Storied Mind

Depression Is a Creative Force in Human Evolution?

john — Fri, 05 Mar 2010 22:05:17 +0000

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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.

The Draft Revisions for DSM-5: Dimensional Assessment

john — Wed, 24 Feb 2010 05:56:00 +0000

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Like many, I’ve been worried that the revision of Diagnostic and Statistical Manual of Mental Disorders, the source for all our diagnoses, could lead to what’s been called the medicalization of normality. But there are even more fundamental problems inherent in the classification system itself. It slots you into a fixed category based on a checklist that ignores many symptoms, and the categories lack any means for measuring the progress of treatment over time.

In my own case, I’ve always had a depression diagnosis (under the DSM-4 system, that’s major depression – recurrent – non-psychotic). I’ve had various symptoms that don’t show up in the official criteria for this category. I’ve discussed some of them – especially anxiety (though it took me many years to think of mentioning it) – with psychiatrists and therapists, and they’ve been quite responsive. The problem is that there were many I never brought up, especially relating to the upside of the cycles that included the recurrent major depressive downside. Those high energy phases didn’t strike me as manic, as I understood the word (no climbing tall buildings or emptying bank accounts), so why talk about feeling incredibly good, or the less friendly but high-intensity fits of rage. What did they have to do with depression?

As John McManamy points out, there’s significant overlap between unipolar recurrent depression with bipolar depression, yet the classification system shuts them into different categories. I don’t know if I’ve been incompletely diagnosed all these years, but I do know that antidepressants have never worked very well for me and that I’ve done much better since I started taking lamictal.

Before the draft came out a couple of weeks ago, I was encouraged by a statement of guiding principles relating to dimensional assessments. The leadership seemed open to changing some of the basic problems of the classification system. You can read their ideas in the FAQ section of the DSM-5 website, especially the description of dimensional assessments. It’s worth quoting:

… In the earlier versions of DSM, as with the current DSM-IV, disorders were described and arranged by category, with a specific list of symptoms for each mental illness. In this categorical system, a person either had a symptom or they didn’t, and having a certain number of symptoms was required to receive a diagnosis. …

… The categorical syndromes do not always fit with the reality of the range of symptoms that individuals experience. … Also, because the criteria for diagnosis are “yes/no” (i.e., does the individual have this disorder or not?), in most cases there is no method in DSM-IV to account for the severity of the disorder, and thus no specified way to determine if the patient is improving with treatment.

… [D]imensional assessments … would allow clinicians to systematically evaluate patients on the full range of symptoms they may be experiencing. For instance, information about depressed mood, anxiety level, sleep quality and substance use would be important for clinicians to know regardless of the client’s diagnosis … [and] would allow clinicians to rate both the presence and the severity of the symptoms … . This rating could also be done to track a patient’s progress on treatment, allowing a way to note improvements even if the symptoms don’t disappear entirely.

This statement and the formation of a Working Group to develop proposals for dimensional assessment led me to hope that the draft might address the rigidity of the classification system itself. It doesn’t do that at all but does add an important element to the categorical approach in the form of severity and frequency ratings. If used in practice, a psychiatrist would have a much more complete picture of all symptoms, not just those that are part of the limited diagnostic definition – as well as new tools for measuring the progress of treatment.

The main practical concern of the draft is the development of very simple questionnaires for clients and psychiatrists to fill out. So there are more checklists, this time with scales to capture severity for the cross cutting dimensions and frequency for the mood disorders. (You can download drafts of the short forms for depression, anxiety and anger as well as the draft dimensional assessment on this page.)

The Dimensional Assessment has questions on the occurrence and severity of symptoms in three “domains” – suicide risk, substance abuse and a cross-cutting group for mood disorders. (This and the other assessment instruments have been developed through a National Institutes of Health program, called PROMIS, that is working on measurement of cross-domain symptoms for the practice of medicine as a whole.)

This dimensional information provides the basis for a severity-scale rating of the total condition of the patient rather than only the diagnosed disorder. The rating can range from normal (not ill at all) to “among the most extremely ill patients.” The questionnaires for specific disorders allow tracking of progress in terms of frequency of occurrence. The depression scale, for example, asks if you felt x in the last seven days, never, rarely, sometimes, often or always. This is hardly a perfect system, but it seems like a step forward in providing a much more useful approach to the condition of a client than that of the static diagnosis.

There are dozens of changes that have provoked severe criticism by many psychiatrists, psychologists, therapists and counselors. One of the most telling – and the one that I can readily confirm from my own attempts to make sense of this complicated document – is inconsistency in the writing and organization of the whole work. Dr. Allen Frances, who chaired the DSM-4 Task Force and is a sharp critic of the current revision, attributes this to lack of coordination and direction of numerous Working Groups that have been focused exclusively on their own subjects with very little communication across groups. The result, he says, is a collection of proposals that are full of ambiguous terms and that lack consistency with one another in terminology and approach. It’s well worth reading his recent critique, Opening Pandora’s Box: The 19 Worst Suggestions for DSM5.

If you haven’t already noticed, discussion and debate about the revisions are all over the media, but a great starting point in the blogging world is John McManamy’s extensive coverage at Knowledge is Necessity. His multi-post report cards on the depression and bipolar revisions are excellent guides, and they comprise only a small part of his detailed and ongoing review. The Carlat Psychiatry Blog also follows the revisions closely.

There will be more to come on DSM-5 here as well. Like it or not, this catechism of diagnosis affects everyone. Next up is an attempt to make sense of the proposed revisions for defining “mental disorder” and for diagnosing major depression.

Prozac for Crowd Control?

john — Sun, 21 Feb 2010 08:00:23 +0000

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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.