The Spectral Boom in Depression
I heard on the news this morning that Aetna is planning to cover depression treatments in some of their health plans. The New York Times reports:
Under the plan, Aetna will pay primary care doctors additional fees to screen patients for depression and to provide follow-up consultations for patients who are either put on antidepressants or, in more severe cases, referred to psychiatrists or psychologists. Aetna plans eventually to offer the program nationwide.
The additional costs of identifying and treating depression, Aetna said, can in many cases be more than offset in avoiding the larger financial costs associated with the disease - and the higher medical expenses that often arise when other chronic conditions, like diabetes and heart disease, are compounded by depression. Depressed patients with such diseases often stop taking their medications or fail to carry out recommended exercise and diets.
Researchers said that 33 million Americans require treatment for depression each year, and at least one in six people have the disease, with varying degrees of severity, at some point in their lives.
Now, it’s certainly awful to be sad, listless, and unmotivated. (I’ve been there. You too, probably.) And I think it can be a very good thing to take mood-enhancing drugs when you feel low. Depression certainly makes you feel uneasy, but is it really a disease?
The “paradox” of prosperity crowd makes hay out of rising rates of depression diagnosis. Lane, in The Loss of Happiness, for example, characterizes it as an “epidemic.” However, it is at least as likely as not that the “epidemic of depression” is an artifact of, among other things, (1) an egregiously lax and ill-defined diagnostic category, (2) shifting cultural norms about the range of normal function, (3) and diagnostic zealousness driven by the interests of the mental health profession (we’re like real doctors and we deserve to be paid like it!) and (4) pharmaceutical companies who want to sell huge quantitites of mood-enhancing drugs to people who inhabit a culture that doesn’t think it’s OK to take drugs unless you’re “sick.”
This grandly evasive passage from Lane captures the thinness of the evidence and the desperation to build mansions of conjecture upon it:
Rising depression of this magnitude is a tragedy for any civilization, but the epidemological study of these tragic phenomena is dependent on measurement instruments that are being perfected, and the longitudinal data are in their infancy.
That is to say, “We can’t really say with any certainty whether the incidence of depression is really rising or not, but my book will be much more exciting if I act like I know that civilization is in the throes of tragedy.”
As an antidote to depression hysterics, I strongly recommend “The Age of Depression,” by Allan Horwitz and Jerome Wakefield in the penultimate edition of the Public Interest.
After examining the epidemiological numbers, they write:
No plausible theory of depressive disorder, whether genetic, psychological, or social, can explain why rates of depression would have increased so much in such a short period of time. Instead, the explanation appears to lie in changes in the ways that physicians, mental-health professionals, and people themselves characterize and diagnose their mental states. There are, and always have been, true depressive disorders, in which the response to loss goes awry and takes on a debilitating life of its own. But in the past, such disorders were distinguished from normal sadness that arises in response to life’s vicissitudes. That traditional, common-sense distinction has broken down in contemporary psychiatry, resulting in the conflation of depressive disorders with normal sadness. The sources and social implications of this breakdown are as yet largely unappreciated. [emphasis added]
Horwitz and Wakfield provide a fascinating history of depression through the ages and an extremely illuminating account of how theory wars over the DSM categories led to an overly inclusive “theory neutral” clinical conception of depression.
The basic flaw, then, is that the DSM-IV fails to exclude from the disorder category sadness reactions to events other than death of a loved one that are intense enough to meet the DSM-IV’s criteria but are still normal reactions. The age of depressive disorder in which we find ourselves today is partly an artifact of a logical error.
The section on “The Constituencies for Depression” is also key to understanding the political and financial stakes surrounding medicalization of sadness. For example,
the DSM’s criteria are used in virtually all of the thousands of studies done in recent years on depression, and many researchers’ careers are built around these studies. Consequently, any major reconceptualization of diagnostic criteria would throw all that into doubt. Adequately distinguishing normal sadness from depressive disorder could also possibly narrow opportunities for research funding, especially if the NIMH followed suit by focusing its efforts on true disorder.
And perhaps more important:
Many private-practice clinicians will readily admit that a sizable proportion of their “depression” caseload consists of individuals who are psychiatrically normal but experiencing stressful life events. To obtain reimbursement for the treatment of such patients, the clinician must classify the individual within a DSM category of disorder, and depression is one of the more commonly used and easier ones to justify given the ubiquity of its symptoms. The result is a strange case of two “wrongs” seemingly making a “right”: The DSM provides flawed criteria that do not adequately distinguish disorder from nondisorder; the clinicians, knowingly or unknowingly, incorrectly classifies a normal individual as disordered (Why should the clinician question a diagnosis officially sanctioned by the DSM?); and the patient receives desired treatment for which the therapist is reimbursed.
The news about Aetna simply illustrates how much many people have to lose should depression be recategorized in order to become scientifically legitimate. In any case, the Horwitz and Wakefield paper is very important.
If we put the overdiagnosis of depression together with the framing effects of self-reporting discussed yesterday, we arrive at the possibility that we are happier than we think, possibly even happier than we have ever been.
Also recommended:
Stanford Encyclopedia of Philosophy entry on “mental illness” by Christian Perring.
Allan Horwitz, Creating Mental Illness
Jerome C. Wakefield,”The concept of mental disorder: On the boundary between biological facts and social value,” A merican Psychologist. 1992 Mar Vol 47(3) 373-388
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The Spectral Boom in Depression
[Cross-posted to Happiness and Public Policy] I heard on the news this morning that Aetna is planning to cover depression treatments in some of their health plans. The New York Times reports: Under the plan, Aetna will pay primary care…
I wonder how much of the boom in depression can be linked to the boom in obesity of the last decade or so, especially since moderate physical exercise can be as effective as antidepressants for some. Are we depressed (and perhaps overweight as well) because we’re sedentary?
At the risk of being one of those ‘I suffer from depression so I know’ sorts of people, I would like to offer a few comments. I am in excellent physical shape and while it has helped deal with my depression it hasn’t erased it. For me, depression was something that was diagnosed probably 20 years after it started. And in my case it began to have physical manifestations. I do feel it is a disease. It effected my ability to function. Not on a small scale, but in terms of being able to get out of bed, to be able to talk to people, to interact in the world. After twenty years of dealing with it without medication and the difference medication has made for me, it’s clear that a chemical imbalance in the brain is as much a byproduct of a disease as a low red blood count is, or high cholesterol. And I encourage people to get help. And I’m glad Aetna is beginning to pre-screen people for this. It would have helped me a lot twenty years ago and it will save people and businesses a lot in terms of lost productivity.
Deron, I have no doubt whatsoever that people suffer from real organic neurological disorders, that it can be crippling, that medication helps, and that people suffering in this way deserve sympathy and help. That’s not in dispute.
The problem is that people who simply feel sad (which is healthy, and functional) because they’ve broken up with their boyfriend, or lost a job, are diagnosed with the same disorder as people with serious imbalances of hormones and neurotransmitters stemming from organic malfunction. I guarantee that I could walk into a psychiatrist’s office this afternoon, describe my bouts of ennui, and come away with a depression diagnosis. And that’s like lumping people with spinal cord injuries together with people with sore backs.
Also, let me emphasize that I don’t think there’s anything wrong with taking mood-enhancers simply because you’re sad, or simply becuase you’re not sad but would like to feel even better. There’s no reason we should have to be “sick” in order to have access to drugs that will make us feel better. Perhaps one of the unintended conseuquences of the War on Drugs is the pathologization of normal, healthy human emotions, in order to justify access to drugs we ought to have access to anyway.
I agree with you that the diagnostic criteria for “depression” have been widened way too much in the past 50 years or so. On the other hand, it’s not always easy to draw the line between the kind of depression that seriously impairs your ability to live/work/eat/sleep for extended periods of time and a bout of sadness that’s way longer than normal. It’s kind of all up to what the patient tell his doctor, right?
In any case, Mark McClellan and David Cutler estimate that advances in technology mean that each extra $1 spent on treating depression yields $6 in benefits (in terms of productivity and quality-of-life measures). As long as the Masses Who May or May Not Be Truly Depressed are paying for Prozac with their own cash, I don’t necessarily see how more people taking anti-depressants is, on net, a bad thing.
Hey Will,
Good points, and I think, overall, good discussion.
I’ve seen people live normal productive lives, and then get hit with something that wouldn’t harm another, but was their downfall. They might climb out of it over a course of years …
Are such people counted in this conclusion?:
“If we put the overdiagnosis of depression together with the framing effects of self-reporting discussed yesterday, we arrive at the possibility that we are happier than we think, p-cacbly even happier than we have ever been.”
P.S. - are their any scholars in this field who support my intuition that our ideas of “happiness” “sadness” “depression” and “despondency” are pretty similar, given our similar “machinery” of emotion?
Yeah. I mean that the average happiness may be higher if we take into account. There are of course very unhappy people, but my conjecture is that their number is smaller than in the past.
I think you missed my meaning. I was asking if those people who fell, due to “normal” problems got lumped into “misdiagnosis.”
Speaking of “fell” I suppose that was an echo of Waugh’s “Decline and Fall” … hit a few of life’s normal little problems … and suddenly you find yourself up the Amazon ;-/
It’s a tricky issue that turns on whether the ongoing depression is the consequence of some sort of breakdown of normal function.
It’s sort of like the difference between having a cold and having an immune deficiency. A bad cold can last a long time, and you probably want to treat the symptoms, get rest, drink fluids etc., to make it go away. But a cold isn’t a problem with the normal function of your body; the symptoms in fact express normal function of the immune system.
If somebody has a cold, and gets diagnosed with an immune disorder, that’s misdiagnosis for sure.
We could rerun that paragraph with the word “pneumonia” but it would be kind of pointless.
We could also, in terms of “framing” ask how many poor souls think they are happy because they’ve hurt so much worse … again pointless.
Why not accept the subjective, when all we are tying to do is understand (and improve) the subjective?
I am accepting the subjective. The point about framing is that people don’t have a way of reliably reporting the quality of their subjective states. And so, BECAUSE we care about the truth about subjectivity, we have to take people’s self-reports with seveal grains of salt. When Kahneman talks about objective well-being, he’s not dismissing subjectivity. He’s talking about objectivity ABOUT subjectivity, rather than subjectivity about subjectivity.
I’m new to this, and learning a lot for your blog. I’ll keep reading. It’s just that I’ve got my intuition too … for what it’s worth though, I’m not a total newbie. My intuition has been shaped by reading things like Discarte’s Error, The Blank Slate, and at more of a tangent, The Winner’s Curse. I’ve read maybe a half dozen other books that spanned the area I was interested in at the time … human economic behavior enlightend by modern brain theory, evolutionary phsycology, etc.
My intuition is that our happy sad scales run parallel, and that correlation problems are minor.
I’m more inclined to believe that people on the “hedonic treadmill” need to jump off, rather than consider their spinning as progress.
We’ll see how those intutions hold up as I read more
Yes, I’m a Szaszhole
Cato’s Will Wilkinson — blogging at his new site focused on the subject of happiness studies, and its intersection with public policy — is rightly skeptical of the claims of folks like The Loss of Happiness in Market Democracies author
[…] And millions of people take Vitamin C supplements indicating . . . what? A near-pandemic of scurvy? Again, I’ll point to my depression posts here, and here, my depression op-ed, and the Horwitz and Wakefield essay that got me on this kick. […]
[…] And millions of people take Vitamin C supplements indicating . . . what? A near-pandemic of scurvy? Again, I’ll point to my depression posts here, and here, my depression op-ed, and the Horwitz and Wakefield essay that got me on this kick. […]
I think there may be an evolutionary psych argument that supports a rise in real depression in the US. It revolved around two factors.
The first is a function of our genetically driven pursuit of status. In ancestral times, there really weren’t many things to build a status heirarchy on - hunting skills, shelter-building skills, warrior skills, etc. However, nowadays, those “skills” are no longer valued in any meaningful way in prosperous societies. Status is now a function of attention more than anything else. Those who get the most attention are looked upon as the high-status individuals in our society. Unfortunately, the ability to obtain high-status attention in today’s society is not possessed by the average person, and the average person knows that. Furthermore, the distance between the average person’s place on the heirarchy and the high-status positions gets larger and larger as time goes on. The result is more people lamenting their own position in life, even if they have it better than the vast majority of humans ever have. In short, the goal posts of contentment have moved considerably. This leads to the second factor - the role of despair.
In a paper called, The Evolution of Hope and Despair, University of Michigan professor of psychiatry and psychology, Randolph Nesse, lays out the idea that hope and despair are simply emotions driven by our appraisals of whether or not our environment will favor or disfavor the realization of our goals. Despair is like a neurological motivational response that is designed to spur us to get into situations that bode better for us. And, if Nesse is right, depair is tied in severity to how likely it is that we feel our goals can be realized - the less likely it is (by your own assessment) that things will go your way, the more despair you’ll feel. Couple that with the chasm between average status and high status and you have severe despair popping where it never did before. And like many other neurochemical responses, small differences can produce vastly different responses. It may be that depression, the real kind, is *produced* by an over-abundance of despair.
I know this is a little flimsy, but there may very well be something to it.
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