Today I have the pleasure of interviewing one of my favorite psychiatrists, Dr. Ron Pies. Dr. Pies is Professor of Psychiatry and Lecturer on Bioethics and Humanities at SUNY Upstate Medical University, Syracuse NY; and Clinical Professor of Psychiatry at Tufts University School of Medicine, Boston. He is the author of “Everything Has Two Handles: The Stoic’s Guide to the Art of Living” and has been a past contributor to the World of Psychology blog.
Question: You’ve written a lot of the topic of grief and depression. How does a person know when grief becomes depression or another mood disorder?
Dr. Pies:
I think it’s important to understand that grief is often a component of clinical depression, so the two are by no means mutually exclusive. For example, a mother may be experiencing intense grief over her recently deceased child, which would be an expectable and quite understandable reaction to such a devastating loss. As I try to explain in my essay on this topic, grief may take one of several “paths”, over longer periods of time. Through a process of mourning; receiving comfort from loved ones; and “working through” the meaning of the loss, most grieving persons are able eventually to move on with their lives. Indeed, many are able to find meaning and spiritual growth in the admittedly painful experience of grieving and mourning. Most such individuals, however, are not crippled or incapacitated by their grief, even when it is very intense.
In contrast, some inviduals who experience what I have called “corrosive” or “unproductive” grief are, in a sense, devoured by their grief, and begin to develop signs and symptoms of a major depressive episode. These individuals may be consumed by guilt or self-loathing–for example, blaming themselves for the death of a loved one, even when there is no logical basis for doing so. They may come to believe that life is not worth living any longer, and contemplate or even attempt suicide. In addition, they may develop bodily signs of a major depression, such as severe weight loss, persistent early morning awakening, and what psychiatrists call “psychomotor slowing”, in which their mental and physical processes become extremely sluggish. Some have likened this to feeling like a “zombie” or like “the living dead.”
Clearly, folks with this kind of picture are no longer in the realm of ordinary or “productive” grief–they are clinically depressed and need professional help. But I would resist the notion that there is always a “bright line” between grief and depression–Nature doesn’t usually provide us with such clear demarcations.
Question: I very much enjoyed your piece on Psych Central, “Having Problems Means Being Alive.” Early in my recovery, I was so afraid to take medication because I thought that it would numb my feelings, keep me from experiencing life’s highs and lows. What would you say to a person who is clinically depressed but afraid to take medication for that very reason?
Dr. Pies: People who are told by a physician that they would benefit from antidepressant medication, or a mood stabilizer, are understandably anxious about possible side effects from these medications. Before addressing the question you raise, though, I think it is important to note–as you may know from your own experience–that depression itself often leads to a blunting of emotional reactivity and an inability to feel the ordinary pleasures and sorrows of life. Many people with severe depression tell their doctors that they feel “nothing”, that they feel “dead” inside, etc. Probably the best description I’ve seen of severe depression is William Styron’s account of his own depression, in his book, “Darkness Visible”:
Death was now a daily presence, blowing over me in cold gusts. Mysteriously and in ways that are totally remote from normal experience, the gray drizzle of horror induced by depression takes on the quality of physical pain…. [the] despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this caldron, because there is no escape from the smothering confinement, it is entirely natural that the victim begins to think ceaselessly of oblivion… In depression the faith in deliverance, in ultimate restoration, is absent…
I present this description to place the question of antidepressant side effects in perspective: how bad could the side effects be, in comparison with severe depression itself?
Nevertheless, you raise a good question. There is, in fact, some clinical evidence that a number of antidepressants that boost the brain chemical serotonin (sometimes referred to as “SSRIs”) may leave some individuals feeling somewhat “flat” emotionally. They may also complain that their sexual energy or drive is reduced, or that their thinking seems a little “fuzzy” or slowed down. These are probably side effects of too much serotonin–perhaps overshooting what would be optimal in the brain. (By the way, in pointing this out, I am not taking the position–sometimes promoted by pharmaceutical companies–that depression is simply a “chemical imbalance”, that can be treated merely by taking a pill! Depression is, of course, much more complicated than that, and has psychological, social, and spiritual dimensions to it).
The sort of emotional “flattening” I have described with SSRIs may occur, in my experience, in perhaps 10-20% of patients who take these medications. Often, they will say something like, “Doctor, I no longer feel that deep, dark gloom I used to feel–but I just feel kind of ‘blah’…like I’m not really reacting much to anything.” When I see this picture, I will sometimes reduce the dose of the SSRI, or change to a different type of antidepressant that affects different brain chemicals–for example, the antidepressant bupropion rarely causes this side effect (though it has other side effects). Occasionally, I may add a medication to compensate for the SSRI’s “blunting” effect.
Incidentally, for individuals with bipolar disorder, antidepressants may sometimes do more harm than good, and a “mood stabilizer” such as lithium is the preferred treatment. Careful diagnosis is needed to make the correct “call”, as my colleague Dr. Nassir Ghaemi has shown [see, for example, Ghaemi et al, J Psychiatr Pract. 2001 Sep;7(5):287-97].
Studies of patients with bipolar disorder who have taken lithium generally suggest that it does not interfere with normal, everyday “ups and downs”, nor does it appear to reduce artistic creativity. On the contrary, many such individuals will affirm that they were able to become more productive and creative after their severe mood swings were brought under control.
I do want to emphasize that most patients who take antidepressant medication under careful medical supervision do not wind up feeling “flat” or unable to experience life’s normal ups and downs. Rather, they find that–in contrast to their periods of severe depression–they are able to enjoy life again, with all its joys and sorrows. (Some good descriptions of this may be found in my colleague, Dr. Richard Berlin’s book, “Poets on Prozac”).
Of course, we have not dealt with the importance of having a strong “therapeutic alliance” with a mental health professional, or the benefits of “talk therapy”, pastoral counseling, and other non-pharmacological approaches. I virtually never recommend that a depressed patient simply take an antidepressant–that is often a recipe for disaster, since it assumes that the person will not require counseling, support, guidance, and wisdom, all of which ought to be part of the recovery process. As I often say, “Medication is just a bridge between feeling awful and feeling better. You still need to move your legs and walk across that bridge!”
23 comments
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I have a lot of concerns how Dr Pies continues to push for lumping grief into a depressive diagnosis, which I interpret to say these people with grief issues should be quickly medicated. As a psychiatrist, what do we gain by calling more life experiences as psychiatric disorders? I for one am cringing as the DSM V comes closer to being published, as this runs the risk of alienating my profession from the general population who will responsibly say “Enough!” when the people concocting this manual are basically just trying to label anything that is even briefly disruptive or disconcerning a disorder. I ask Dr Pies, how many of your close colleagues practice psychotherapy with patients more than 20% of their practice these days? I would hazard to guess less than 10% of them. If my estimate is true, doesn’t that bother you at least a bit? Are you going to advocate for medicating people struggling with recession related problems next, if they are not with full stigmata of depression or anxiety? God I hope your answer is no.
The decade of the brain in the 1990’s has lead to the ruin of psychiatry: it is not about biochemical imbalances, folks, but the multifactorial process of biology, psychology, and sociology. Anyone who tells you less and is quick to recommend pills is selling you out.
therapyfirst, board certified psychiatrist
I appreciate the opportunity to clarify some issues regarding my views on “grief” and depression. First, contrary to the inference reached by the anonymous psychiatrist (“therapyfirst”), I do not “lump” grief and major depression together. I merely point out that grief is often a component of major depression.
If we say that fever is often a component of a viral illness, it does not mean we are “lumping” fever and viral illnesses together. For a more detailed presentation of how I think ordinary grief differs from major depression, readers can read my paper “The Anatomy of Sorrow” at the PEHM website:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2442112
I am also quite puzzled that “therapyfirst” somehow concludes that I believe “…people with grief issues should be quickly medicated.” To my knowledge, I have never claimed or advocated such a position in any of my published writing. If “therapyfirst” would care to cite any references to papers of mine in which I take such a position, I would be very interested in seeing them.
In fact, I do not believe that even those who have a bona fide major depressive episode should, in most cases, “be quickly medicated.” For many such patients, a trial of psychotherapy is often effective, and may avert the need for medication. I point out as much in my book, “A Consumer’s Guide to Choosing the Right Psychotherapist”, where I also note that medication and psychotherapy may work through different mechanisms to ameliorate different symptoms of depression; for example, medication may help with insomnia or low energy, but is probably not as effective as psychotherapy in dealing with feelings of intense guilt or low self-esteem. Often, in severe cases of major depression, the two modes of treatment together work better than either one alone.
I would certainly agree with “therapyfirst” that depression is far too complicated to be described solely in terms of “biochemical imbalances”, as I clearly indicated in my interview with Therese
Borchard; i.e.
“I am not taking the position–sometimes promoted by pharmaceutical companies–that depression is simply a “chemical imbalanceâ€, that can be treated merely by taking a pill! Depression is, of course, much more complicated than that, and has psychological, social, and spiritual dimensions to it.”
No well-informed psychiatrist would embrace the false choice between “biochemical imbalances” and “the multifactorial process of biology, psychology, and sociology”. There is a complex, cyclical relationship between psychosocial factors and one’s brain chemistry. Thus, social stressors can adversely affect the brain; the altered brain can, in turn, affect the way we behave socially.
As for the percentage of psychiatrists who “practice psychotherapy with patients more than 20%” of the time, I share the reader’s concern.
As “therapyfirst” probably knows, a recent study by Mojtabai and Olfson showed that, among psychiatrists,
“Psychotherapy was provided in 5597 of 14,108 visits (34.0%)…sampled during a 10-year period. The percentage of visits involving psychotherapy declined from 44.4% in 1996-1997 to 28.9% in 2004-2005 (P < .001). This decline coincided with changes in reimbursement, increases in managed care, and growth in the prescription of medications.” [Arch Gen Psychiatry, 2008; 65, 962 – 970].
I consider this a very unfortunate trend, but I do not think we can attribute it primarily to “the decade of the brain”. Most of the psychiatrists I know lament the decreased role that psychotherapy has in their practice, but–as the above article makes clear–there are many forces working against the provision of psychotherapy by psychiatrists.
In a letter now in press in the journal Academic Medicine, my colleague, Cynthia Geppert MD and I argue for increased attention to teaching psychiatric residents how to do psychotherapy, as well as to greater integration of the humanities into psychiatry. Similarly, in a blog on the Psychiatric Times website, I also lament the use of the “15 minute med check” in the psychiatric setting, and deplore what I call
“the McDonaldization” of psychiatry [see http://www.psychiatrictimes.blogspot.com/%5D.
In short, I think “therapyfirst” makes several unwarranted assumptions, regarding my treatment philosophy. Indeed, I suspect that we share more concerns about current psychiatric practice than “therapyfirst” realizes. I hope that my concerned colleague–and interested readers–will look at some of the other references and blogs I have cited, and reach their own conclusions.
Sincerely, Ronald Pies MD
[Note: a disclosure statement for Dr. Pies may be found on the Psychiatric Times website. Dr. Pies is Editor in Chief of Psychiatric Times. He reports no conflicts of interest with respect to this communication].
I appreciate Dr Pies’ above reply, and I assume I stand corrected. That said, you wrote a piece in a prior Psych Times issue that came across that grief is often depression (sorry I do not have the article to quote directly, but that is how I read it), and I read the above posting here the same way. So, I am glad you seem to echo my concerns and expectations, and am sorry to challenge you falsely. Thank you again for the clarification.
sincerely,
therapyfirst
Thanks to Dr. “therapyfirst” for the gracious and open-minded reply. For those who want to delve into the Psychiatric Times article in question, it is readable at:
http://www.psychiatrictimes.com/display/article/10168/1357799
At the same website, there is also a series of letters debating this topic, including one by Dr. Sid Zisook and myself. –Best regards, Ron Pies MD
I have been taking a SRRI anti-depressant for a number of years and it has remarkably improved my quality of life. I no longer suffer from dysthymia and my social anxiety is gone! One thing I do notice is that it is really difficult for me to cry. But I have so much joy in my life that I will probably never go without my Paxil.
Dr Pies:
“Major depression after recent loss is still major depression–until proven otherwise”? Don’t you think that can be interpreted more than one way? I stand by what I said earlier, that giving a little lattitude with liberal colleagues will lead to over prescribing because people will over-interpret sadness from loss.
Me thinks you are trying to have it both ways. I hope the readers will read the above comments and your article and come to their own well thought conclusions. You mean well, I sense, but, the road to hell is paved with good intentions.
By the way, what are your thoughts about DSM V? I think you commented at Psych Times in a recent editorial there about this topic, but, care to relate this topic to the potential of over-diagnosing that might be the end result? I think there are readers who would be interested in an opinion of your expertise.
I’ll give you mine, if you haven’t guessed it already: DSM V is a disaster ready to do more damage to our field than most can possibly imagine. I sense you will politely disagree, but in the end, diagnoses have gone too far. And, if what I read at Furious Seasons earlier this week has any credibility, the specter of Bipolar Disorder being labeled under the tent of Psychotic Disorders is, well, I have no word for this intent. To bring it back to this posting, we as psychiatrists have to be careful we do not overdiagnose, as much as underdiagnose. Treatment is a work in progress, I would hope you would agree with this perspective at least.
Happy Memorial day to you and all interested in this posting. Get out and enjoy the sun and air, hopefully weather permitting!
Therapyfirst is to be commended for comments which call for commonsense and humanity in a field where many psychiatrists and pharmaceutical companies are making huge profits with questionable results. Whatever it is that Dr. Pies purports to believe with regard to the so-called antidepressants, the bottomline is that our society is one that is frighteningly overmedicated. And it would be one thing if these drugs were prescribed with an end in mind, but instead it seems that many people who take them do so for years and years at a time.
The comment by the reader above who says she has difficulty crying is emblematic of the problem. Crying is a natural and necessary part of human existence. I had a stomach ulcer as an 11-year-old. At the time I was told I was “worrying too much” and needed drugs to calm me down. I was put on Librax for several years, and as I look back, I believe the drug numbed me emotionally to a significant degree. I do not believe that is a good or healthy thing to do to a developing adolescent. Later research showed this treatment was, in fact, not efficacious.
Where will we be in 30 years when we look back at antidepressants, atypical anti-psychotics (so often prescribed off-label for a host of maladies), drugs for ADD and ADHD and a host of other drugs? My prediction is that they will look as pathetic as giving an 11-year-old Librax.
I pray that more and more people will take to heart what therapyfirst is saying.
I thank all the readers of this piece for their comments and observations. For the most part, I think these comments avoid the tendency to divide the world into armed camp– for example, pitting those evil, soul-stealing, biological psychiatrists, in the pocket of Big Pharma, against those finger-wagging, anti-medication, Puritans who want to deny seriously depressed people life-saving treatment! These caricatures do not serve anyone well, and least of all, our
friends, family members, and loved ones who suffer with severe mood disorders.
For a more detailed perspective on why antidepressants and other psychotropics should neither be deified nor demonized, readers may want to see my essay on the Psychcentral website,
http://psychcentral.com/blog/archives/2008/03/02/devil-or-angel-the-role-of-
psychotropics-put-in-perspective/
Re: the notion that our society is “frighteningly overmedicated”: when it comes to the use of antidepressants, I think the story is much more complicated than one of simple “overmedication”. While it is true that, in outpatient medical practice, depression is being diagnosed and treated with substantially greater frequency
than it was, say, 20 years ago, it is far from clear that this simply represents “overdiagnosis” or “over-medication”.
And, when you look at the actual numbers, the changes in the past decade do not point to a tidal wave of depression or antidepressant prescription. For example, research by Sclar and colleagues(Int Clin Psychopharmacol. 2008 Mar;23(2):106-9) compared depression diagnosis and antidepressant treatment rates in 1992-1993 to those in 2003-2004. They found that concomitant diagnosis of depression and antidepressant use increased from 6.5 to 11.4 per 100 for whites in the general community; from 2.6 to 5.2 for blacks, and from 3.0 to 5.6 for Hispanics. To be sure, these are large increases in statistical terms, but the absolute numbers of diagnosed and medicated patients in the community are still quite small.
Increases in diagnosis and treatment could reflect “overdiagnosis” and over-treatment
in some cases–but they may instead (or also) reflect (a) increased awareness of depression among physicians and the general public; (b) actual increases in depression among the general population; or (c) the effects (good or bad) of
“direct-to-consumer” (DTC) advertising of antidepressants, on the part of pharmaceutical companies. Alternatively, the increased rates could reflect some combination of the above
factors.
There is also evidence that some segments of the population may be under-diagnosed and under-treated. For example, while treatment rates are
lower among African-Americans with depression, their depression may typically be more severe than among their white counterparts (see Williams et al, Arch Gen Psychiatry. 2007 Mar;64(3):305-15). This is a serious concern that requires more investigation.
My own view is that there is a “twin peaks” phenomenon at work: over-diagnosis of depression can occur in some settings, particularly those that lack highly-trained, specialized clinicians; but under-diagnosis can also occur in these
settings, as well as in communities that lack access to good mental health care.
There is also evidence that many individuals with bipolar disorder are mistakenly diagnosed with (unipolar) depression–and that, too, can lead to inappropriate use of antidepressants.
It is also important to point out that by far the greatest percentage of prescriptions for antidepressants are written by non-psychiatrists; i.e., by general and family practitioners. I believe my hard-working GP and FP colleagues are
doing the best they can, under very difficult circumstances–often in the absence of readily-available psychiatric referral or consultation. Nonetheless, the lack of available expertise in mood disorders can sometimes lead to instances of
misdiagnosis, hasty diagnosis, and inappropriate or inadequate treatment–especially when “mis-managed care” is pushing the GP, FP, or even the psychiatrist, to do 15 minute “med checks” instead of thorough, painstaking evaluations.
That said, I believe most psychiatrists would argue that under-treatment of severe depression is a more pressing problem than over-treatment of “normal sadness”. In my view, the danger in failing to treat a person with severe, suicidal
depression is much greater than “overcalling” the diagnosis and starting antidepressant treatment in a person whose depression might have gone away
on its own–even allowing for the side effects (weight gain, sexual side effects, elevation of blood sugar, etc.) that can sometimes accompany use of antidepressants, especially when continued for several years. (By the way, psychotherapy, too, can have adverse “side effects” if it is mishandled, or provided by a poorly-trained therapist).
Let’s also remember: patients who freely seek out mental health care are not passive vessels, into which medications are poured by physicians or nurse practitioners! Even depressed patients have an affirmative and proactive role to play
in their treatment: they can and should ask questions about the treatment proposed by their clinicians, including both the benefits and its potential side effects. If the patient is too cognitively impaired or lethargic to participate actively in his or her care, then family members or loved ones may need to play the role of “advocate” in behalf of the patient, and press the doctor on these matters.
Regarding my colleague’s concerns about DSM-V, I will reserve judgment until I see the final shape of things. I am encouraged by reports that a “dimensional” approach may be part of the DSM-V, allowing clinicians to avoid the “either-or”
pigeon holes inherent in the DSM system. As for too many diagnoses in DSM-V, it is a real danger–but from the report by Dr. Grohol on this website (5/26), it sounds as if the DSM-V committees are not inclined to add too many new
diagnoses, and may even eliminate at least one or two. I have personally argued against including some proposed categories–such as “Pathological Bigotry” and “Internet Addiction”–as mental disorders.
That said, we should not become so cynical about the DSM process that we scoff at any new diagnostic category that is proposed. After all, in neurology, four ”new” types of headache were added to the official classification in the 15 years between the first and second editions of the International Classification of
Headache Disorders. It is not clear that this was simply a result of nefarious economic forces or bad intentions on the part of the neurologists–nor did it create a huge uproar in the media, as changes in psychiatric diagnoses seem to do. The classification of dementias has also grown rapidly over the last 20 years;
e.g., Lewy Body Dementia (progressive dementia with hallucinations) was hardly recognized as a diagnosis in the 1980’s yet is now thought to be fairly common.
Medical diagnosis changes over the years and we need to be prepared to accept that. The real question is, how careful are we to test the new and proposed diagnoses over time, to see how reliable, valid, and useful they are?
I will close with the words of physician and educator Alfred Stille (1813-1900),
with which I suspect we can all agree:
“It is quite as necessary for the physician
to know when to abstain from the use of medicine as it is…[to know] when medication is necessary…â€
Sincerely, Ronald Pies MD
I find the above debate a crucial and timely one, but one which perhaps is better seen as a fundamental difference in world view between two camps.
One perspective that I feel helps us to understand the growing propensity to diagnose and “treat” depression is the tendency of some more pharmacotherapeutically oriented mental health practitioners to regard symptoms as things that ought to be removed.
Perhaps an analogy is of value: When a patient presents with an unusual and vigourous tumorous growth, the responsible practitioner would, I would hope, be inclined to conduct further investigations into the origin and meaning of the “symptom”: The tumour. To simply surgically remove and discard the tumour and send the patient home with some pain-killers would be actionable practice.
By the same token, I hold that there is a strong case to be made for the investigation of what lies beneath psychological or psychiatric “symptoms”. If there is an exponential growth in the prevalence of depressive symptoms, is there not a case to be made for a more considered, bigger-picture consideration of what this might be about, rather than a corresponding rise in the number of prescriptions written to remove the symptoms. Should another dozen patients present with the same tumour, we’d be very inclined to investigate what’s in the drinking water of the affected community.
In much the same way that physical symptoms are indicators of underlying imbalance/pathology/illness, psychotherapists work from the assumption psychiatric “symptoms” are often the best indicators we have of systemic problems in family systems, communities, relationships, etc.
But, because there are no incontrovertible physical markers of emotional distress and what the “underlying” problem may be, this whole approach to human unhappiness appears to sit uncomfortably with professionals trained to observe and work primarily with clear, black-and-white markers of ill health.
Whether or not Dr. Pies is correct in asserting that “Major depression after recent loss is still major depression–until proven otherwiseâ€, his focus on attaching a diagnosis, I suspect, may speak more to the comfort he derives from being able to attach a diagnosis, if for no other reason than that a diagnosis makes a clear case for what many psychiatrists are wanting to do: Apply what the common psychiatric consensus says is the “best” way to remove the symptoms.
I have no argument with the use of antidepressants for those who are significantly disabled by their emotions or who are actively suicidal. Ultimately, this is a decision that should be made by the sufferer. But the very active and vigorous marketing of their use for the “removal” of less distressing – albeit uncomfortable – symptoms (which constitute the majority of prescriptions for which antidepressants are written) is, I believe, ethically questionable.
Given that the serotonin hypothesis about the origins of depression remains just that – a hypothesis – as a psychotherapist I balk at the idea of labeling any emotional discomfort simply because that prescribes one or another kind of treatment. I have a far greater interest in understanding the meaning of the loss, the grief, the anhedonia, or whatever the “symptom” may be. I’m most interested in what it points to in the life of the individual and his or her context.
Suppose, for argument’s sake, that we, as a society or generation, are living unsustainably pressured, materially-obsessed lives and our symptoms are pointing to the problems inherent in that paradigm of life, I’d far rather have the symptoms talk to me about the bigger problem that simply remove them.
To simply excise the symptoms feels too much for me like the removal and disposal of the tumour. Personally, I’d prefer the biopsy.
Dr Pies:
Thank you for your reply. Agree with the basis of your comments. Like a colleague who has his own blog on mental health issues, I sense you are being more the mensch than speaking a bit harsher, which in my opinion the dialogue about over aggressive psychiatry needs in its face.
So, we agree to disagree on some matters.
Sincerely,
therapyfirst
As with most arguments and disagreements there is no right or wrong answer … only what is right for whom and when. My personal experience convinces me that many years of talk therapy and various other supports were unproductive until I was given a medication that allowed me to think clearly and rationaly. Likewise if I had a certain kind of severe injury I might take pain medication so that I could benefit from physiotherapy. I am fortunate to have a psychatrist who takes the time to thoroughly monitor my medications (Bi-Polar Disorder 1). He does not do any therapy that I am aware of. Psyciatrists are at a premium in Ontario Canada where I live. However, my psychiatrist referred me to services right away that provide me with counselling, managing relationships and daily living tasks as needed while I work toward stabalizing my mood. I am not a professional but as a survivor of mental illness, who knows the reality of my condition better than I. The DMV I imagine uses the information of professionals in the field of mental health to arrive at their conclusions re diagnosis. These professionals I assume are gathering information and forming opinions while interacting with the mentally ill. Surely if many patients are displaying symptoms not entirely consistent with accepted diagnosis and are not responding to therapies suited to that diagnosis it must be useful to identify this set or subset of symptoms. Publishing such identifications along with treaments that DO work should relieve much suffering by helping sufferers get to the therapy they need. If the DMV includes a diagnostic category that does not meet everyones approval (internet addiction)… is that more harmful than having too few diagnonise at the expense of not treating those who are suffering because they do not fit nicely into the available categories. We could of course simplyfy things by having just one category. All the non normals are insane and off to the asylum they go!
I agree that it seems that today’s doctors are giving out more drugs than in the past rather than counseling their patients and properly diagnosing the depression. I think the assumption is if someone goes to a doctor to seek help they must be clinically depressed. This means they must have a chemical imbalance which concludes they need drugs to cope with their depression. Sometimes it looks like the patient is a ginny pig and the doctors are experimenting until they find the right med for that individual. I realize in some cases depression is a chemical imbalance and needs the assistance of certain drugs, but in some ways I wish they would approach the patient with an open mind that they might not need to be medicated.
I give the highest respect to psychologists because they deal everyday with problems they cannot physically see or touch but have to go off with what the patient is telling them and their past experiences with certain disorders. From what I’ve noticed, unfortunately, people they don’t always tell the truth especially when it comes to their medical history.
It is very important to help people better understand normal grief. I deal with many Boomers who are coping with the recent death of their parents. This is often their first experience with loosing a parent. These mourners have no context to understand how grief affects a persons basic decision making ability. They begin to feel a real loss of capacity to cope with daily life’s stresses. Antidepressants are most effective in helping people begin to regain confidence in coping with their lives. It make a psychologists job much easier in helping their patients learn new coping skills and eventually move on with their lives.
Dr. Mikol Davis
Eldercare Psychologist
AgingParents.com
“A Pill For Every Ill or Mood”
I believe this has been, and is, a pervasive and destructive, message throughout society.
Script drugs are destroying relationships, and families every day, and that connection is being virtually ignored.
The overuse of medications and the connection to upending relationships and families must be exposed.
And get the drug ads off TV! There are so many Natural Means to overcome most of the illness.
Why isn’t Psychiatry pushing these methods?
Big Pharma is in control and destroying the interior of many millions daily. Why are you letting this happen?
These drugs cause many more physical and emotional problems than they help and they cure nothing!
Well, it’s evident that a deceptively “simple”
question from Therese Borchard has opened a portal into a world of philosophical, ethical, and scientific controversies. So, bravo,
Therese, for mining such a rich vein of varying opinions!
Despite the passionately conflicting views
sometimes in evidence above, I believe we all share the same basic goal: enhancing life for those who suffer with emotional and psychological problems. Clearly, we sometimes differ as to the best means of reaching that goal.
I believe we need to distinguish three basic areas of controversy in the comments posted; namely, (1) the risks and benefits of medical/psychiatric “diagnosis” (especially using
DSM-type categories); (2) the meaning of psychological “symptoms”; and (3) the proper role of medication in mental health treatment.
I believe some comments on the proper role of medication have gotten tangled up in discussions of the upcoming DSM-V, and with the general issue of DSM diagnostic categories. Some people
view the DSM system as an example of “biological psychiatry” or of the “medical model”. This is a common misperception. The DSM system–whether good, bad, or mediocre–has no logical, conceptual or scientific connection to the issue of prescribing medications,nor is the DSM grounded in “biology” (Some would argue that this is part of the problem: the DSM-IV’s categories and criteria are not specifically linked with biological markers, even though such biomarkers are available for several major disorders-see
http://www.psychiatrymmc.com/beyond-reliability-biomarkers-and-validity-in-psychiatry/).
Specifically, the DSM system neither validates nor invalidates a decision to prescribe an antidepressant. Yes,I know some conspiracy
theorists insist that the framers of DSMs are in cahoots with “Big Pharma”, and have intentionally designed the DSM’s diagnostic criteria
with an eye toward prescribing medication. But even if this were the case –and I don’t believe it is– the question of prescribing an antidepressant must still be considered on its own terms.
A physician may reach a DSM diagnosis of “major depressive disorder” and yet decide not to prescribe a medication; or, the physician may
prescribe a medication without having reached a DSM-based diagnosis. By the way, psychiatrists have long been among the most vociferous
critics of the DSM approach, as seen in the seminal essay by my colleague, the late Dr. Paul Genova [ see http://www.psychiatrictimes.com/display/article/10168/47316?pageNumber=1%5D The DSM-V is very likely to reflect some of these criticisms).
This raises the more general issue of “diagnosis”–another widely misunderstood term. When some critics hear the term “psychiatric
diagnosis”, they naturally think of the DSM “pigeon hole” diagnoses, and reflexively resist the idea of “labeling” the patient. But this
misunderstands the nature of medical diagnosis. The origin of the term “diagnosis” is in the prefix “dia–” (across, between) and “gnosis”
(knowledge or knowing). So “diagnosis” is essentially, “Knowing the difference between” one condition and another.
If a patient comes to me with a chief complaint of “feeling down”, and –after carefully assessing her history, symptoms and complaints–I
conclude that her feelings are a mild, understandable reaction to having just broken up with her fiancee last week, I have in fact
reached a “diagnosis”! I have discerned the “difference between” what is most likely a mild adjustment reaction that does not require
professional help, and a major depressive episode that would need such help.
Yes, sometimes the act of reaching a diagnosis does provide a measure of “comfort” to the clinician–though I can recall hundreds of
instances in which diagnosing schizophrenia or dementia did not provide me with any comfort at all! It is equally possible that attaching a
“meaning” to each of the patient’s symptoms (see below) is also of comfort to the psychotherapist–and, at times, provides an appealing narrative that enables the therapist to maintain interest in the patient. These narratives may not always be correct, and may sometimes even delay or obstruct appropriate treatment [see http://pn.psychiatryonline.org/cgi/content/full/44/5/21 ]. Thus, the composer, George Gershwin, spent many weeks in psychoanalysis, having the “meaning” of his depression endlessly analyzed, while an undiagnosed brain tumor was slowly killing him.
The real question is not whether therapists feel comforted by their diagnoses or formulations of symptoms. The real question is,how do we
provide appropriate care and comfort to the patient?
Now, as to symptoms: symptoms are neither good nor bad, though they may be distressing or incapacitating to varying degrees. Symptoms are
neither demons to be exorcised, nor idols to be worshiped. Symptoms are merely windows onto the larger landscape of the patient’s life and
condition. Some have deep-seated “meanings”; some do not. Nonetheless, some symptoms–such as crippling panic attacks with agoraphobia–may
need to be alleviated before the patient can work in therapy, or even leave the house!
This brings us, finally, to the issue of antidepressant or other medications for psychiatric disorders. First of all, our modern
understanding of how antidepressants work no longer points to merely “revving up” brain chemicals, such as serotonin. Perhaps a decade ago, that was a popular view of depression, but it has long been supplanted by much more sophisticated models of biogenetic and psychosocial interactions.We now have good evidence that antidepressants work through their effects on genes and gene products. For example, antidepressants seem to switch on genes that produce nerve growth factors (like BDNF) that enhance the connections between brain cells. This is a far cry from the notion that antidepressants merely “cover up” or “excise” symptoms. These
medications are addressing–and often enhancing–fundamental aspects of brain functioning.
Indeed, properly prescribed, psychotropic medications are not primarily aimed at “removing” symptoms. They are prescribed in the context of
understanding the nature of the symptom, and in the service of alleviating the patient’s suffering and incapacity. Removing or
mitigating a symptom is desirable only in so far as it serves the larger interests of the patient, and affirms the fundamental ethical
principles of medical care. That is, symptom alleviation is a “good thing” only in so far as it reduces suffering and incapacity, and
enhances what the ancient Stoics called “euroia bion”–the “good flow of life.”
If, by instantly “removing” a patient’s insomnia, I were to increase her suffering and incapacity, and diminish her “good flow of life”, I would be acting unethically. Fortunately, this is rarely the case when it comes to mitigating the symptoms of severe depression–and count me among the skeptics as regards the “value” of suffering with insomnia, loss of appetite, loss of sexual drive, and loss of pleasure in all things! Yes, a certain degree of anxiety, sadness, perplexity, and “angst” is part of being human, and should not provoke a knee-jerk rush to “medicate away” these feelings. But neither should we buy the
perverse and destructive notion that “suffering is good for the soul” and insist that patients in the depths of life-killing despair (see
William Styron’s account, above) must “learn” from their suffering and attend to its profound “meaning”,no matter how long it takes and no
matter the personal toll.
Moreover, to insist that each of the patient’s symptoms must correspond to some covert but discoverable “meaning” is to heap one’s own ideology on the back of the already burdened patient. I am sure my colleagues who authored the messages above would agree with that.
So how do psychiatrists think about symptoms and the role of medication? Here is an analogy that may help. If a structural engineer notices cracks in a bridge, and then places steel girders beneath the bridge, it does not follow that this action is based on the philosophy, “We must remove cracks in bridges!” The engineer has made a structural “diagnosis” and concluded that the cracks are “symptomatic” of underlying structural problems of a very serious kind. That the
cracks may disappear, or not get bigger, after the steel girders are in place, is neither the main point nor the goal of the engineer’s
intervention. The goal is to stabilize the bridge!
By analogy, when a psychiatrist prescribes an antidepressant because he or she perceives symptoms of severe major depression, it is not done with the goal merely of “removing” symptoms, though that may be a welcome outcome for the suffering patient. Rather, medication is
prescribed in service of treating the patient’s underlying disease state and helping to stabilize the patient. The psychiatrist does not assume that all the “structural problems” in the patient’s life will be magically solved by prescribing a medication; but neither does she
assume (incorrectly, as I have noted above) that the medication is merely having a “cosmetic” effect, or that it is merely “excising” the
symptom.
Medication, properly prescribed, may be likened to one of several steel girders. The other “girders” may be an examination of the
patient’s family issues; his or her spiritual beliefs; the patient’s irrational cognitions; the patient’s social and interpersonal issues,
etc. It is no more the case that medication is designed to “remove” a symptom than a therapist’s exploring the patient’s anxiety about love
is directed merely at “removing” that anxiety. In both instances, the doctor or therapist is interested in relieving suffering and incapacity, and enhancing the patient’s ability to flourish in the world.
Indeed, readers may be very interested in the poignant and astute piece, now available at Psychiatric Times, by Dr. Jan Goddard-Finegold.
She describes how,in dealing with her own severe depression,medication and psychotherapy were not mutually conflicting, but complementary,
modes of treatment. [see: http://www.psychiatrictimes.com/display/articl/10168/1416841?pageNumber=1%5D
This complementarity is also implied in the very interesting comments (see above) from Dr. Mikol Davis, a psychologist who deals with bereavement. He reports that sometimes, a medication may actually facilitate the mourning or grieving process, without negating the therapist’s helping the patient come to terms with the meaning of the
loss–a finding confirmed in a study by my colleague, Dr. Sidney Zisook[see J Clin Psychiatry. 2001 Apr;62(4):227-30]. In short, this is not a “zero-sum game”, in which medication cancels insight! We can both
understand the nature of a patient’s symptoms and also reduce their intensity to manageable proportions. And that,in essence, is the art
and science of psychiatry!
Ronald Pies MD
Couple of replies to the above comments:
To Dr Mikol Davis, I read your comment as advising to often medicate patients you see for grief treatment. Well, all I can say to this is bunk! I se a good many people come to me who complain that quick use of antidepressants have just numbed them and made it harder to feel they are processing grief. I have no argument for those who present with major depressive features and are compromised by their symptoms, but that is NOT a sizeable percentage of people in grief.
To Dr Pies, first I found the length of your post to be so voluminous, I almost stopped reading it after paragraph nine (of about 19)?, and I find that the more people pontificate about something, the readers/listeners lose interest (and I know this as I have this mistake myself in the past). I understand some of your perspective, but if you read some of the blogs in this media of the internet, we as psychiatrists are more alienating the population we serve than better engaging them.
As an interesting example, check out http://www.Furiousseasons.com ‘s posting today about what Mr Dawdy talks of the potential for an ’embitterment syndrome’ being entertained as a DSM V diagnosis. He might be in error about this matter, but, I find a lot of my older, established colleagues are, in my humble opinion, basically selling out those of us who are younger and trying to fight the poor choices and influences that are mostly fostered by non-clinicians, like managed care, big pharma, and antipsychiatrist opinion makers who swarm the web. I do not lump you in this established set, but, I worry, that what I interpret as naivetee, you minimize the influences by those in your circles you as a professor and journal editor have to politically appease.
To avoid this comment becoming more voluminous, I’ll just end with this point: the biochemical imbalance model has so pervaded the field of mental health, too many therapists have bought it and sell it as a substitute for the work they should be doing in the first place. I read Dr Davis’s comment as an echo.
But, to Dr Pies, thank you for participating in the dialogue. This kind of conversation can never happen at sites like Furious Seasons, and if you read the commentary threads, you’ll realize why.
I do ask readers reading here to go to Mr Dawdy’s site and peruse, and consider contributing to his fundraiser drive. He is a valuable contributor to essential dialogue that this field NEEDS to hear and consider. As a disclaimer, I am not at all involved with Mr Dawdy, so this is truly an unbiased recommendation.
Sincerely,
Skillsnotpills (formerly therapyfirst)
The line between marketing and science has been so severely blurred; it’s extremely difficult to determine if a doctor who’s promoting psychiatric drugs (as is Dr. Pies) is acting in the interests of the patients or in their own financial self-interest. Unfortunately, unlike almost every other industry, in the field of psychiatry, a doctor is allowed to conceal conflicts of interest. We have no way to evaluate Dr. Pies’s credibility, because we have no way of knowing to what extent he is benefiting financially, directly or indirectly, from the drug companies marketing the drugs that he’s promoting. Every patient seeking “treatment” from a psychiatrist should be extremely skeptical of the recommendations. Unfortunately, a psychologically unstable patient is very much at risk, any may not have the ability to question their doctor’s advice.
Ronald W. Pies, MD, reports no current affiliations of any kind with any pharmaceutical companies. He has received no monies, stock dividends, speaking honoraria, or other benefits from such companies since at least January, 2007. Prior to that, Dr. Pies received occasional speaking honoraria or unrestricted writing grants from Abbott Pharmaceuticals, Janssen Pharmaceuticals, Glaxo-Smith-Kline, Cephalon, and Alkermes. Dr. Pies is Editor-in-Chief of Psychiatric Times, a peer-reviewed journal that does accept advertising from pharmaceutical companies. A signed disclosure form is viewable on the Psychiatric Times website by clicking on Board Members names.
http://www.psychiatrictimes.com/editorial-board
R. Pies MD 6/1/09
Dr. Pies received direct financial support from the drug companies who produce the very drugs that he has promoted. Unfortunately for his patients, there is no legal requirement for Dr. Pies, or any other doctor for that matter, to make complete and verifiable disclosures of these payments. The medical community, and the psychiatric community in particular, is very unique in this regard. In virtually every other industry, conflicts of interest are either prohibited, or at the very least, require full disclosure required by law. Doctors who make obscene profits by prescribing psychiatric medications to their patients are able to legally conceal the fact that they receive these payments as a reward for the “treatment” they provide for their patients (customers). Dr. Pies has admitted that he has received money from multiple drug companies. How much money has he received prior to February 2007, and how much has he received since? He says none since 2007, but there’s no way to verify this. Unfortunately for his patients (and any doctor who has been influenced by his “contributions to medical science”), he is perfectly free to conceal any payments he has or is receiving from the drug companies who produce the drugs that he is promoting. Anybody reading this article should be aware that Dr. Ron Pies has received money from multiple drug companies, and he is involved in marketing the very drugs that they produce.
Tim, we don’t allow personal or ad hominem attacks against other commentators, or our authors or contributors, no matter how passionately you may believe in your opinion. I’d ask that if you’d like to continue commenting here, you abide by our guidelines and terms of service, and limit your comments to debating topics, not the people who forward them.
Dr. Pies is a well-respected professional and we are honored to have his contributions be a part of Psych Central, and for this interview.
If you’d like to continue discussing the topic of emotional flatness brought about by some antidepressant medications, you’re welcomed to do so. Dr. Pies has said he’s found this in approximately 10 to 20 percent of his patients, and it’s an important topic to discuss. But please check the personal attacks at the door.
I am a psychotherapist with bipolar 2 and lost my child 5 years ago.
Hell does not come close to describing the journey.
it is a roller coaster, much determined by the bipolarity and also the grief.
sometimes i can separate depression from grief, sometimes i cant. i seriously doubt it can be clear cut , a bright line, as described by Dr Pies in the initial article. i agree that there are no clear demarcations and nor should there be. It is a life experience, a tragedy which needs to be addressed in whatever way possible. it should not be boxed and over analysed as that can also make the grievor feel invalidated (again)…everyone grieves differently and uniquely. functional grief versus dysfunctional grief, seems irrelevant at the bereaved mothers support groups i attend. it is just grief. unless you live it you cannot know, understand or fix.
where the debate becomes futile in my opinion is when health practitioners get into the MY THERAPY IS BETTER THAN YOURS circus. if it is to progress science then debate is right if it is for personal egos and soap boxes about saving society and the rest of it, let it go.
i think it is really very simple.
if you have medical knowledge of neurobiology and neuropharmacology and good diagnostic skills, as we hope you should have with your expertise, then it is your duty to assist a person in need. without it some of us would be dead. yes dead.
if psychotherapy is not your bag, then refer out to someone else who can.
to each his own. there is no ego in caring. there is only our small contribution to hopefully help a person in pain feel better. that’s duty of care and professional ethics 101.
unfortunately, in all fields, there are unethical practitioners who will over-prescribe, under-prescribe, be corrupted by money, be stubborn in their limited views etc…
as tim put it it is legitimate to question the doctor but unfortunately a mentally ill patient may not have the cognitive ability to do so. and here is the societal dilemma. the choice of the individual is absent which makes him/her vulnerable to unethical treatment.(meaning not the best care provision).
this medium of blogging is extermely helpful to educate patients and share in their findings and stories, other media also are useful to empower the individual. And through the education process as with all other societal issues, we may progress as human beings.
so let the debate go on..just dont get too “ivory tower” about it. keep it real.
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