Melancholic Mysteries

When I was a young physician, getting on for half of a century before, depression proved to be a rare illness, or at least a condition which was seldom diagnosed, which isn’t quite the exact same thing. In its acute forms it was unmistakable. Patients that would to all appearances have all to live for would turn their faces to the walls, almost literally if their beds had been adjacent to a wall; they may even suffer with Cotard’s syndrome, even the delusional belief they had or were nothing, their bodies had rotted away, they had been at the very last stages of impoverishment when they had millions in the bank. I recall a patient who told me he was dead and all that remained of him has been that the gangrenous trick of his nose. No logical argument can convince him he was mistaken. Electro-convulsive treatment (ECT) returned very quickly into his usual condition, which of a prosperous and successful businessman.

It was impossible to not conceive of him as being ill, pure and easy. However, what about lesser types of depression and human misery? When did misery, understandable from the individual’s circumstances, become illness? There was at the time a lively polemic between those who thought that gloomy mood had a bimodal, and those who thought it had a unimodal, distribution. Those who thought that there was a bimodal distribution divided depression into endogenous (that is to say, originating from the victim’s constitution) and responsive (that is to say, originating from the individual’s response to his plight ). The former tended to be, but was not necessarily, more acute, intense and bizarre compared to the latter; they admitted that circumstances, in some circumstances, could cause deep depression, to a evident disgust with life and also to suicide.

Lately, there was a similar lively polemic between those who thought that elevated blood pressure has been bimodally distributed and those who thought that it was unimodally distributed. In the bimodal version, there were a distinct group of those who suffered by an as yet undiscovered ailment that resulted in exceptionally severe high blood pressure, whilst everyone else had blood pressures which were distributed around an average.

It is now generally accepted that those who believed at unimodal distributions, either of gloomy mood and blood pressure, won the argument. Personally, I think that is right in the example of blood pressure, however, incorrect in the case of depression. Once you have seen melancholia, because it was called, you can’t confuse it for depression of mood, however protracted. But I’m rather conservative.

In the last twenty five years, identification of depression has gotten so common that up into a sixth of adults in western states are now taking antidepressants–or alleged anti-depressantsas critics may say. The term unhappiness has nearly been excluded in the lexicon, and no one complains of itif they complain at all, it’s of depression.

Clearly, anybody who attends into the history of Rasselas, Prince of Abyssinia won’t agree, but a few people do attend it. The issue remains, addressed within this publication without definitive response (because none could be awarded ), regarding whether the increased number of people diagnosed, or self-diagnosed, as suffering from depression reflects a true gain in the incidence of the disorder, better comprehension of a state which has been always there but dismissed, or possibly a cultural manner.

Jonathan Sadowsky’s Empire of Depression has much to recommend it. It is brief and succinct, ” that the writer writes clearly without resort to jargon to give his writing a false atmosphere of profundity, also he is undogmatic in a field not needing in dogma and dogmatists. He’s obviously read a fantastic deal on the subject, and generally his reasoning is solid. This isn’t to say I would agree with his conclusions, but none of these is indefensible.

For instance, I think he is much too generous to generally psychoanalysis and Freud in particular. That Freud was frequently acute because of his observation of humankind is true, but were La Rochefoucauld and Lichtenberg (a higher percentage of the time, in fact, plus much more pithily). Even fortune tellers are often severe observers of their customers, but these acuteness does not need the vast superstructure of concept which Freud claimed to own erected on the grounds of supposed observations, but really on those of preconceptions supported (as by now has been fairly well-established) with a significant resort to mystification and blatant lies in the outcomes of his remedy. Far from being an aid to comprehension, psychoanalysis has often exerted an obfuscating effect both on physicians and patients, and as has been pointed out many times previously was run professionally almost as a religious cult, complete with heresies, heretics, heresiarchs, excommunications and anathemata, with which signs or fact had very little to do. The observation that miserable adult patients have frequently had mentally deprived childhoods (if accurate ) is one which may be produced with no psychoanalytic concept at all.

One of the issues of depression as an object of study is that there aren’t any clear-cut biological markers to distinguish instances from non-cases. Some endocrinological conditions mimic sadness, and a few medications undoubtedly cause it. In the terrific majority of instances, however, there are no measurable bodily adjustments, except those brought about by the symptoms themselves: in depression, symptoms and disorder are one, at least at the present condition of knowledge.

The writer is concerned to prevent false dichotomies: genetic vs environmental, physical versus mental, social versus person, endogenous versus responsive. It is rarely in medicine, he says, the causes of a disorder are both necessary and adequate; Koch’s famous postulates aren’t often satisfied even in relatively easy conditions, let alone at something as complex as depression.

Though he says that scorn isn’t valuable to understanding background, he is somewhat scornful of the notion that there is a moral dimension to depression. At no time does he consider a conscious attempt to be resilient, by way of instance, may play a useful role in the prevention of depression: he believes a willingness to admit and accept emotional vulnerability is an advance. Oftentimes, it may well be so; nevertheless it being would be perfectly compatible with a rapid increase in depression on a public foundation. As a colleague of mine, Dr. Colin Brewer, once placed it, misery increases to meet the means available for its alleviation.

The writer does not (in my view ) sufficiently think about the cultural importance of the replacement of this term unhappiness by depression in ordinary parlance. The technical effect is considerable. A miserable person should either put up with his insecurities, or analyse the reasons for it and try to change either their or her plight. The depressed person is announcing himself ill and placing the responsibility on somebody else to heal him. In present medical circumstances, in which physicians have very little time for every individual (and much of the taken up with inputting data, or pseudo-data, on a computer), a prescription is the most probable result.

The writer suggests that those who downplay or deny the seriousness of depression are inclined to use the expression character defect to consideration for its apparently increasing incidence. However, is there such a thing as personality defect?The pills prescribed might or might not help; if they do, then it might or might not be because of a genuine antidepressant effect. Oftentimes, however, they do not get the job done as a placebo (that they may even function as a nocebo, a theory which makes no appearance in this book). Fortunately for your physician, perhaps less so for your individual, there are many unique dosages and many unique pills which may be attempted before all pharmacological therapy possibilities have been exhausted. A sort of pas de deux may occur between the physician and patient lasting many months, by which time the feelings of depression might have remitted in almost any circumstance.

But things are far from straightforward. It is not unusual in medicine, at least nowadays, to prescribe medicine into a hundred people understanding it will work in only one of these, but never understanding in which . Here is the explanation for this prescription of the two antihypertensive drugs and statins, which in almost any human patient are more likely to cause minor side-effects compared to do some good: though when they do well, it’s a very good good really. And precisely because depression is so protean, so obscure and so ill-understood, it isn’t easy to tell which individual will benefit from which therapy. Can there be more rejoicing in heaven over one recovered depressive than over ninety-nine depressives given medication uselessly, as well as harmfully? I don’t think there is, or may be, even a definitive response.

The writer suggests that those who downplay or deny the seriousness of depression are inclined to use the expression character defect to consideration for its apparently increasing incidence. However, is there such a thing as personality defect? If there is not, does that not quite empty all human existence of moral importance, just as critics of this over-diagnosis of depression says it does? Indeed, the writer almost suggests the use of expression personality defect may be thought of –a personality defect.

However, the problem is complex. I recall a patient of minein her early seventies, that for approximately twenty years were lacking energy, had enjoyed nothing, and had sat about moping. As in everyone’s life, there were variables that may plausibly describe her misery. No remedy worked; she remained the same. I was about to write off her as character-defective when I prescribed an monoamine oxidase inhibitor for an old-fashioned drug which needs the individual to abjure certain foods to prevent a potentially dangerous reaction. To my surprise and enjoyment, but in addition to my shame at having almost written off her as character-defective, she recovered her joie de vivre, began to play the piano again and became vivacious. I found it tough to believe this was a mere placebo reaction: why such a response really late in the day? It is not difficult to write people off as bad characters, which isn’t to say there are no such men and women.

The story I have just told would not surprise Professor Sadowsky since he has a complex and sophisticated instead of a simplistic and crude view of depression. He is fair-minded rather than polemical, but there are omissions. There is surprisingly little amount of suicide from the publication; he does not address the issue of how to differentiate between a plausible and a real cause of a psychological state. In the end, everyone has a reason to be miserable but not everyone is miserable, even if his motive to be miserable is very strong.

I’m glad to say, however, that Professor Sadowski is still a worthy director of Hamlet: he does not disdain or hate attempts to describe man’s state, but does not think either the center of the puzzle is about to be crawled out.