Monday, September 19, 2011

Is This Depression?

Over on KevinMD, an anonymous doctor has post up called the Absence of Joy about his own problems with depression.  He writes:


For ten years I fought against the feeling that for long periods of time I was abnormally unimpressionable.  Not all the time, but certainly for moments. I was neither incredibly happy nor depressingly sad.  I put all this down to the stresses of making ends meet by moonlighting in ER’s, working impossible hours, studying for interminable exams, followed by the stresses of looming loan repayments, cash flow crises, parenting and marriage demands as my practice struggled to find its feet.

During moments of reflection I would question my condition, briefly consider depression as a factor, and then disregard it completely.  I was sleeping well.  I was not miserable.  Just stressed, like many of my colleagues.  Burn out was the diagnosis I chose for myself, and there seemed to be no easy option to deal with that.

But as the joy withdrew from my life, I was unable to identify the cause within.  I looked for other causes.  If the reason was not internal, it had to be external.  I found subtle fault with everyone around me, my wife, my kids, my career, my patients, my staff.  I considered changing my situation, leaving all of these, building another life, because this one did not appear to make me happy.
My wife saved me from myself.  Some ultimatums later, I was presented with a diagnosis of subclinical depression and began taking an SSRI.

He goes on to talk about how much better he feels and how much less labile his moods are.  He mentions things rolling off him like they'd roll off a duck's back, and of course we Shrink Rappers are big into ducks. 

So why am I writing about this blog post?  I think because I wasn't so sure I would have offered this patient medications.  Of course it's only a snapshot, and sometimes a recounting of symptoms on paper does not match the distress that a live person can convey, but the writer does not describe clinical major depression, what we think of as an illness.  He does a great job of describing existential angst, and makes no mention of whether he's had psychotherapy.  Perhaps he describes dysthymia (a low grade chronic depression that depletes the patient) but I wasn't totally sure.  I almost had the sense while reading that he's taking a happy pill that moves him to complacency. But the writer describes a huge relief, satisfaction with his outcome, and who am I to second guess? 

Just thought it might make for some good conversation here on Shrink Rap.  Do check out the whole post over on KevinMD by clicking here.

23 comments:

Anonymous said...

yep, my first impression was - hello, placebo response. on the other hand, i'm not all that sure a placebo response is a bad thing at all.

Anonymous said...

Subclinical depression and the absence of joy? I know o whole lot of people who would be very happy with that and never dream of taking a pill. What is subclinical depression? Is it like diet Coke? is it like an electric cigarette?

Anonymous said...

Just because someone is not majorly depressed does not mean that s/he is not suffering. Why should someone have to live a tasteless life? Why must this man live a substandard life with no help or sympathy just because he can sleep, his appetite is normal, and he still is able to drag himself to work and social functions?

Do you know what life is like in the complete absence of pleasure? What it is like to feel completely numb, to be a zombie? To not even be able to enjoy a vacation in a gorgeous location with someone you used to love? Such a life is not worth living, which is probably why even subclinical depression significantly increases the risk of suicide.

Anonymous said...

Anonymous 4, agreed....but it's unlikely that the ssri is what magically rejuventated his life.

Alexis said...

While we're at it, someone posted this link on Facebook earlier today, and I found it very irritating: http://chrisnorriswordsandmusic.com/pages/stories/medicated.php

I feel like he mixed together the possibility of the rebound effect with a lot of hand-wringing over taking anti-depressants. I really have a problem when people start pulling out cliches about walking around zombified and 1 in 10 Americans taking "mind altering drugs."

Sideways Shrink said...

When I found that the suicide rate among ALL physicians was 1.4 more likely and among female physicians 2.4 more likely I felt, frankly, relieved about my own interior mental life. The question brought up on KevinMD was about provider depression. People can say whatever they want on these sites about "people being over-medicated" but these sites are for providers to share their experiences in what is an otherwise isolated profession.
I will admit I didn't realize the feeling that things are overwhelming is not uncommon among practitioners. When I started reading MD blogs, I began to feel so much better: I saw that no one can run a private practice working less than 60 - 70 hours a week(and those peple have office staff); that the isolation of private practice is an existential devastation unto itself; the financial responsibility of huge student loans, supporting a small family in a tiny rambler is a strain in psychiatry; and that some patients have a disrespect for medical providers regardless of whether they are a certain kind of specialist or any kind of generalist. Previously, I had interpreted some patient's rotten behavior as having to do with psychiatry, especially because so much of my office work is done by me.
But I do wish that Shrink Rap had more shrinks posting on it OR what I really mean is just less rabidly anti-psychiatry people posting on it. I have been on both sides of the "couch" (though I would NEVER lay on that couch ask Dr. Stern) and Shrink Rap would be a nicer place to post if there weren't the fear of someone coming out of left field with a bizarre attack tangential to the subject at hand.
(P.S. I can understand why the posting provider bought his meds from a supplier and avoided psychiatry: fear, stigma, fear, stigma, so sad for all of us.) Try being a shrink finding a shrink....

Anonymous said...

We have serotonin receptors in our gut as well as our brain. We know there is some mind-body connection. Is it not possible for the individual who is serotonin-sensitive to possibly experience some "righting" in the corporeal as well as mental existence? Wouldn't that account for the dismissive placebo effect?

I suffered from an "adjustment disorder" (professional courtesy) and finally resorted to Zoloft. I experienced such absolute joy---for a few days, until the migraines from hell kicked in. Was it from the placebo effect? Was it from finally taking action? Was it, in fact, the medication acting somewhere within the body?

If it makes a difference and life becomes less of a slog, then where is the harm?

Dinah said...

I'm not sure I wouldn't have offered medications-- I usually mention that they are an option even if I suggest someone try psychotherapy for a bit first.

"Placebo response" would not have been in my consideration.

I also agree that people can be suffering who don't meet criteria for a mental illness (or at least not for a major mood disorder) and sometimes such suffering is relieved by medications (ever take a dose of ativan before an MRI or dental procedure?).

It really does seem to be something that should be an individual decision and something that often comes down to a patient deciding if they feel better on or off the medicines.

Sideways, you are always welcome at Shrink Rap. The conversation is interesting no matter who comes, but I'm glad it's been more civil lately. I also understand the doc's decision to get meds from a drug rep--- totally.

rob lindeman said...

Of course we must dismiss the placebo response! For the sake of our careers, right?

wv = molex. High-end timepieces for rodents

mantolama said...

Not depressed, just think:)

Parwathy Narayan said...

I think it's very important to address depression of any level, but not resort to medication first. For one, exercise has helped me tremendously. Many people aren't open to exercise, but it's about finding an activity you enjoy doing. Maybe that's difficult for someone that's depressed. You really do have to push yourself, but I think we are too quick to resort to medication.

Sideways Shrink said...

Placebo response did not occur to me in this case due to the extreme amount of real stressors the individual was under, his withdrawal from his support system and his flatness of emotional life for such a relatively protracted period of time.
If placebo response could account for his sustained remission, hot diggedy dog! I think the Relative Value Units assigned to psychiatry by that committee at the Center for Medicare Services would be much higher. Because if we could show the spooky placebo effect along with the benefits of therapy and medication already demontrated, we would certainly at least be paid for the latter. Instead of being paid 1/3 the RVUs of medical neurologists, perhaps we would be paid on par with them.

Anonymous said...

First of all, of course Anhedonia and Depression are not one and the same. (Not sure why that has not been pointed out once after a dozen postings).

I have longstanding depression. I treat my (thankfully) infrequent anhedonia as a serious wakeup call that something is wronger than usual, and I pursue immediate medical attention (including, but not limited to, talking to an MD about meds). It's not just that anhedonia is an icky feeling I need to suck up and bear - it puts me (personally) at a greater risk of serious self-harm, and I consider it a discrete problem out of the ordinary. (And anyone who glibly suggested at such times that a couple extra visits to the gym were all I needed would quickly regret saying that.)

As someone pulled back from the abyss twice by SSRIs, and who cares not one whit whether that reaction was reality or placebo effect, I have to ask those clutching their pearls: What's it to you?

jesse said...

It seems strange to me to disbelieve the anonymous doctor's response. The history consists only of slices of history and one cannot extrapolate from it to conclude he did not have a major depression, only that the information in that regard is incomplete. He does tell us he responded well to the little white pill. What would lead anyone to doubt him on that? If you conclude he did not have MDD, it just tells us the medication is useful in other conditions, not that it was not useful.

Dinah said...

Jesse--
I completely agree with your assessment.

The post just got me thinking in terms of accusations that we as shrinks over-medicate, and that we as a society turn too quickly to Happy Pills, and in terms of the question of what else was offered (for example, therapy). And hearing how helpful the patient found the little white pill (might it have been peach colored?) I did wonder how fast I would have been to offer it if the description was more of existential angst and a long standing questioning of values, then of a Major Depression. In these cases of less-than obvious Here Is This Disorder>>> Use This Pill (or This Category of Pills) the treatments offered can be quite variable.

Anonymous said...

If this were a patient having a bad response to treatment it would be strictly anecdotal. ;-)

Retriever said...

If the sufferer felt helped by the meds, more power to him.

But I can't help thinking that better living thru chemistry isn't the whole answer. As someone who has suffered from anhedonia for long stretches in the past, I've found that it can be a spiritual as well as a biological condition.

Sometimes meds can work wonders in restoring the feeling of being human, able to feel pleasure and pain, like a human instead of a zombie.

But sometimes becoming involved in a church, or a meaningful secular volunteer project, or even getting a dog or cat, or taking a class and studying great literature can help a person rediscover meaning, purpose, comfort in the midst of a cold and humdrum life.

Think of how many lonely people come back to life as they make efforts to rehabilitate atraumatized rescue dog, for example. Saint Francis wrote that in giving we receive, and even if one isn't a believer, many people find their own lives enriched by finding ways to help others.

Obviously, I'm not advocating guilt tripping miserably depressed people to "think of the starving people in India" (as my parents urged us), but even when one is burned out one can often be renewed by connections and new activities.

Liz said...

this is a fascinating and important conversation. thank you.

http://pocketshrink.blogspot.com

SEO Classes said...

Depression itself sound in low and patient feel themselves very helpless. Taking pills is not the solution but make themselves busy in other work.

Jen said...

i just read this blog http://thoughtbroadcast.com/
and it made me think of this post. (disclaimer, i am just a reader of both blogs.) i find it interesting that the therapists are the ones who wouldn't think of placebo response while those of us who've lived through the hell of clinical depression recognize the unlikeliness of a bit of SSRI clearing up subclinical depression as being anything more then placebo. (again, i think placebo is great. but call it what it is!)

Daniela said...

Anhedonia is a significant and subtle symptom of depression, and in my experience, often the last to go and the most difficult to treat. In high functioning, overworked people, it's often the FIRST symptom to show up, and it's insidious and difficult to identify. Lack of insight and rationalizations justifying it are very common. Doctors, as a group, are people with a deep commitment to persistence and some would say a masochistic tolerance for stress. This is a good thing when things are going well, but can lead to burn out if it goes on year after year. Burn out is a stress condition of excessive adrenalin production, leading to high cortisol levels, leading to insulin dumping and in the end to disrupted sleep, chronic exhaustion, and a move from mild to more severe symptoms of depression if your brain is wired that way. I would agree with ArtemisRetriever that a big part of the cure is to re-engage with meaningful non-work activities, but for that to happen, you have to have the insight that it's the pace of your life that is the problem and you need to slow it down. Which, if you feel financially trapped to maintain the pace, isn't going to happen until something comes along to force a change. In KevinMD's case, it was his wife who helped him out. She obviously felt he wasn't himself. Our loved ones are our safety net if we can only take in their feedback. Yay love! And It's always happy news when an intervention has a positive effect, be it a medication or joining a church. The act of taking action to help ourselves out seems to be therapeutic all by itself.

pat said...

really...sometimes this happy pill is your rescue. it might be better not to dig too deep into the problems. just to take a pill and stay happy.I think about doing so often...

boya badana said...

I think it's very important to address depression of any level, but not resort to medication first. For one, exercise has helped me tremendously. Many people aren't open to exercise, but it's about finding an activity you enjoy doing. Maybe that's difficult for someone that's depressed. You really do have to push yourself, but I think we are too quick to resort to medication.