who knows if seratonin levels are off because of depression or people are depressed because their seratonin levels are off.

Placebos clearly have an effect in some cases but does that mean that depression is "all in the head?" I think not.

Besides, depression is such a general term. It's all a self described condition. There's not an objective test for it that I'm aware of. Of course we all can relate to the list of symptoms; it is part of being human. But what I would describe as malaise is not measurable against what you would describe as malaise. Does that mean that because a placebo cures you, it will cure me? Does that mean that depression doesn't exist except as a illusion in our own minds?

A tumor can be objectively measured. It's so many mm's and located in such and such an area. Tangible terms. If we could only take a patient's word that they had a tumor, I bet you'd find a similar cure rate to this articles. But if we could as accurately describe depression, it's possible that we would find varying degrees and causes. Placebos might work on one kind of depression but so might time. Others might be resistent against everything medical research can throw against it. It seems that this article (and you Steve) are lumping everybody together and trying to dismiss it all.

I know this is all full of logical holes (I'm a manatee, dammit) but I thought that I get the ball rolling and maybe I'll learn something.

Jeff E. said...

I'll pick up that ball. This post has definitely qualified me for one or more of these diagnoses. Thanks a lot Steve for using your blog to give me a medical condition.

My thoughts about this are very open-ended, like this post itself. I'm merely wondering here too, and not at all sure of what I say. I'd like to start by saying that the bald declaration that these conditions are not medical doesn't just kick the condition out of the field of medicine. But we could argue about the definition of the word "medical" 'til we're all blue in our faces (is that listed on WebMD?), but I don't think it would be very productive.

The meat and potatoes of this issue are: can we identify a real problem and, if yes, can we identify the causes. And finally, if yes, can we identify remedies. Sure humans go on crying jags and sometimes don't want to get out of bed in a big way. But would you, Steve, agree that there are *some* non-humdrum cases (however rare they are when compared with common conceptions of these ailments) that qualify as problems so large that they might be more than just signs of the human condition? Unless you're willing to lump ectopic pregnancies and Alzheimer's disease into *just part of the human condition*, I think there are plenty mental problems that so qualify.

So, with a handful of admissible depression cases that are so bad as to render some folks incapacitated or suicidal, what kinds of causes might there be for this? Cases of post-graduation maturation pangs, bad break-ups, and (presumably) other types of losses typical to life seems to rankle the ire of our host, but they certainly still warrant investigation. What do we do when that investigation leads us to test for bio-chemical levels that turn out to be woefully deficient when compared with the wider, healthier population? Hopefully we don't ignore it, but rather use that information to move forward.

Now we're onto my third stage: remedy. If those deficient chemicals could be augmented with little Pfizer-designed pills, what is the moral dilemma in doing so? Is it right to withhold treatment and insist that these sad sacks are responsible for restoring their equilibrium on their own? How would that be different from asking people with recently removed wisdom teeth to just "Take the pain!"? Our august host raised the issues of side-effects. If we grant that there are side-effects, who is to be the judge here? Who should weigh the costs vs. benefits and say, "These pills will allow Mr. Jones to get out of bed in the morning and hold down a job, but he will never make another decent scrap metal sculpture again. Consequently, he must never be allowed to have any."

So even if we accept many of Steve's concerns about authenticity of personality as real concerns, who is in a position to stop our great nation of depressives from willingly demanding and taking the soma? I think the answer is no one, but that drives my point closer to Steve's real concerns: that there are actually strong forces pulling in the opposite direction. It's not so much that they're aren't *any* cases in which Pfizer-designed pills are appropriate, it's that Pfizer (and others) are trying their damnedest to get the whole nation hooked whether they it's their pill that would cure what ails you when sugar would work just as well.

It would be interesting to take this even further, but if this gets any longer it would be downright crude of me. Given more space it would be interesting to discuss the possibility (bullshit klaxons should be sounding now) that our Western-urban society has raced ahead of our ability to keep it together mentally as a species. Perhaps the answer is just a straight yes, 30% or more of our society does belong on mood-elevators. I've asked a lot of questions in this post so I'll just leave it with this one, if that is true about the 30%, is it the place of the 70% to dump all over those unfortunates for not pulling themselves up by their own bootstraps?

Kevin Caron said...

Ooh - this is gonna get good, I can tell.

What if, by defining 'clinical depression' as a medical condition, and by prescribing drugs to counter it, we are doing folks lasting harm? What if being defined as 'clinically depressed' creates something of a self fulfilling prophecy, causing the diagnosed to constantly define their own limitations based on the diagnosis? What if using drugs attacks the symptoms, causing the problem (perhaps 'non-medical' as Steve and Mr. Greenberg suggest?) to continue to be unaddressed, perhaps even hampering one's ability to ever address it? What if changes to diet, exercise, and sleep habits (not to mention life-habits) could help someone demonstrably, but are being tossed aside for easier solutions (i.e. drugs) by patients, by doctors, by parents?

I'm (as usual) a fence sitter on this issue - being very close friends with someone diagnosed with clinical depression has left me asking myself these questions, but also understanding that I've never felt anything close to what he goes through, emotionally, motivationally...

steve said...

All three of you make excellent points (you can tell how genuinely perplexed I am by this whole issue by how NICE I'm being ...), but I'm no clearer on the subject than before.

Beepy, you seem to come perilously close to saying that depression - not the mood, but the alleged medical condition - can't be measured objectively. Of course that goes against every fiber of my Jesuitical being; the MOOD 'depression' might feel different from you to me, but a MEDICAL CONDITION simply cannot, not and retain any pretense of reality.

Jeff, yes: I whole-heartedly agree that there are some cases of clinical depression (I allude to the father of a former friend, one of the only ironclad cases I've personally encountered) that certainly seem 'non-humdrum' - cases where the sufferer isn't at all prone to self-pity or the MOOD depression, cases where it certainly looks like they're objectively, medically AFFLICTED with SOMETHING. I guess I often let my irritation with the REST of the alleged sufferers drown those few (in my opinion) genuine cases out. The vast numbers who irritate me are the people who use the badge of a DSM listing (and the crutch of a 'cure') to VALIDATE what amounts to simple everyday whining. Considering the fact that pharmacuetical companies make boatloads of profit every year, I think it would be silly in the extreme not to suspect them of non-Hippocratic motives.

And Kevin! I'd argue that you HAVE felt things very close to (or exactly the same as) the things your 'diagnosed' friend feels, emotionally, motivationally, etc. Everybody feels these things. My question is this: how many people (especially very, very young people, who are by definition both biddable and lazy) who might identify themselves as a candidate for 'anti-depressant' drugs have ever first tried ANY of the things you mention: healthier diet, regular exercise, regular sleep habits, etc? Without a single exception, every single person I've ever met who claimed to suffer from 'clinical depression' had two things in common: they ate crap and they never, ever exercised. Since the human body has a wide range of nutrition needs AND an evolutionary need for exercise, this state of affairs just deepens my perplexity...

beepy said...

I think that it's when the "whining" stops that we are looking at real depression. As long as someone is "whining" there is the implicit hope that the future might be better, the idea that what is wrong can be fixed. Once the person is no longer complaining about his lot in life, they have given up that hope. That's the difference that I see.

Eli said...

I just read the article in Harpers and came across this response while perusing the net.

As someone who has battled with Major Depression (I went as far as suicide a few years ago), this subject obviously fascinates me.

What I took from the article was that there certainly is a form of 'scientism' being promoted, likely in large part from profit-driven big pharma. We really don't know as much as they'd like us to believe about how serotonin works, not to mention the variety of SSRIs.

But I also got the impression that the author, Greenberg, was really into himself. He came off as snarky and arrogant, obviously baiting his subjects into his own sneaky agenda.

A big logical fallacy he repeatedly used was to build them up as a straw man. He framed their perspective as offering a complete cure to depression, "happiness in a pill". He portrayed their opinion of the mind as a simple machine, capable of being totally manipulated by drugs.

Sure, if you were to watch their commercials you might get the impression these were indeed wonder drugs. But just because ads for Pepsi show the world changing, does that mean it doesn't taste good? The problem is not that the drugs don't work at all, it's that they have a very finicky efficacy. Despite biased flaws inherent in the clinical trial system, they do show a consistent benefit.

I never felt promised more. I've been using Effexor for years now, even through my suicide. And though it obviously didn't cure my depression, it has offered considerable relief - all I've ever heard claimed by prescribing doctors.

And ultimately, without ascribing magical properties, the mind really is nothing more than a machine. Yet these drugs are not claimed to completely change it. They simply give it a little nudge when needed.

Sure there are a variety of environmental and psychological factors that can be dealt with through talk-therapy, no doctor has ever suggested otherwise. The use of drugs is simply to SUPPLEMENT the behavioral process.

As for placebos often being "just as effective", that doesn't mean the drugs don't work. It means they work selectively, that often times people don't respond to certain drugs at all. This is true with many different medical treatments.

Eli said...

I just read the article in Harpers and came across this response while perusing the net.

As someone who has battled with Major Depression (I went as far as suicide a few years ago), this subject obviously fascinates me.

What I took from the article was that there certainly is a form of 'scientism' being promoted, likely in large part from profit-driven big pharma. We really don't know as much as they'd like us to believe about how serotonin works, not to mention the variety of SSRIs.

But I also got the impression that the author, Greenberg, was really into himself. He came off as snarky and arrogant, obviously baiting his subjects into his own sneaky agenda.

A big logical fallacy he repeatedly used was to build them up as a straw man. He framed their perspective as offering a complete cure to depression, "happiness in a pill". He portrayed their opinion of the mind as a simple machine, capable of being totally manipulated by drugs.

Sure, if you were to watch their commercials you might get the impression these were indeed wonder drugs. But just because ads for Pepsi show the world changing, does that mean it doesn't taste good? The problem is not that the drugs don't work at all, it's that they have a very finicky efficacy. Despite biased flaws inherent in the clinical trial system, they do show a consistent benefit.

I never felt promised more. I've been using Effexor for years now, even through my suicide. And though it obviously didn't cure my depression, it has offered considerable relief - all I've ever heard claimed by prescribing doctors.

And ultimately, without ascribing magical properties, the mind really is nothing more than a machine. Yet these drugs are not claimed to completely change it. They simply give it a little nudge when needed.

Sure there are a variety of environmental and psychological factors that can be dealt with through talk-therapy, no doctor has ever suggested otherwise. The use of drugs is simply to SUPPLEMENT the behavioral process.

As for placebos often being "just as effective", that doesn't mean the drugs don't work. It means they work selectively, that often times people don't respond to certain drugs at all. This is true with many different medical treatments.