Psychiatry and clinical and abnormal psychology are, as Thomas Szasz will gladly tell you, scientifically suspect endeavors, at best. That’s not to say, as Szasz in fact has said, that there is no such thing as mental illness. It is beyond serious debate at this point that there are psychological disorders which are, in fact, biochemical disorders or imbalances and treatable as such. So called bipolar disorder and clinical depression are examples of such, if only in the sense that the symptoms of such disorders can typically be mitigated, eliminated or controlled by medication.
In fact, we have more confidence in calling any so-called cognitive, affective or behavioral disorders genuine illnesses only when and precisely because they are amenable to medication. They fit the ruling ontology of the day; namely, that everything, including the mental, is ultimately physical and therefore susceptible, at least in principle, to physical, i.e., medicinal or surgical treatment.
By contrast, historically and still in large measure today, psychiatry and clinical psychology are mostly taxonomic arts – disorders are diagnosed by noting behavioral signs and symptoms and checking them against the latest version of the Diagnostic and Statistical Manual of Mental Disorders, currently in its fourth edition and known simply as DSM-IV. As far as an underlying etiology or cause of the current list of disorders goes, theories abound but little is actually known.
Getting back to the depressing business of depression, the WaPo article explains the current diagnostic attitude as follows:
Diagnoses are currently made on the basis of a constellation of symptoms that include sadness, fatigue, insomnia and suicidal thoughts. The diagnostic manual used by doctors says that anyone who has at least five such symptoms for as little as two weeks may be clinically depressed. Only in the case of someone grieving over the death of a loved one is it normal for symptoms to last as long as two months, the manual says.
The problem here, of course, is one of differentiating merely situational depression (how the “sh*t happens” facts of life affect us all) from clinical depression, reserving the prescription of, for example, selective serotonin reuptake inhibitors (SSRI’s) like Prozac for the latter. A new study suggests, however, that “extended periods of depression-like symptoms are common in people who have been through other life stresses such as a divorce or a natural disaster and that they do not necessarily constitute illness.” (Emphasis added.)
As the kids say, “Well, D’uh!” I haven’t checked on the rest of the symptom list for depression, but chronic recurrent sadness, fatigue, insomnia and suicidal thoughts are also symptomatic of parenthood, a condition that typically (tragically) lasts considerably longer than two weeks. And who the hell said you get just two months to grieve for a lost loved one?
DIGRESSION #1: A guy is playing golf with his friends one beautiful Saturday afternoon. As a funeral procession passes the course, the man stops, bows his head and crosses himself. A friend says, “Hey Joe, I didn’t know you were so religious,” and the man answers, “I’m not really, but what the hell? I was married to the woman for nearly twenty years.”
The problem here, well, one of them anyway, is that in the absence of a specific biochemical or pathogenic etiology psychologists are pretty much free to slice up the whole gamut of human emotions and behavior pretty much anyway they choose. Hence, for example, back when I was in college the DSM still defined homosexuality as a psychological disorder and schizophrenia came in any number of varieties as a grab-bag of serious psychoses that didn’t fit another category. Rumor has it that the immediately prior edition had just two differential diagnoses: whacko and possessed. I don’t deny that subsequent research and reaction to criticism have had no effect on later editions of the DSM, but how many and which symptoms a patient must experience and for how long to qualify for this diagnosis or that is, to put it mildly, ultimately just a tad arbitrary.
DIGRESSION #2: Giving my medical history to a new primary care physician recently, I had already told him I was adopted at birth and thus had no biological family history. Moments later, he asked if there had ever been any suicides in my family. Why, I asked. Well, he said, there have been studies suggesting that even in the case of adopted children, the example of a suicide in the family correlates to an increased likelihood of suicide. Maybe. And maybe like too many physicians he just couldn’t bring himself to say “Oops, I forgot.” (Actually, there was a suicide in my family and a pretty damned amusing one at that. Remind me to tell you about it some time on a slow news day.)
Ignoring the backstage role of ‘Big Pharma’ in all of this, a case can be made for keeping clinical depression diagnostic criteria flexible enough to ensure that genuine cases don’t go undiagnosed and thus untreated, a point made in the Post article. On the other hand, as that article also quotes Rutgers sociologist Allan Horwitz, “People are starting to think that any sort of negative emotion is unnatural, that they can take medication and feel better. [Psychoactive drugs can] make it less likely for people to make real changes in their lives that might be better than medications.”
As psychopharmacology inevitably improves, the line between chronic affective disorder correcting and merely mood enhancing drugs becomes increasingly problematic. It is one thing to be depressed when everything is going well in one’s life, another to be depressed when it isn’t, and yet another to be as happy as can be even when one’s life is a shambles. Analogically, it’s great that we have analgesics to treat pain. But the ability to experience pain is a highly useful, possibly even essential survival trait. Happily enough, so is the ability to feel sad.
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BONUS: Speaking of old Rolling Stones' song titles and, well, drugs, celebrity corpse Keith Richards is reported today as claiming (a claim now being denied by his manager) that he once "snorted his father's ashes mixed with cocaine." What a drag it is getting old.
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