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Mental illness in academic philosophy

Brian Leiter

With over 1500 responses, more than 60% of respondents reported some diagnosis for mental illness, with almost one in four respondents mentioning depression in particular.   There is substantial co-morbidity between depression and the various anxiety disorders, as there are among the anxiety disorders, so, e.g., the 24% that report depression may also include some of the 5% that checked social anxiety disorder or the 4% that chose OCD.  I assume in a poll like this, people are not so perverse as to vote "strategically" or otherwise try to muck up the results.  So I think we can conclude from this that the majority of faculty and students in philosophy have confronted some kind of mental illness in their lives.  I've opened comments if readers have other thoughts about these sobering results. 

Philosophy faculty and students: which, if any, psychological disorders have you been diagnosed with? Check all that apply.
Depression
   24%370
Bi-polar disorder
   3%43
Generalized Anxiety Disorder
   11%166
Obsessive-Compulsive Disorder
   4%70
Social Phobia/Social Anxiety Disorder
   5%76
Panic Attacks
   7%109
Other Anxiety Disorders
   4%55
Post-traumatic stress disorder(s)
   2%24
Schizophrenia
   0%7
Other mental illness
   4%56
I have never been diagnosed with any mental illness/psychological disorder
   38%593

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18 responses to “Mental illness in academic philosophy”

  1. Tim O'Keefe

    So I think we can conclude from this that the majority of faculty and students in philosophy have confronted some kind of mental illness in their lives. – See more at: http://leiterreports.typepad.com/#sthash.79phU0Q2.dpuf

    While I agree that mental illness is a major problem, I don't think we can conclude this from the poll. Why think that this is representative sample, that people who have and have not confronted mental illnesses are equally likely to respond to the poll?

    BL COMMENT: You're of course right that's a possibility. But do you have an hypothesis about why those who had confronted mental illness would be more likely to respond than those who had not?

    Reply
  2. Neil Easterbrook

    Two thots:

    Whatever the size of this sample, and whatever the peculiarities of self-selection in answering the poll, it would be nice to know the way these results reflect, or don't, the general American population.

    And from what I've read in the Chronicle (and similar publications), my understanding is that the incidence of mental illness (across the scale, from the mildest to the most severe expressions) is higher among professionals than among the general public, so even if the survey results track higher than the general public I wonder if that's a surprise. (The joke version I've heard of this: "do the humanities attract or produce neurotics?")

    BTW, since I'm not a philosopher, I didn't vote in the poll.

    Reply
  3. Tim O'Keefe

    Well, it might be representative, or it might not be. If not, one possibility is that issues of mental illness in the profession are more salient to people who have confronted mental illness, so they're more likely to spend the small effort to respond, while people who haven't are more likely not to bother. (A parallel case: if you had asked whether people were caregivers for somebody with a disability, and if so, what sort of disability, I suspect that caregivers would disproportionately respond.)

    Reply
  4. Anon Grad Student

    Here's a hypothesis: people are more likely to go to a blog / engage in a discussion / vote in a poll when they have some connection to the issue.

    In general, internet polls are worth the price paid for them. Participation is unrepresentative (I don't think you can infer from the poll to your readership, much less from your poll to the philosophical population at large), and there's far too much distortion. I probably vote 'honestly' barely half the time! My votes are often affected by what I would like the results to look like. For years, I lied to the Washington Post about my zip code because I felt some (meaningless) allegiance.

    You can think I'm some pervert, fair enough — but based on conversations I've had, I'm not idiosyncratic. (And, honestly, if perversion means over-reporting on an Internet poll, perversion has become pretty damn boring.)

    Reply
  5. CSyd

    Professor Leiter,

    This survey, if only preliminary and partly vulnerable to the statistical objections noted above by Tom O'Keefe, is, of course, beneficial and salutory. Thank you for running it. I should like, however, to issue a couple of caveats on the issue of "depression" in particular.

    First, because diagnoses in this area of psychiatric morbidity are syndromal rather than based on distinct disease entities, symptomatology is the touchstone of currently orthodox depressive nosology. The DSM, the institutional and clinical embodiment of this orthodoxy has, since around the early 1980s, viewed and continues to view "depression" as a unitary phenomenon whose relative sub-classifications depend primarily on identifying the degrees of *severity* and *chronicity* by which the mood disorder affects the patient. So, a patient may receive a diagnosis ranging from "depressed mood", "minor depressive disorder", "dysthymia", to "major depressive disorder" (there is also a whole category of clinically sub-syndromal mood disorders that, particularly in primary practice, are not uncommonly pathologised by being redescribed as "depression").

    When one thinks about it, this is a very peculiar method for classifying illnesses. The analogy is of course imperfect, but consider an oncologist: he or she does not primarily diagnose a tumour by reference to whether it is severe or only mild. Rather, severity is a potential property of some types of cancer, whose nature is classified by reference to traits biologically internal to, and often distinctive of, that type.

    The current approach embodied in the DSM supplanted earlier ones which (I simplify drastically, of course) distinguished (to the extent possible in a discipline which must grapple with the overlap between the subjective/phenomenological and the biological dimensions of the illnesses it seeks to treat) endogenous from exogenous depressions, autonomous from reactive depressions, and melancholia from non-melancholic depressions. These distinctions did not always depend or focus on presumed differences in the *aetiology* of the distinct depressions they posited. Some depended on very close examination of the course of a patient's illness, whatever the "cause" which precipitated the illness may have been. In this way, such a method presupposed no binary distinction between the biological and the environmental: negative environmental triggers could in some cases precipitate an autonomous neuro-psychiatric process which becomes biologically entrenched and thus unresponsive to subsequent positive environmental stimuli. The research which Maxwell Bennett has been doing on the effect of exposure to chronic stress on neurological networks is one area where this idea of "autonomous" versus "reactive" depressions may apply (though I do not think he invokes those terms since his prime focus is neurology not depressive nosology).

    Secondly, the reason I mention this bit of history, and the departure the extremely influential DSM initiated from it, is that the DMS's unitary conception of "depression" may be one reason why statistics such as that which resulted from your survey appear to indicate a pervasive epidemiological crisis when it comes to rates of "depression" in the populace and over the course of anyone's life. Statistics that 80% of people will suffer from at least one episode of "depression" over their lifetime are also not infrequently heard. In one sense, the publicity of statistics in this way (i.e., in a way which omits to disclose the weaknesses of the clinical framework according to which "depression" is currently diagnosed in the first place) is quite clearly well-intentioned: it seeks to destigmatise an illness which can ruin people's lives, thereby encouraging them to seek treatment for it.

    But, thirdly, I don't think good intentions are always conducive to good outcomes, especially if they are based on misconceptions. I should explain this a bit more.

    (a) An extremely lively current debate in psychiatry examines what is often referred to as the "paradox" of over-diagnosis and undertreatment of "depression". It is a paradox generated by the DSM "cookbook", as one eminent psychopharmacologist colloquially refers to it. Though the determinants are multiple and complex, involving not only the prescriptions of the clinical framework but also the time and resource-pressures under which many primary care physicians struggle and the influence of pharmaceutical companies, over-diagnosis is partly driven by the DSM's unitary conception of depression and its variable and often subjectively applied sliding scale of severity and chronicity. Over-diagnosis may not present as anything medically harmful if the medications prescribed to treat "depression" were uniformly negligible in their side-effects. But any patient will tell you this is not the case. Nor is it the case that newer medications are less prone to less serious side-effects than older agents, though it is the newer agents which are routinely prescribed. In contrast, the side-effects of older agents, such as the very effective MAOIs, are vastly exaggerated.

    (b) Undertreatment may be thought of as the more serious, and sometimes tragic, aspect of the paradox. It, too, is partly driven by the deficiencies of the current clinical framework. If "depression" is in substance a unitary entity, this often supports an inference that treatment should be too. If we restrict our attention exclusively to pharmaceutical interventions, the conventional "algorithm" prescribes starting with the least effective (narrow-spectrum) agents and progressing to the more robust and broad-spectrum ones, with adjunctive therapy between each stage. Now, this algorithm presumes that all depressions are responsive to, or capable of response to, each of the agents the algorithm includes, no matter what their psychopharmaceutical mechanisms and effects relative to the nature of the depression being treated, and no matter whether they target a single neurotransmitter or each of the catecholamines and 5-HT. The result is that a patient who is suffering terribly from a melancholic, autonomous, or endogenous depression is forced to proceed through a raft of ineffective treatments (assuming he or she is not directed into psychotherapy first!) before he or she is even given the opportunity of trialling a medication which has a greater chance of being successful (i.e., a TCA, an MAOI). To prolong suffering for the sake of an algorithm that assumes depression is a unitary phenomenon is gratuitous and futile. In my view, this is not medicine.

    (c) As for social outcomes, the increase in the rate of diagnosis since the unitary view of depression was introduced (which to some extent must be conceded to be attributable to the hugely beneficial removal of stigma and awareness campaigns which encourage sufferers to seek treatment), can have the counter-productive effect of bringing out what is most cynical and dismissive in those people, often people exercising administrative or other power, who have little empathetic imagination and even less personal experience of mental health adversity. If I may take the liberty of speaking of an episode in my own undergraduate life, I have been affected for years by severe melancholia, with psychomotor retardation as the key disabling symptom. I have trialled many, many medications (trials which take weeks, sometimes three or four months). They have not been effective. In spite of my academic skills and competency, I was in substance excluded from my Faculty not because of my efforts at treatment, but because their ineffectiveness is something entirely beyond my control. I was forced to "show cause" multiple times, in spite of my disclosing in advance the medical difficulties I faced. After I was excluded, the Dean went into print and referred sceptically to the number of students who had registered with disability services; and went on to say that those students who listed a psychiatric disability (i.e., "depression") did so ex post facto because they were just too indolent to drag themselves out of bed in the morning and sit an exam for which they were assumed not to be prepared. The Pro-Dean has subsequently publically announced that the goal of the Faculty is to produce "tough" students.

    Now, there may be some truth in the Dean's speculation about some opportunistic students. But what both announcements seem to embody to me is a cynicism about the very legitimacy of "depression" as now understood, a cynicism founded in the increase in the rate of students seeking consideration on the ground of "depression", an increase which is itself partly driven perhaps by the DSM-facilitated "over-diagnosis" to which I referred above. The unitary conception allows administrators to paint everyone with "depression" with the same broad brush, and those who have suffered from an autonomous depression for years and persevered in spite of this are assimilated to those whose moods have been negatively affected by life challenges which (it is hoped) will prove to be transient and responsive to counselling or a more conducive environment.

    I would recommend that anyone interested in these debates about depressive nosology consult the work of Professor Gordon Parker.

    Reply
  6. Richie Whitehead

    I'm an agnostic. Still, Ecclesiastes 1:18 is most appropriate: "For in much wisdom is much grief: and he that increaseth knowledge increaseth sorrow."

    Reply
  7. Joseph Zizys

    These results are entirely unsurprising to those of us of the NeoPlatonic persuasion. "Only the priests of the Muses, only the greatest hunters of good and truth, are so negligent and so unfortunate that they seem to neglect totally that instrument with which they are able to measure and comprehend the universe. The instrument is the spirit itself, which doctors define as some vapor of the blood, pure, subtle, warm, and clear. From the warmth of the heart, where it is produced from thinner blood, it flows to the brain, and there the spirit works hard for the functioning of the interior, rather than the exterior, senses. That is why the blood serves the spirit, the spirit serves the senses, and the senses, finally, serve reason." – Ficino qouted in Spiritual and Demonic Magic: From Ficino to Campanella By Daniel Pickering Walker. 😉

    Reply
  8. CSyd

    The experience of "sorrow", of course, is not a "mental illness"; nor does the acquisition of "knowledge" lead to pathologies. It should be stressed that autonomous depressions cause a deficit in the capacity to acquire, analyse, retain and deploy "knowledge", rather than being the result of hyper-intellection. In the psychomotor retardation which is characteristic of melancholia as a clinical phenomenon, the mind – possibly because of underlying dysfunction in certain brain circuits – becomes so "shrunken" and paralysed that any movement itself becomes very difficult and, in catatonic states, even suspended. I should think that such a person would give a great deal just to have a few hours of attentive functionality to be to acquire and gain pleasure from acquiring "knowledge ".

    This is a serious disease the secret of whose amelioration and relief does not lie in taking on board "wisdom" which is otherwise apt, salutary and beneficial were it directed at that range of distresses, sorrows, and disappointments which any person experiences in a human life.

    Reply
  9. Daniel Nascimento

    My problem is how we can go from "was diagnosed with" to "have confronted". I assume the conclusion you intend to draw is that the diagnose was right, and not – say – that any of these people have actually dealt with their disease in any particular way ("confronted" as opposed to "chose not to see", etc.). My problem with this inference is that, as I see it, we have been diagnosing mental illness a lot more today than we used to. Some say that means we are paying more attention. I, for one, tend not to be so optimistic. What I believe is that people have been pushing pills down a lot of sad people's throats. How do we separate depression from sadness? Is a mere reference to the "good functioning" of the individual enough? I'm not so sure. But my point is that I think we have no reason to believe that the case with depression is different from the case with DDA. Does anybody still doubts that there is an over-diagnosing of DDA going on, and that such practice is directly related with the attempt to sell more medication and improve student performance, as opposed to solving a pre-existent psychological disorder? That being said, i think this results does provide us with good grounds for more research into the topic.

    Reply
  10. CSyd

    I think your point about over-diagnosis of "depression" is correct; and I think you are right to enquire into, or prompt enquiries into, the basis on which this phenomenon has increased. I would also agree that one reason – not the only reason – is the influence of pharmaceutical companies and their commercial interest in disease-mongering. In my view, the *main* reason is related to the authoritative status of the DSM criteria themselves (see my earlier comment). It follows from this view that I think the main reason is the omission of the psychiatric profession, under the influence of the DMS, to be critical, rigorous, and robust in its depressive nosology. This is in no way a radical view. It is emerging as a minority consensus among specialists and researchers.

    There are, however, a number of hasty, and factually illicit, inferences you draw from your scepticism (or, as you describe it, your tendency "not to be so optimistic").

    First, you seem to infer from the fact of over-diagnosis based on what you accurately intuit to be loose and clinically questionable criteria, that the identification, clarification, testing and formulating of rigorous diagnostic criteria for "separat[ing] depression from sadness" are tasks which psychiatry has not, and is not, undertaking. This is simply wrong. The supposition, also, that the promotion of the "good functioning" of the individual organism is taken by such rigorous criteria to be the paramount determinant in diagnosing a sub-type of depressive illness is also entirely mistaken. I am not sure to whom you intend to refer by your use of the third-person pronoun "we", but it cannot in fact include any fair and intelligent person with the slightest acquaintance with the current research.

    Secondly, you seem to infer from the fact of over-diagnosis that anyone who happens to be diagnosed according to the same criteria which enable (though do not necessitate) such over-diagnosis, has ipso facto been illicitly pathologised: he or she is, in fact, just a "sad [person]". While the clinical culture of over-diagnosis certainly imposes unnecessary and unjustifiable burdens on sufferers who are disabled by biologically autonomous depressive illnesses, it does not follow that no such illnesses exist just because depression is currently over-diagnosed. Such a minority of persons should not be assumed to be over-diagnosed cases simply because so many others plausibly are.

    Thirdly, you seem to infer that because medication is being (as you put it, rather callously) "push[ed] down a lot of sad people's throats", medication may not ever be clinically appropriate and necessary. There is certainly mounting evidence of the over-medication (in the form of the barely-superior-to-placebo SSRIs) of minor or sub-syndromal so-called "depression" (see the work of Gøtzsche at Cochrane) and evidence of trials for medication efficacy being frequently compromised by the inclusion of patients with only very minor symptoms and thereby liable to respond in any case to the placebo effect. Over-medication is a serious problem, particularly in primary medicine, and you are right to raise it. But there are medications and there are medications (I'll let you in on a secret: most of the newer agents, from SSRIs to SNRIs, are sub-optimal and defective, and speak more to the pharmaceutical companies' marketing and profit imperatives than they do to any intrisic advances in psychopharmacology). And there are illnesses which are drug-treatable and those which are not. Effective medication for illnesses which respond to and require it should not be deprecated on the ground that the patients who need it desperately are assumed to be (in your brutal description) "sad".

    The level of engagement with the fundamental issues which Professor Leiter’s survey raises is thus far very poor. It may be of some benefit to offer citations to current conceptual and empirical research in depressive and neuro-psychiatric nosology for contributors better to inform themselves. I would be happy to provide these, but it appears that my earlier attempts at clarifying the issues have not (doubtless because of my own faults in articulating them) stimulated any feedback.

    Reply
  11. Byron von Stapleschlaunker

    Quick question. Were you by any chance Elmer Klemke's houseboy back in the day?

    Reply
  12. Anon Grad Student

    I'm a grad student with a mental disorder, which is part of the reason why I settled on the philosophy of psychiatry/science as my area of research.

    I do not wish to enter into a dispute about the nature, or 'reality', of mental disorders, overdiagnoses, medicalization, and so on . I can't see how pursuing these questions in an online discussion forum would be productive (though, I'm willing to be surprised on this score).

    What I would like to do, rather, is offer some resources for those interested in pursuing these questions further. This is by no means a comprehensive list, so I encourage anyone who finds it wanting to add their own suggestions:

    1. Rachel Cooper: 'Classifying Madness: A Philosophical Examination of the DSM' and 'Psychiatry and the Philosophy of Science.'
    2. Dominic Murphy: 'Psychiatry in the Scientific Image.'
    3. Kincaid and Sullivan (ed.): 'Classifying Psychopathology'
    4. Kendler, Zacher, and Craver: 'What kinds of things are psychiatric disorders?' – Psychological Medicine (2011), 41, 1143–1150.
    5. Lawrie Reznek: 'The Philosophical Defence of Psychiatry'
    6. Edward Shorter: 'A Historical Dictionary of Psychiatry'
    7. Andrew Scull: 'The Insanity of Place / The Place of Insanity: Essays on the History of Psychiatry'

    Reply
  13. CSyd

    Thank you for that list of suggested philosophical readings, Anon Grad.

    There is one reason why identifying and examining (in a necessarily simplified way) issues you prefer, with some justification, not to pursue in an online forum *can* be "productive": while doing so, of course, won't *resolve* any of them, such identification and examination at least enable us to become aware of them and thereby contribute to our sense of the range and complexity of the issues involved in Professor Leiter's survey and the results which sprung from it.

    I will follow up on the conceptual and philosophical readings you recommend.

    I'd like to take up your invitation to suggest other readings, though my (very selective) list includes only empirical research and disciplinary speculation based on it. I think some appreciation of the range and depth of the empirical studies into mental disease in which psychiatry and neurology have been engaged recently are essential to understanding, and contextualising, such results as Professor Leiter's survey revealed. My hunch is also that the philosophical and conceptual examination of psychiatry need to be informed by (if not governed by) empirical research.

    The lecture by Railton has yet (it appears) to elicit commentary. I would like to discuss his disclosure of his chronic major depressive disorder in another comment. I would agree with Brian Leiter that Railton's lecture is deeply humane and it would be a surprise, and disappointing, if it were not to have a salutory effect on the discussion of and approach to mental illness in academe henceforth. It would, incidentally, be interesting to consider if there is a precedent among eminent academics for Railton's unequivocal and direct revelation?

    Most of papers I list below – or at least abstracts of them – are accessible on the superb PubMed site: http://www.ncbi.nlm.nih.gov/pubmed

    I organise the papers by reference to categories of issue discussed in my previous comments and those of other contributors.

    KEYWORDS:
    Primary Blog
    ———-

    1. Pharmeceutical Company Influence

    Chan & Gotzsche (et al), "Empirical evidence for selective reporting of outcomes in randomized trials: comparison of protocols to published articles" [JAMA]

    Gillman, "Pharmaceutical company influence" [PLoS Med]

    Gillman, "Disease mongering: one of the hidden consequences" [PLoS Med]

    Goldberg & Thase, "Monoamine Oxidase Inhibitors Revisited: What You Should Know" [J Clin Psych]

    Gotzsche (et al), "Ghost Authorship in Industry-Initiated Randomised Trials". PLoS MedMorgan (et al), "The cost of drug development: a systematic review". [Health Policy]

    Healy & Thase, "Is academic psychiatry for sale?" [Br J Psychiatry]

    Kesselheim (et al), "Whistle-blowers' experiences in fraud litigation against pharmaceutical companies" [N Engl J Med]

    Kirsch & Moore, "The Emperor's New Drugs: An Analysis of Antidepressant Medication Data Submitted to the U.S. Food and Drug Administration" [Prevention & Treatment]

    Light, "Basic research funds to discover important new drugs: Who contributes how much?" in "Monitoring financial flows for health research: Behind the global numbers", MA Burke and A de Francisco (eds) 2006, Global Fund for Health Research: Geneva

    Pattison & Warren, "Drug Industry Profits: Hefty Pharmaceutical Company Margins Dwarf Other Industries"[Public Citizen Congress Watch]

    Spielmans, "The promotion of olanzapine in primary care – an examination of internal industry documents"[Soc Sci & Med]

    2. Anti-depressant Medication

    Gillman, "Fifty years of poor science" [Br J Psychiatry]

    Gillman, "Advances pertaining to the pharmacology and interactions of irreversible nonselective monoamine oxidase inhibitors" [J Clinical Psycho Pharm]

    Gøtzsche, "Why I think antidepressants cause more harm than good" [The Lancet: Psychiatry]

    Leon, "Paradoxes of US Psychopharmacology Practice in 2013: Undertreatment of Severe Mental Illness and Overtreatment of Minor Psychiatric Problems" [J Clinc Psychopharm]

    Parker (et al), "Clinical trials of antidepressant medications are producing meaningless results" [Br J Psychiatry]

    Parker (et al), "Assessing the comparative effectiveness of antidepressant therapies: a prospective clinical practice study" [J Clin Psychiatry]

    Parker, "Are the newer antidepressant drugs as effective as established physical treatments?" [ANZ J Psych]

    Parker, "Assessing the comparative effectiveness of antidepressant therapies" [J Clin Psych]

    Schwartz, "Neuroscientific Update on Monoamine Oxidase and its Inhibitors" [CNS Spectrums]

    3. Depressive Nosology

    Editorial, "Bringing Back Melancholia" [BiPolar Dis]

    Macintyre (et al), "Treatment-resistant depression: definitions, review of the evidence, and algorithmic approach" [J Aff Dis]

    Parker, "Commentary on diagnosing major depressive disorder: ask less that we embrace major depression and ask more what the concept does for us" [J Nerv Ment Dis]

    Parker, "Classifying depression: should paradigms lost be regained?" [Am J Psychiatry]

    Parker (et al), "Discriminating melancholic and non-melancholic depression by prototypic clinical features" [J Aff Dis]

    Parker (et al),"Issues for DSM-5: Whither Melancholia? The Case for Its Classification as a Distinct Mood Disorder" [Am J Psych]

    Parker, "Is Context everything to the Definition of Clinical Depression?" [J Aff Dis]

    Wakefield, "Mapping Melancholia: The Continuing Typological Challenge for Major Depression" [J Aff Dis]

    4. Neuro-Psychiatry

    Bennett, "Stress and Anxiety in Schizophrenia and Depression" [Aust NZ J Psych]

    Bennett, "Synapse Regression in Depression" [Aust NZ J Psych]

    Bennett, "The Prefrontal-Limbic Network in Depression: A Core Pathology of Synapse Regression" [Prog Neuro Bio]

    Buyukdura (et al), "Psychomotor retardation in depression" [Prog Neuropsychopharm & Biol Psych]

    Heim & Nemeroff, "Role of Childhood Trauma in the Neurobiology of Mood and Anxiety Disorders" [Biol Psych]

    Meyer (et al), "Elevated monoamine oxidase a levels in the brain" [Arch Gen Psych]

    Parker (et al), "Disrupted Effective Connectivity of Cortical Systems Supporting Attention and Interoception in Melancholia" [JAMA Psych]

    KEYWORDS:
    Primary Blog
    ———-

    Reply
  14. CSyd

    A site I frequently consult for accessible information and rigorously-reasoned analysis of neuro-psychopharmacology and the culture of psychiatric practice is psychotropical.com. It is the site of Dr. P.K. Gillman, a distinguished psychopharmacologist and retired clinical psychiatrist who is also a world expert on the serotonin syndrome: https://scholar.google.com.au/citations?user=ea6KeD0AAAAJ&hl=en.

    Most of the citations under topic (1) in my directly previous comment were taken from Dr Gillman's essay entitled, "Why Most New Antidepressants are Ineffective": http://www.psychotropical.com/why-most-new-antidepressants-are-ineffective.

    Dr Robert Hsiung, an Associate Professor of Clinical Psychiatry at the University of Chicago, administers a lively and informative site called "Psycho-babble" which is worth consulting for those interested in the concerns, particularly the medication concerns, of those affected by psychiatric illness: http://www.dr-bob.org/babble/

    Reply
  15. Farses

    CSyd-

    A few things:

    I also have psychomotor retardation. I never knew the word for it – I didn't know it was a common thing, indeed, I came up with many (mostly unflattering) theories as to why I couldn't move properly when I was in deep depressive phases. The fact I now know the word will make me feel much better about myself, next time I'm in the dumps and I break something I like or can't replace. So, many thanks for that.

    I don't really understand your point about side effects, however. I can understand if you've trialled many medications over many years, you might consider them a serious concern, but that's simply because most side-effects manifest in the first months of a new medication. The first few weeks on my meds (venlafaxine) weren't great – but still, basically preferable to a bad depressive period. Now, I have two side effects – first, I don't get orgasms any more. Two, I have a higher risk of strokes. I barely even notice I've taken it, other than the fact I have persistent (mostly) sane responses to the world. However, all told, my quality of life (and my personal safety) is so much better, that I'd honestly take that and then some for the rest of my life. Frankly, I'd rather vomit every two hours, and be like this, than to be back where I was.

    Also, I guess I've suffered this depression for a few years, but I don't think it's autonomous. As I see it, the barrier between autonomous depression and depression that is in response to an event is flexible to the point of nonexistence. I know exactly why I was sad when I started feeling sad, and I know some bad stuff happened after, but now, no matter how much good stuff happens, if I get off medication I'm persistently suicidal. Brains change. Implying that one form of depression is a legit disability and the other is 'overdiagnosis' is ignoring the fact that thoughts are physiology, and sometimes what seems like a passing mood can become your life.

    As I see it, skepticism about depression stems from the same source as every other form of skepticism about the disabled – the endless desire of unjust societies to blame scarcity on their most vulnerable members. That's not much to do with the DSM – otherwise, it wouldn't be the case that every kind of disabled person, from the undeniably so to the subtly, who is constantly in a struggle for bare existence. And, sadly, even in developed nations, that's still the case.

    Reply
  16. CSyd

    Farses, I am very glad to hear you've been able to place a name on, and thus identify and understand more about, the movement disorder you've experienced in the worst phases of your depression. i am still learning about it myself, and it has been worth the effort. I don't think psycho-motor retardation (typically more prnounced in the morning than in the evening), to the point of catatonia in the worst cases, is common at all. It is correlated with a high degree of depressive severity.

    As it happens, my experience reflects yours in not, for some years, having the understanding to identify it as a specific category of symptom at all. I mentioned it always in consultations but no specialist highlighted that symptom in partculiar or distinguished it from affective symptoms like hedonic deficit, blunted-affect, etc. It is only since I have read some of the research into melancholia, which considers, according to Professor Parker's CORE framework, psycho-motor retardation as not merely required for a diagnosis of melancholic sub-type (a *primarily* neuro-psychiatric and biological process and depressive condition) but, if severe enough, in itself adequate.

    I am interested to hear of your positive response to venlafaxine. That is a potent SSRI but its noradrenaline reuptake only occurs at high doses over 150mg and then is not as potent as nortiptyline. But the most important thing is, of course, clinical effect on you. I also had success on venlafaxine but it only lasted three months or so. I hope your response continues.

    If I may, there's a couple of misunderstandings, probably generated by me, in your subsequent points that I'd like to clarify. First, about side-effects. I totally agree that the cost-benefit ratio favours, in most cases, enduring side-effects rather than the prolongation of the pain and life-depletion of depressive illness, *if you are in fact suffering from a sub-type of depression which will respond to medication*. Quite clearly, with your psychomotor retardation, you have a serious clinical depression and thus are a prime candidate for drug responsiveness. My point about side-effects was restricted to those situations where powerful medication is being prescribed, often in primary practice, to patients whose clinical features may not objectively warrant it, or warrant it only on the loosest criterion of what constitutes "depression". In such circumstances, side-effects are not necessarily off-set by a positive change in the course of the illness which the clinical effects (in contrast to the placebo effects) of the medication alone can substantially induce.

    On your point about "autonomous" depression. That is a term I used to refer to the diagnostic efforts of certain psychiatrists to concentrate on *course of illness* in contrast to *cause* as a tool for identifying the processes of those depressions which are – given the course of the illness ("brains change") – substantially biologically entrenched and likely to be unreactive to and immune to sustained improved response from subsequent positive environmental stimuli. On this understanding of "biological" – which looks *primarily* to phenotypical traits not to aeiteology – your depression strikes me as, without much doubt, "autonomous" (but I'm no clinical expert!). After all, if the "cause" *was* independently biological (in that there was no apparent environmental or subjective "trigger" for it)in what way would the symptoms you have suffered over the course of your illness be distinguishable from those of such an endogenous "biological" depression? My guess is that symptoms would be identical. This is not an argument for rejecting "biological" depression or for embracing "exogenous" factors are determinative; rather, it complicates the binary aridity which is intended to separate the "endogenous" from the "exogenous" by reference to the relative origin of the putative *cause* of the depression. I agree that biological processes and neurological changes underlie dysfunction in both cases, though I'm not sure they do so in *all* cases of depression in a way which makes their processess entrenched, repetitive, and substantially unresponsive to positive modification by the "environment".

    I would question your idea that "thoughts" *are* physiology: though without doubt the normal human *capacity* for thought necessitates neurophysiological correlates.

    On the issue of "over-diagnosis", I did more than imply, but stated, that the failure of the unitary concept of depression, as institutionaled in the DSM, properly to distinguish, for *clinical* purposes, sub-types of depression has many negative consequences, including the over-prescription of medication based on loose diagnosis of sub-syndromal or minor depressive mood, and the under-prescription of truly effective medication to patients who are suffering from a sub-type of severe, intractable, depression ("melancholia", if you will).

    I haven't sought to advance any scepticism about "depression" tout court, because in my view it is not an homogenous entity. I think the best interests of people who are disabled terribly by "depression" is best served by being as rigorous as we can about what we mean by it.

    With this qualification, I do share your observations on the unjust attribution of responsibility for scarcity to the most vulnerable. In more than a trivial sense, a patient is in a vulnerable class vis-a-vis a specialist who works from and exclusively implements the DSM criteria: to the extent that such criteria are defective, therefore, in the clinical domain there is a real issue about responsibility here: the responsibility of physicians to the patient who has entrusted him or herslef to their expert care.

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  17. Greg

    It is a well known fact in my grad program that over half of the professors are on antidepressants. Two in particular have had to take time off for mental instability reasons.

    Treated or not, the practical consequence is that if you are working with said persons, your dissertation stops when they are no longer available.

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  18. CSyd

    Greg,

    To or among whom is the "fact" "well-known" and by what means (direct, indirect, etc) was such information received and subsequently confirmed?

    I am curious to know whether there is a degree of hyperbole in your statement that "your dissertation *stops*" when "said persons …are no longer available". Do you mean to say rather that *supervision* with your primary supervisor stops? And if so, does your Department not make it mandatory to appoint an associate supervisor who can step in precisely when situations such as the one you describe arise?

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