Tuesday, April 10, 2007

Who Should be Treated?

I want to update my take on the overdiagnosis of depression. Excellent reader comments, in combination with my realization that I wrote my prior post in haste, have led me to detail my ideas further.

Depression Diagnosis is Arbitrary: As an astute reader (Dr. BK) pointed out, there is no doubt that having to meet a selected number of symptoms to qualify for a diagnosis will always leave some room for error. In the case of depression, it’s a lot of error, as someone could have only three symptoms of depression and not qualify for a depression diagnosis. If these are really nasty symptoms (say, extreme sadness and guilt along with suicidal ideation), then it’s a little odd to say the person is not depressed.

But let’s not get all tied up in the DSM definition of depression – I could go on regarding this topic for days.

I have two more main concerns.
1. Expanding the boundaries of depression and anxiety to indicate that less severity = you still need treatment.
2. If someone is experiencing depression/anxiety as a normal reaction to some sort of loss, is treatment a good idea?

Expanding the Boundaries. It seems that expanding the boundaries of depression and anxiety, meaning stating that more people with less severe manifestations of these conditions require treatment, is based on a very shoddy foundation. It’s somewhat like lowering the threshold for what constitutes high blood pressure or high cholesterol. Treatment may help some of these people who did not “need” intervention until recently, but the great majority of them will see no benefit. Likewise, if we move the bar from, say, more depressed than 85% of the population to more depressed than 60% of the population, is there any long-term (or even short-term) benefit from treatment? Are we really reducing the risk that these folks will become more depressed and more anxious later in life? Are we improving their quality of life?

And let’s face it – these people, the “worried well,” are in large part not receiving psychotherapy. And there is not much data to say that if they did receive therapy, they’d be any better off. We know that psychotherapy works fairly well with folks who have various DSM conditions, but for these lower grade problems, I don’t think there is much supportive evidence. I believe that psychotherapy may indeed help some of them, but like I said, the point is relatively moot, as expanding diagnostic boundaries leads to more people receiving meds, with a somewhat negligible effect on those receiving psychological intervention.

To my knowledge, no drug has any consistent data to support its use in this group of “patients,” and this is certainly true for long-term outcomes. So, if we’re going to treat people who have mild anxiety and/or depression, keep in mind that it is based on hope (for profits and/or people’s well-being), not science. If the drugs (namely, SSRIs) relate to increased suicidality and sexual side effects, then is that the price we’re willing to pay? What if people frequently have difficulty discontinuing the medication due to withdrawal effects?

“Normal” Depression and Anxiety: If you are having significant problems with your family members, friends, spouse, boyfriend/girlfriend, coworkers, boss, etc., and you are experiencing depression/anxiety as a result, do you need treatment? It would seem somewhat normal to struggle to a degree when dealing with the aforementioned life circumstances.

I’m advocating that in some cases we may want to take a [gasp] minimal intervention approach. Suppose someone rolls up to your office and she is pretty bummed out after losing a job and is having a tough time in a relationship. Before whipping out the prescription pad, maybe provide some brief counseling. Have the person follow up in a couple weeks and see if she is improving on her own. People are generally pretty resilient. With some time, many folks will bounce back on their own or with a little bit of help. Though the analogy is not exact, we know that chasing after victims of hurricanes and other disasters and insisting that they all receive some sort of counseling does not seem to help their psychological state. So, we shouldn’t be so sure that we can just intervene with everyone who is undergoing some type of hardship and expect positive results. One could argue that the people seeking treatment are the ones who are not very resilient, and that’s a discussion to be had at another time.

To be clear, if someone is falling apart, then by all means offer serious treatment. If someone is mildly anxious/depressed, then it would seem that a more mild intervention (like brief counseling with some follow-up) is in order. Have I gone out of my mind? Does this seem unreasonable?

Maybe this is all pie in the sky hypothetical crap anyway. Most of the people who have some sort of problem adjusting to life’s many problems are likely heading to their primary care physician, who is likely not all that well-trained in mental health, who very well may have the belief that SSRIs are harmless and should be prescribed for whatever mental ailment, short-term or long-term, mild or debilitating, that you have. And how can we blame the doctor – he/she has little training in mental health, has been encouraged to treat mental health cases rather than refer them, and is likely unable to understand the limitations of the research regarding the treatments he/she prescribes because that sort of information was not covered in medical school or in the continuingmedical educationclasses he/she has taken for the past ten years since leaving med school.


supergirlest said...

you've EXACTLY nailed the problem that i hear over and over. one friend was in nyc on 9/11. he returned home and found himslef still horribly shaken. his general doc handed him a bag of zoloft and told him to take them. he never took them, said he knew what the problem was and o pill was ever going to be able to fix that.

i've heard this story, in varying forms over and over and over. "see if this works." pretty tricky little game to be playing with meications that could very well cause a chemical imblance in someone that doesn't already have one, methinks - not to mention the other myriad side affects i've been told of.

my biggest trouble is that these medications can't get to the root of the dis-ease - they only serve to *hopefully* ease symptoms.

Anonymous said...

You gave me "something" to read today. At least i forgot about my own depression a little while.

herb said...

Right on doc!

But don’t forget, on the other hand, there are those who are very seriously depressed and whose illness goes beyond situational stresses and are governed by genetic predispositions and who are more than willing to utilize the final option that need immediate care, attention and/or various treatment options.



Ruth said...

You have to wonder about the effect of constantly broadening our sense of what constitutes 'pathological' depression and anxiety on the levels of resilience exhibited by people in the throes of highly stressful, but nevertheless common, experiences.

If the not-so-subtle message that percolates through is that all pain is pathological, then we could see resilience withering away like an unused muscle as we rush to have our pain 'managed' by the pain management professionals.

Apart from resisting the temptation to pull out the prescription pad, the ubiquitousness of "having significant problems with your family members, friends, spouse, boyfriend/girlfriend, coworkers, boss, etc.", along with how much these things can be really f**king painful for just about anybody on occasion, needs to be emphasised. Not necessarily by doctors, who may be misinterpreted as saying "just pull yourself together", but by ourselves, to ourselves, in everyday life. This may sound corny, but we can give ourselves a terrific "emotional education" simply by reading novels and watching movies that demonstrate that we are a long way from being alone in our experiences, for the illusion that we've been singled out to suffer often comprises a great deal of our suffering.

Hopefully we will then continue to be able to point to recent research that indicates that 'people are generally pretty resilient'.