Courtesy of ONN, The Onion News Network

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What is it about depression that draws people to search for the benefits it brings to its lucky victims? Since I’ve been writing this blog, many writers have had great success with books and articles describing its positive role in life – giving people a creative edge, helping them figure out their lives or simply serving as a healthy and normal response to misfortune. The problem with each of these essays is that they invite confusion between mild depression, or limited periods of deeper mood changes caused by life events, and the much more severe depressive disorders.

The latest contribution in this vein is Jonah Lehrer’s New York Times article, Depression’s Upside. It’s about a theory that takes depression’s virtues to a much higher plane than that of individual insight. Depression, it turns out, evolved as part of our genetic makeup because it enhanced the human capability for analytical thinking and problem-solving. In short, depression has helped the human race survive.

This isn’t his idea. He’s summarizing the conclusions of a scientific paper by J. Anderson Thomson, a psychiatrist, and Paul Andrews, an evolutionary psychologist, but he adds a lot of additional material to support the notion that depression has its brighter side.

The concept is that depression improves the mind’s ability to focus attention on “complex social problems” (failing marriage, loss of job) through the process of rumination – the repetitive analyzing of a single problem. (Hence, the theory is called the analytic-rumination hypothesis or ARH.) Rumination fires up the area of the brain that specializes in analytical thinking, making it easier to break apart the elements of a problem that might otherwise seem overwhelming and so make it easier to find a solution.

Isolation from the rest of the world supports this tight mental focus and keeps the mind from being distracted, as does – I presume – loss of interest in sex, food, human relationships and fresh air. Since all these symptoms are coordinated so nicely to help with problem-solving, the authors contend that they must represent an evolutionary adaptation rather than a malfunction.

If this is true, I’ve really bungled the gift of my genetic inheritance. In all the decades of dealing with severe depression I never solved a single complex social problem. Amazingly enough, my mind was infinitely distractible, incapable of clear decisions and subject to aimless drift into a cloud of nothingness. At other times, I obsessed about my failings and worthlessness in prolonged self-torture and often thought of suicide. Perhaps, though unaware of it, I did sharpen my analytical abilities while sleeping all the time. However, my isolation from my family, if you can believe it, seemed to create problems rather than solve them. Clearly, I’ve given evolution a setback, especially since I’ve likely passed on this my distorted version of this gift to our three sons.

But quite possibly, it’s not true at all – at least when you untangle the confused use of the word depression. Lehrer has taken a lot of heat for failing to do that. The psychiatrist Ronald Pies, for example, writes in his Psych Central post, The Myth of Depression’s Upside that Lehrer ignores many studies that reach the opposite conclusions about the effects of depression on thinking, relating both to mental function and the level of activity in the brain. He offers this anecdote:

The notion that severe depression may bring forth good things reminds me of a lecture I once attended on “fire safety” in the hospital setting. We were shown a movie of a house that had burned down in such ferocious heat that a package of frozen muffin dough had been completely baked. “So, the house wasn’t a total loss!” quipped one of the world-weary attendees. Yes, of course—people can learn from their severe depressive episodes, but often at the cost of emotional and spiritual conflagration.

Edward Champion at Reluctant Habits attacks Lehrer’s interpretations of the experiences of Charles Darwin, Kay Redfield Jamison and David Foster Wallace.
Peter Kramer also has little patience for the idea. That’s not surprising since Kramer produced a very convincing study, Against Depression, that attacked a long-standing tendency in our culture to glorify depression.

Prior to Lehrer’s article, Jerry A. Coyne, a Professor in the Department of Ecology and Evolution at the University of Chicago wrote a devastating two-part critique of the Thomson-Andrews paper itself. He’s an expert on evolution and author of the highly praised Why Evolution Is True. He methodically takes apart the speculative reasoning and “paper-thin evidence” supporting the conclusions of Thomson and Andrews about the evolutionary benefits of depression. He looks at the original research papers cited by them and brings out the way in which their interpretations distort the actual findings of the studies.

So what’s going on? Why have there been so many claims about depression as a boon to human life, and why has there been a strong positive response from the public (excluding, of course, the hundreds of thousands of us who’ve lost so many years to the effects of this illness)?

I think part of it has to do with the confusion about what “depression” means. The same word is used to refer both to feelings of sadness or dejection in everyday life and to a set of clinically defined illnesses. Unfortunately, the psychiatric profession, however much it hopes to dispel this confusion with the Diagnostic and Statistical Manual (DSM), only reinforces it.

By setting the bar so low for a diagnosis of a major depressive episode (experiencing five out of nine listed symptoms for at least two weeks), the DSM invites psychiatrists and physicians to prescribe treatment for even isolated occurrences. To add to the prevalence of a depression diagnosis is the startling fact, reported in a recent study, that a quarter of psychiatrists and two-thirds of non-psychiatric physicians do not bother to use the loose DSM criteria when making a diagnosis.

Even when studies or popular books and articles do make the distinction between severe and mild depression, they tend to drop the qualifiers after that caveat, rely on the single word and make much more sweeping claims about depression’s beneficial impacts on life. The influence of drug industry advertising also encourages the idea that people shouldn’t put up with sadness but rather take the latest medication to restore a happy outlook on life. (But that’s a long story for another day.)

Many people do value depression as a factor that gives them a distinctive outlook on life, and they don’t want to sacrifice this dimension of mental experience to a drug-induced “cure.” I have no quarrel with that and respect whatever adaptation to depression people need to make. But individual experience and choices are one thing. Speculative theories about the brighter side of depression from psychiatric researchers are another. They have real-world consequences and need a lot of rigorous testing before put into practice. Unfortunately, that usually happens, if at all, long after the idea has gotten wide publicity and influenced attitudes of public and providers alike.

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I’ve heard of a number of off-label uses for antidepressants, but turning them into non-lethal weapons for crowd control is a new one for me. The Soft-Kill Solution in the March Harper’s describes research on the use of “calmatives” or central nervous system depressants for just this purpose.

The article describes the history of the use of non-lethal methods by both the military and civilian law enforcement. The following quote refers to a research report that was published online in 2002 by the Sunshine Project.

As [the Pentagon's Joint Non-Lethal Weapons Directorate] research director Susan Levine told a reporter in 1999, “We need something besides tear gas, like calmatives, anesthetic agents, that would put people to sleep or in a good mood.”

[Academic researchers reported in 2000] that “the development and use of non-lethal calmative techniques is both achievable and desirable,” and identified a large number of promising drug candidates, including benzodiazepines like Valium, serotonin-reuptake inhibitors like Prozac, and opiate derivatives like morphine, fentanyl, and carfentanyl …

The report cited in the article is The Advantages and Limitations of Calmatives for Use as a Non-Lethal Technique, prepared by the Applied Research Laboratory at Pennsylvania State University. Here’s one of its key conclusions.

The use of pharmacological agents to produce a calm behavioral state, particularly as relevant to management of individuals and/or groups that are agitated, aggressive and/or violent, is a topic with high relevance to achieving the mission of law enforcement and military communities. … pharmacological agents can effectively act on central nervous system tissues and produce a less anxious, less aggressive, more tranquil like behavior and, ultimately, an easier to manage individual.

So it seems that all those agitated people thinking they’re out in the street protesting injustice or demonstrating for human rights are really seeking mass treatment for their anxieties, phobias, depression and impulse control disorders. Crowd-level dosage promises fast action with no permanent damage, though the experience may be a little rough. It turns out that potentially harmful side effects may be included during “administration of the technique” (otherwise known as “gassing”). As the report says:

…perhaps hundreds, if not thousands, of compounds are discarded or shelved by the pharmaceutical industry. Often an unwanted side effect, such as gastrointestinal distress, will terminate the development of a promising new pharmaceutical compound. However, in the variety of situations in which non-lethal techniques [techniques = weapons] are used, there may be less need to be concerned with unattractive side effects; indeed, perhaps a calmative may be designed that incorporates a less than desirable side-effect (e.g. headache, nausea) as part of the drug profile. Furthermore, it may be appropriate to develop a working relationship with the pharmaceutical industry to better incorporate their knowledge and expertise in developing a non-lethal calmative technique. Perhaps, the ideal calmative has already been synthesized and is awaiting renewed interest from its manufacturer.

No doubt there is a lot to be learned by emptying the trash cans of the pharmaceutical companies. It’s a bit like rescuing the ugly duckling from those raucous, unappreciative ducks and finding it a new home among swans where its beauty can be appreciated. The perfect “technique” for turning the agitated and the unruly into tranquil, manageable citizens may already be out there!

The Harper’s article also says that after this research report appeared online, the Pentagon denied that it had any plan to use these drugs as non-lethal weapons. Since 2002, information about such research has been withheld altogether or heavily censored, but the National Research Council put out a report on non-lethal weapons in 2003 that urged further research into incapacitating chemical agents, including the so-called calmatives.

The Bradford Non-Lethal Weapons Research Project, a university center in the UK, published a history of recent research in this field in 2007 which indicated that work was continuing in several countries, including the US. But…”Given the controversial nature of research in this area, especially with regard to military involvement, little information is available … .”

Let’s see if the Obama Administration’s Open Government Initiative will let us have a peak inside the research labs.

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The ongoing revision of the Diagnostic and Statistical Manual of Mental Disorders has provoked prominent psychiatrists to declare that the next version (DSM-V) is in danger of medicalizing normality. Since “normality” covers quite a few people who don’t think of themselves as mentally disordered, I thought it would be important to look into this rather than keep pawing obsessively at the wrapping of my own little human package. There is a powerful social world out there, after all, and it has stamped me, for one, with a numerical code for major depression. That number may not be so ominous as one consigning me to prison, but it’s mine for life in the eyes of that world, no matter how fully recovered I might consider myself to be.

The debate about how the revision should be handled clarifies for me the evolution of the DSM and the effects of the present system. I’m interested primarily in getting a handle on the basic approach rather than following details of the major battles. (Go to the excellent Carlat Psychiatry Blog to stay current on the controversy.) The public exchanges among prominent psychiatrists reveal the darker side of current and potential methods for diagnosis and treatment.

A lengthy, footnoted editorial by Dr. Allen Frances, the former chairman of the DSM-IV revision committee, makes some telling points. He attacks the claim that DSM-V will mark a paradigm shift in diagnosis. (A response, however, by another distinguished psychiatrist argues that this is an exaggeration.)

Whatever the DSM-V revision group may or may not be claiming, Dr. Francis helps a lay person like me understand the basic nature of the DSM system of classification. He points out that the manual relies on descriptive diagnosis, meaning that it labels each set of symptoms as a given mental disorder but without, for the most part, any proven physical basis explaining its cause, or any scientific method of testing for the condition. He argues that there can’t be any great advance in a descriptive system until knowledge of the biology and neuroscience of the brain have advanced far beyond the current state.

Many of his criticisms echo the ones that have been made for years about his own handiwork – DSM-IV. Take, for example, the phrase from the title – “mental disorders.” Lacking knowledge of the specific physiological changes giving rise to symptoms, the editors of the DSM decided they couldn’t characterize the conditions they observed as “diseases” – like diabetes or cancer. So they came up with the word “disorder” to cover the conditions they identified. Unfortunately, that word has no precise meaning. According to DSM-IV itself: “…it must be admitted that no definition adequately specifies precise boundaries for the concept of mental disorder.” DSM-V may try to push those boundaries farther out and, in so doing, extend the psychiatric domain over millions of additional people.

For example, the DSM committees have been considering adding diagnostic categories for “subthreshhold” conditions that are milder forms of the existing disorders. As Dr. Frances puts it:

The reported rates of DSM-V mental disorders would skyrocket, especially since there are many more people at the boundary than those who present with the more severe and clearly “clinical” disorders. The result would be a wholesale imperial medicalization of normality that will trivialize mental disorder and lead to a deluge of unneeded medication treatments – a bonanza for the pharmaceutical industry but at a huge cost to the new false positive “patients” caught in the excessively wide DSM-V net. They will pay a high price in side effects, dollars, and stigma, not to mention the unpredictable impact on insurability, disability, and forensics.

(Of course, DSM-IV did quite well at achieving the same result but evidently left a lot of room for growth.) Even worse than the subthreshold disorders, though, is the idea of adding a “pre-psychotic” category. This would be used for anyone thought to be a high risk for later developing a psychotic disorder. What would you call later? A month, a year, 10 years, 20?

I can’t imagine the criteria for such a diagnosis, but I suppose it would hardly matter which vague symptoms would need to be observed or what the time projection might be. A psychiatrist would have a frightening power to stigmatize someone for life. There’s plenty of over-medication and involuntary confinement now, but this could trigger the use of such methods without the bother of having to wait for actual symptoms to occur.

Dr. Frances’ scenarios may be overdrawn, as defenders of the DSM-V process claim, but this debate brings out issues that predate the current battle and go to the heart of the impact of the DSM on all of us. Dr. Paul Chodoff, writing from his perspective as a practitioner with 50 years of experience at the time, entitled a 2002 editorial, The Medicalization of the Human Condition.

He points out that much of the “medicalization of normality” that alarms Dr. Frances was already a problem under DSM-IV. As he says, the vagueness of the definition of “mental disorders” created a gray area between pathology and normality. In that area fall many undesirable feelings and behaviors “that are not readily distinguishable from the range of experiences that are often inescapable aspects of the fate of being human.”

Extreme shyness, for example, has gradually been transformed from a personality trait to a medical condition. The screening criteria for major depression have created such a low threshold as to include many states that used to be considered part of the ups and downs of any life. These changes in definition, he argues, have caused the apparent skyrocketing of social phobia and depression. While DSM supporters claim that strict adherence to the prescribed diagnostic procedures would prevent such problems, Chodoff responds that subjective interpretation of checklists can’t get it right all the time.

He believes that the early application of DSM principles helped to lift psychiatry out of the days when psychoanalysis was the dominant model, and medical explanations were scorned. But now, he believes, medicalizing psychological conditions has gone too far. People suffering from what he calls “problems of living” should seek psychotherapy alone without medication. But that approach is rarely accepted by insurance companies. They seem to be much happier paying for drugs, despite the soaring costs and ever more common use.

What Chodoff urges (and it makes so much sense to me) is that psychiatry and the other helping professions need to accept the reality that their work “transcends” the medical model. It often deals with conditions that are not pathological but still cause a lot of suffering. People need help for many reasons, but they don’t always need medication.

The next post will look at a proposed alternative to the DSM diagnostic method that goes beyond changing psychiatric practice to changing how we think of our own lives.

What’s your experience with the results of the DSM approach? These days it’s quite common to get multiple diagnoses for each aspect of what troubles us. Has that been helpful to you or has it set you back?