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?