It is refreshing that The New York Times in the space of four days has published two articles which take a critical view of the current mental health paradigm. An article by Alan Sroufe called “Ritalin Gone Wrong” points out that there is little evidence showing any long-term benefit to medication use for children diagnosed with ADHD, something which has been known to professionals for a while but is only recently being told to the general public. The second article by Gary Greenberg argues that psychiatrists are not really treating diseases but are treating “categories of suffering.” Greenberg discusses efforts to remove the bereavement exclusion – “the two months granted the grieving before their mourning can be classified as ‘major’ depression” – and points out that “the move would raise the numbers of people with the diagnosis, increasing health care costs and the use of already pervasive mind-altering drugs, as well as pathologizing a normal life experience.”
To see an example of what Dr. Greenberg is talking about, you do not need to go far. Several years ago Dr. Ronald Pies had an article in The New York Times titled, “Redefining Depression as Mere Sadness.” The main thesis was that having an organic disease is not a prerequisite for psychiatric treatment, and that even people who are experiencing the ups and downs of normal life experience can benefit from seeing a psychiatrist.
The article starts off with the following case example: “Let’s say a patient walks into my office and says he been feeling down for the past three weeks. A month ago, his fiancée left him for another man, and he feels there’s no point in going on. He has not been sleeping well, his appetite is poor and he has lost interest in nearly all of his usual activities.” Most people would call this normal sadness, or as Greenberg would say, “a category of suffering.” Most people would not call this a disease. In fact, we think most people have been in a similar situation at some point in their life- and have gotten through the situation without psychiatric help.
However, Dr. Pies sees him as clinically depressed and would provide him with whatever psychiatric treatments “he needed”. In his words, “Until solid research persuades me otherwise, I will most likely see people like my jilted patient as clinically depressed, not just “normally sad” — and I will provide him with whatever psychiatric treatment he needs to feel better.”
In this day and age, psychiatric treatment from a psychiatrist almost always means medication- and for sadness, antidepressant medication. Dr. Pies seems to be suggesting that while the debates rage on about whether normal sadness should be treated like clinical depression, or whether patients have a serotonin imbalance or not, in the meantime, psychiatrists should not hesitate to treat individuals who do not meet traditional diagnostic criteria for mental illness, or who are reacting understandably to tragic circumstances- and to prescribe antidepressants.
To prescribe an antidepressant for someone three weeks post break-up seems to be a perfect example of medicalization, where medicine has turned a normal response to life-stressors into pathology. We don’t think anyone reading this patient scenario could believe that the patient’s psychological state was caused by a serotonin shortage resulting from a genetic defect. In the absence of a disease, the purpose of the medications for this patient would seem to be to help him get over a difficult time period in his life – a bump in the road some might say. Prior to the advent of the chemical imbalance theory the marketing programs for the older medications usually talked about depression in these terms. For instance, an early advertisement for valium stated, “the daytime sedative for everyday situational stress.” With the rise of the chemical imbalance theory all this changed, and instead the medications came to be seen as necessary to treat a fundamental problem with a person’s biology.
It now appears that we have gone back a bit in time to the idea that a chemical imbalance is not necessary for a diagnosis of depression. Now, a short-lived reaction to unpleasant life events is used to justify the prescription of antidepressants. We use Dr. Pies’ vignette as an example not to single him out, but because he has publicly presented it – and we certainly think his point of view is common in psychiatry.
It is easy to find objections to this strategy, though, from the perspective of science:
Where is the rigorous research showing that antidepressants are effective in bereavement or loss?
In particular, where is the research comparing antidepressants to psychotherapy, peer-support, exercise, etc., clearly showing that antidepressants are the better intervention in situations of bereavement or loss?
Is there a scientific evidence for prescribing antidepressants early when someone suffers bereavement or loss, rather than trying everything else first and leaving SSRIs as the treatment of last resort? If this method isn’t followed, why not?
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
Quite often, patients are complicit in asking for something to get them over their break-up or bereavement. The State approves because it avoids days being taken off work. We’re programmed to think that only wimps need time to grieve, but as we all instinctively realise, this temporarary fix just stores up trouble for the future: it’s the health equivalent of taking out a pay day loan.
” An article by Alan Sroufe called “Ritalin Gone Wrong” points out that there is little evidence showing any long-term benefit to medication use for children diagnosed with ADHD,”
Um, no it didn’t. It pointed out that there is NO EVIDENCE. Was that just a figure of speech? Why would you say that?
Will you please show me the little evidence that shows a long-term benefit of taking stimulant drugs for A.D.D.? I want to see it now.
“Normalization” is an extremely powerful approach to assisting people in moving through grief, anxiety, and other common reactions to life stressors. It can be very reassuring to hear that, “Of course, you’re depressed – your wife betrayed your trust and unexpectedly left you, and you are still reacting to it. Anyone in your situation might feel the same way.” I have had clients feel INSTANTLY better in hearing that they do not have a disease but are reacting normally to difficult circumstances.
The antidepressant argument does the opposite. It de-normalizes experiences that are actually pretty normal, and makes the person feel doubly worried, first that they have the “medical condition” of “depression,” and second, that the doctor thinks they should not feel the way they do and wants to medically make them “better.” I would imagine that this would act to INCREASE a person’s anxiety and hopelessness, while at the same time removing their sense of agency (their belief that they can work through this situation with their own internal resources), and hence lead to feeling worse and more out of control than before.
It is disingenuous at best for psychiatrists to say that prescribing is OK until proven otherwise. Science works the other way – we have an obligation NOT to provide a treatment until it’s proven to work. Offering antidepressants for grief and loss not only isn’t proven to work – it most likely makes things worse.
From my own experience as an adult psychiatrist doing pro bono work, I found that the Royal College of psychiatrist leaflet to give to client after the death of a dear one is often sufficient treatment -after I have also given reassurance that it was normal to behave strangely after the death of a dear one like you told us you use with your clients.
And the best thing is that you can download and print leaflets from the RCPsych website (and not only in English) and they let you use it as long as you do not steal their intellectual property.
Also in my experience, sometimes changing school or class when a gifted child is bored at school or a child is bullied without the teachers paying attention might be enough to solve behavior problems in the classroom- not always of course but more often that I would have assumed before I saw it happen several times.
In 2001, a woman I supported who was suicidal but her early teen aged son had suffer terrible psychological abuses at school the last one was that he had been expelled from his school with very bad grades and comments making it dfficult to find another good school to have him admitted but mother and son had learned it one morning when entrance to the school was denied to the pupil with a “wanted poster” with an enlarged ID photograph of the son and a message telling Not to let penetrate on the school premises. The mother seing no end of that finding a new school problem became depressed , saw a psychiatrist who prescribed antidepressants. She only resumed to be her own efficient and happy self married woman with a top job and two children after I send her to see a lawyer (and the headmaster of that catholic school was dismissed following a letter from her lawyer to the school authority)- but beware that -in my opinion- many a bad lawyer is on the contrary responsible in France for depressive symptoms in people with never ending divorce procedures made worst by the lawyers… Life is tough indeed but becoming numb on antidepressant is no solution.