Monday, July 16, 2007

Grief vs. Depression: Over-medication Redux

Eric has once again sparked a new post with his comments on my rant this Sunday in favor of antidepressants. He agrees that depression still retains a stigma today, and causes a level of suffering, that merits more attention from health care professionals, rather than less, as popular opinion seems to hold.

(Speaking of popular opinion, I Googled the CNN story that sparked my first post, and found quite a lot of tripe, most of it quoting one silly anecdotal story in the article, about a woman whose life was supposedly damaged by a careless prescription.)

But Eric includes an interesting proviso:
I don't know if meds should be prescribed for people suffering emotional tragedies, such as the death of a loved one[...]

Grief is a good example of a disorder which might inspire over-medication. This is also, sadly, a question I have already faced more than once in my young career. Let's look at it.

By the standards of the field, prescribing for bereaved patients is questionable, at best. The Diagnostic and Statistical Manual of Mental Disorders, the clinical touchstone for the field, says that grief and depression look very much the same, but aren't.

However, the DSM specifies that, if the symptoms of grief continue for more than two months, or are extreme (suicidal thoughts is one example), then the subject might be suffering from depression. At this point, we can presume that professionals are justified in investigate this possibility, and possibly prescribing accordingly.

The book describes examples of extreme symptoms fairly carefully. And it is that kind of care, built into the handbook for the field, that strengthens my conviction. If health practitioners simply apply the basic standards of the trade, combined with their own common sense, there will be very little over-medicating. Then the bandwagoneers could turn their considerable energies to figuring out how to resolve the war in Iraq. Everybody wins.

Some might say that I am assuming too much common sense on the part of all health care professionals. But it's only what should be assumed.


Muffy St. Bernard said...

Devil's advocate here. Keep in mind that my vague disillusion about the field of psychology is partially due to the way patients are diagnosed, often through a sort of best-fit pigeonholing that MUST be subjective.

I haven't looked at a copy of the DSM in years -- and sadly the DSM-IV costs over 50 USD for a 200+ paperback, so I'm not buying one right now -- but I remember that diagnosing anything (mood disorders included) is not as simple as filling out a checklist. Human behaviour is much more complex than that, and thank goodness!

My concern is that the standards set out in the DSM are not -- to my recollection -- "simple to apply." There are so many subjective gradients involved, and so many facets of behaviour that can only be discovered after a certain period of observation. Busy doctors (and patients) don't often explore WHY things happen. They take shortcuts, and the DSM helps them.

I do see usefulness in the DSM, but I view it as a double-edged sword.

BTW, my concerns about medicating depression didn't previously involve "Big Pharma" at all. But now that I see "One hundred percent of the members of the [DSM revision panels] on 'Mood Disorders' and 'Schizophrenia and Other Psychotic Disorders' had financial ties to drug companies" I've got a new concern.

(That statistic is from a journal article: "Financial Ties between DSM-IV Panel Members and the Pharmaceutical Industry")

Thinkulous said...

Muffy, I appreciate the devil's advocacy here. I definitely agree that the DSM -- and diagnosing in general -- heck, the entire field of psychology -- is a double-edged sword. I hope I haven't said anything to give the impression that I think people can be neatly fit into boxes. I didn't think so before I entered the field, and my short time doing the work has certainly disproved it altogether.

I also have an inherent mistrust of any company over 10 or 20 people. They almost always are involved in things I wouldn't like if I could ever know about them.

Also, as I've said elsewhere, I am regularly amazed at the difference between clients who all theoretically suffer from the same disorder. And issues of co-existing diagnoses, the influence of personality and environment (including the healthiness of ones surroundings),and much more only provide further complexity.

Finally, empathy has to be the first and last emphasis. My most central, unspoken underpinning as a therapist will always be Carl Rogers' approach. He said that if I am genuine with the client and take the time to get inside his/her world, all the rest will follow (but I have to know all the rest pretty well, too).

With all that said, I am routinely amazed at the effectiveness of the tools of the trade. Even if it's only maybe 40% or 50% of the time, that's still a miracle with such a difficult field. Diagnosis -- when compassionately and carefully applied -- has helped me tremendously in helping clients help themselves. And antidepressants (with the same caveats) have helped clients get to the point where they have the energy and the concentration to investigate and improve their lives in a very holistic and self-strengthening way. They sometimes can then taper off the meds. I'm definitely *not* giving a blanket endorsement of either the DSM or antidepressants, and do agree that over-medication does happen.

I would love to see that journal article about the review panel for the DSM, if you have a reference.

You know a lot about the field, and I'm curious to know what your connection is, if you care to share it.

Muffy St. Bernard said...

Likewise, I don't want to make it sound like I'm dismissing therapy of any kind; I've seen some great therapists in the past, and I had a cognitive therapist once who really did me a lot of good (in a single session!)

And I also distrust groups for the same reason you do. It's sad that organizations have the clout needed to get things done, but the more people (and money) involved, the more the rot has a chance to gain a foothold.

This is long, but I'll try to keep it short: I majored in Psychology, with plans to get into counselling. So I did all the reading and coursework, and I did my volunteering in the Psychiatric ward of our major hospital. I found myself frustrated by the religious zeal behind different (and often contradictory) therapies, and I couldn't reconcile my belief in the complex uniqueness of every person with the hard-nosed, statistical side of things.

In third year I began to take the "disillusionment courses." The symbolic interactionist approach blew the statistical approach partway out of the water, and the one particular "persuasion and healing" course brought most of the therapeutic disciplines -- especially the really zealous ones -- under the umbrella with faith healing, friendship, and placebos.

My faith in behaviourism and cognitivie therapy is intact, but those only work in specialized situations. I grew to see all other counselling approaches as basically being about empathy mixed with a necessarily aloof medical background.

That's all very important and it usually works, but it was a crisis of faith for me; I felt like a preacher who no longer believed in God, but still believed that the discipline was long as the people you're helping think that God exists.

In terms of medication, my issue with it comes more from the volunteering side of things -- seeing the meds entwined as part of a quick-fix control of patients who, instead of being doped up, SHOULD be crying their eyes out and hitting their heads against things. I also have some relatives and acquaintances who use depression and medication as a tool, and their specially-chosen doctors are more than happy to comply.

Finally, like I said, I think it's IMPORTANT to be depressed sometimes. I don't mean chronically depressed, and I do see the (somewhat dangerous) point in using medication to get people to a level where they can function again. But I think our society is too focused on avoiding everything that is awful, which I think leads to denial of reality.

As for that journal article, the link would get mangled in this comment box, but do a google search for Cosgrove Krimsky Financial. The full PDF is the first link.

Thinkulous said...

Muffy, thanks for the continued conversation. I appreciate the complexity of your story. It seems like we probably agree in terms of the usefulness of therapy and meds.

It also sounds like you had some very powerful experiences that shaped your outlook. Thanks for telling about it!

Anonymous said...

Antidepressants like xanax are the most popular form of depression cure. However, as per recent observations and studies, probabilities are rife that the antidepressants are not that suitable to be administered to patients with low to medium depression. They work best only when they are prescribed to the patients with high depression symptoms.

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