I Talk to the Real Experts About Depression (That's You)

From my keynote to the Kansas State DBSA conference in late April ...

Okay. This is going to look like I’m going off on a tangent, but the Yellow Brick Road zig-zags, so bear with me. We’re here, in Kansas, at a DBSA conference. Which means just about all of us here have experienced depression. So - can anyone here give me a one-sentence description for depression?

It sucks.

[More answers ...]

A deep dark hole.

Like having two doberman pinschers waiting for you to get out of bed in the morning. You aren't going anywhere.

It's like you're worthless.

You're on a raft, in the middle of a huge ocean, you can't see any land anywhere, on any horizon, and you're totally becalmed.

It's like trying to walk through mud up to your neck.

And I've got some insights on Kansas mud. Cuz I talk to my mud. I live in southern California where the soil is loose and sandy, and if you get it on your pants and shoes you just go - choot-choot-choot. So three days later, I see some mud from three days ago on my pants, and it's like, "C'mon, mud." And the mud talks back to me - just like skunks - and says, "oh yeh, you people on the left coast, you who eat panini, where do you think the flour from the wheat of that panini comes from? You treat me with respect, and next time you talk to me you address me as sir."

So, that's Kansas mud.

When I'm depressed, I get agitated and angry a lot. I used to joke - because I only got my driver's license two years ago after not driving for 30 years - I get road rage a lot and I don't even drive. Some of you feel like that with your depressions? Okay ...

I just don't want to be here anymore.

I told my doctor a while back, I'm not suicidal; I'm homicidal.

That's me. That's why I'm proud to be crazy. Seriously, I hate these politically correct people who want to take crazy away from me, because that's how I choose to describe myself. Anyway ...

I think especially for a lot of guys, it's withdrawal and grouchiness.

Another one - lack of motivation, total apathy. Okay, we've got a pretty good list here. Now, how many have heard of the DSM, the DSM-IV? Unanimous consent there. Great. Now, as you know, the DSM is a piece of fiction put out by the American Psychiatric Association ... We got a consensus on that.

As you may recall, there is the world famous symptom list. You know, five of nine symptoms. But first, you have to have one of two, okay? So get this - I'm going to read this out - here’s number one, for depression:

“Depressed mood most of the day.”

I'm trying to figure the logic here. Describe depression to me. Depression is - depressed mood most of the day.

Have you ever tried to describe what carrots taste like to someone who hasn't had carrots? Oh, carrots, you know, carrots - they taste like carrots.

Right, that really tells me a lot. I’m depressed. And I’m depressed because - I’m depressed. But what is my state of mind? What are my feelings? What are my emotions? What are my moods?

Well, the DSM does give the example in "depressed most of the day" of feeling sad. But I’m going to put this to the best experts in the world, which is you guys. Does depression equal sad? I mean we've listened to all these other symptoms ... Right.

Well, maybe the other symptoms can help us out. The other one of that "one of two" is loss of pleasure. We're kind of getting there a little bit, but here's four of them in a row:

Weight loss or weight gain. Oh, great, so everyone who goes to Weight Watchers is depressed. 

Insomnia or hypersomnia. That’s not telling us much. Let’s try the next one: Psychomotor agitation. So we walk funny.

What the ...

We’re not through. Fatigue or loss of energy. You get tired at two o'clock. Big deal.

I’m no expert. I’m a patient just like you. But I do know how to count. So we've got nine symptoms on the list, and make that eight because that first one is just too ridiculous for words. So, we've got eight symptoms, and we only need five to cross the diagnostic threshold for a diagnosis.

And four symptoms are physical. We eat too much or too little. Same with sleep. We walk funny. We get tired. Fine fine fine. So does the entire rest of the human race. Tell us something different.

Tell us what friggin’ state our minds are in. Tell us our thoughts, feelings, and emotions.

No wonder no one can help us. No one has even bothered to open up the hood and look in.

So, get this. You people here - turning out on a Saturday, in Kansas - do you want to read out the list here?

It sucks. Deep dark hole. Like two doberman pinschers waiting for you to get out of bed in the morning. You're worthless. On a raft in the middle of the ocean, not going anywhere, totally becalmed. Like walking in mud up to your neck. Just don't want to be here any more. I'm not suicidal, I'm homicidal. Withdrawal and grouchiness.

Is that a better list than the DSM list? Congratulations - you guys have beat the best psychiatrists in the world. Give yourselves a round of applause, here.

Spitzer and the DSM - Part V

Earlier installments in this series framed the creation of the modern DSM in terms of Kraepelin vs Freud. But is that truly accurate?

Robert Spitzer’s achievement represents a Nobel-worthy leap forward in the history of psychiatry, but his DSM-III was only meant to be a first installment to a work-in-progress, not frozen in time as psychiatry’s diagnostic Bible. Its present incarnation as the DSM-IV-TR of 2000 is essentially the same old 1980 book in a new cover.

There are many dangers to this. One of them is that the universal success of the DSM has entrenched its original errors. What may have started out in 1980 as a descriptive trial balloon by 1984 was unaccountably accepted as scientific fact, which by 1990 was regarded as wisdom of the ages. Now, in 2009, thanks to all the stake-holders invested in the status quo - insurance companies and so on - undoing these mistakes borders on the impossible.

For instance, a pharmaceutical company with billions riding on a new antidepressant does not suddenly want to find out that depression no longer means what it used to mean.

Previously, I pointed out that Spitzer was inspired by the pioneering German diagnostician Emil Kraepelin, who was born the same year as Freud. Unfortunately, Kraepelin was undoubtedly rolling over in his grave when the DSM-III was published. This is not an esoteric debate. The health and safety of anyone who has ever been depressed is riding on an accurate diagnosis, and unfortunately the DSM guarantees that won’t happen for a good many people.

It was Kraepelin who coined the term, manic-depression, but what he meant by the term was not a simple synonym for what we later called bipolar disorder. By manic-depression, Kraepelin also meant what we now call unipolar depression. Unipolar and bipolar could not so easily be separated out.

A later generation of researchers (including Jules Angst) did find a sizable exception. These were individuals who suffered from long-term and relentless “chronic” depression. These depressions contrasted with those who cycled in and out of their shorter-term “recurrent” depressions. To Kraepelin, recurrent depression and what we now call bipolar were part of the same manic-depressive phenomenon.

Contrary to conventional wisdom, an astute clinician does not need evidence of a manic episode to suspect bipolar in a patient. A history of recurrent depression is cause to probe for further indicators. Keep in mind, a patient never walks into a psychiatrist’s office complaining that he is feeling better than usual. Also keep in mind that when depressed, our brains trick us into forgetting what is was like to feel good, or, for that matter, too good for our own good.

Thus, unless a family member is present to remind her loved one to tell the doctor about the time he got a speeding ticket driving home from karaoke night with someone who wasn’t his wife, all the clinician has to go on is the patient’s current condition, along with his tale of woe.

During the seventies, expert opinion - led by Frederick Goodwin and David Dunner and others - favored Kraepelin’s approach. No matter how one chose to slice and dice manic-depression, the thinking went, it was crucial to draw a line between chronic and recurrent depression, and to recognize recurrent depression, at the very least, as a close cousin of bipolar.

So what happened? Spitzer and company did the unthinkable. They separated out recurrent depression from bipolar and lumped it with chronic depression. In addition, unless an individual cycled up into an extreme mania, he or she was deemed to have unipolar depression. (It took 14 years to get “bipolar II” with its less stringent hypomania threshold included in the DSM, and a strong body of expert opinion contends this does not go nearly far enough. Today, ironically there is extremely misinformed commentary that bipolar II is some form of new and unauthorized "expanded" version of bipolar. )

The result is that unless a patient is bouncing off the walls and ceilings, he or she is bound to be incorrectly diagnosed with major depression and be prescribed an antidepressant (this happened to me), which tends to worsen the condition. For those with bipolar II, a correct diagnosis is virtually impossible. Their lot is typically the frustration of years of antidepressants that don’t work or make them feel worse.

As for those with recurrent depression, forget about it. So might a mood stabilizer work on this population? Decades ago, lithium pioneer Mogens Schou found promising evidence. But thanks to the DSM, further research in this direction has been strongly discouraged, with pharmaceutical companies typically viewing all depressions as the same. (A notable exception was GSK testing Lamictal on a recurrent population.) Thus, we know that any given antidepressant will have some benefit on 50 percent of those who are depressed. The catch is we have no idea which 50 percent.

We can go on and on about all the DSM screw-ups just within the depression-bipolar sphere - its highly restrictive view of “mixed” states, its failure to account for anxiety symptoms, its bias toward finding depression in women - but let’s stop here. It’s enough to say the DSM, for all its good intentions, fails much of those deemed mentally ill much of the time.

Go to nearly any mental health website (not mine), and you will be treated to descriptions of depression and bipolar based on DSM-IV criteria (as in the screenshot on top). Read a book, glance at a brochure, take an online test, talk to your doctor - all DSM all the time. Spitzer, in the end, proved far too successful for our own good. But the fault lies with his successors, who failed to take corrective action, not necessarily with Spitzer.

Spitzer was a mold-breaker who inadvertently created a dogma as stifling as the Freudian Reign of Error he overthrew. What we now need to break the stranglehold of the Spitzer legacy is another mold-breaker - another Spitzer.

To be continued ...

Previous installments in this series:

Part I
Part II
Part III
Part IV

Spitzer and the DSM - Part IV

In Part I, I introduced Robert Spitzer, architect of the ground-breaking DSM-III of 1980 and what psychiatry was like when Freud ruled the roost. Part II described the Spitzer's triumph in unseating Freud, and Part III recounted Dr Spitzer's boorish behavior at the dinner table at the 2003 APA in San Francisco. To pick up where I left off ...

Yet when I surveyed all that my hands had done
and what I had toiled to achieve,
everything was meaningless, a chasing after the wind;
nothing was gained under the sun.

- Ecclesiastes 2:11

Nearly two years later, the Spiegel profile in The New Yorker gave me an insight into Dr Spitzer’s table manners. According to the piece:

Despite Spitzer’s genius at describing the particulars of emotional behavior, he didn’t seem to grasp other people very well. Jean Endicott, his collaborator of many years, says, “He got very involved with issues, with ideas, and with questions. At times he was unaware of how people were responding to him or to the issue. He was surprised when he learned that someone was annoyed. He’d say, ‘Why was he annoyed? What’d I do?’ ”

Then, following the runaway success of the DSM, things apparently went to his head. According to the New Yorker, “emboldened by his success, he became still more adamant about his opinions, and made enemies of a variety of groups.”

And again:

“A lot of what’s in the DSM represents what Bob thinks is right,” Michael First, a psychiatrist at Columbia who worked on both the DSM-III-R and DSM-IV, says. “He really saw this as his book, and if he thought it was right he would push very hard to get it in that way.”

This sense of ownership cost Spitzer his chance to head up the DSM-IV. The new chair, Allen Frances MD of Duke University, put his committees on notice to cut back on “the wild growth and casual addition” of new mental disorders. In a piece published in the June 29, 2009 Psychiatric Times, Dr Frances appeared to be bragging about how little the DSM-IV task force actually accomplished:

“In the subsequent evolution of descriptive diagnosis, DSM-III-R and DSM-IV were really no more than footnotes to DSM-III ...”

This is one hell of an admission. Basically, Dr Frances is telling us that the diagnostic psychiatry of 2009 is based on a book that was published in 1980, back when psychiatric science virtually didn’t exist.

It is speculative to ponder on the “what-if’s,” but that’s my job. So, suppose Dr Spitzer hadn’t fallen in love with his 1980 opus. Suppose he possessed some rudimentary people skills. Suppose he had been able to combine his innovative brilliance with a sufficiently level head to guide the DSM into its next critical phases - to fill in the blanks from the earlier editions, correct obvious errors, and realign content in accord with new scientific discovery and clinical insight.

Imagine, in effect, if you could pick up a current DSM right now and open the pages to an accurate description of your clinical reality. That book doesn’t exist. The DSM-IV is a dinosaur, and any clinician who relies on it as an authority is endangering his patients.

Things could have been a lot different. But the man who - through his superhuman efforts - unseated that twentieth-century icon Freud, through his own mortal foibles, wound up unseating himself. His personal disappointment turned out to be our huge loss.

To be continued ...