Depression: Disease,distress and double bind

Introduction

Depression is a significant contributor to the burden of disease with its high lifetime prevalence, associated disability, chronic course and recurrence (WHO, 2008). However, the issues are complex and controversial and merit review.

Psychiatric perspective

Psychiatry views depression through the biomedical lens, suggests disease, supposes a central nervous system aetiology and pathogenesis, documents signs and symptoms, offers differential diagnoses, recommends pharmacological therapies and prognosticates about the course and outcome. However, the diagnosis of mental disorders in general, and depression in particular, poses challenges. The absence of laboratory tests to diagnose mental disorders has forced psychiatrists to rely on clinical symptoms and signs. The use of many symptoms commonly encountered in daily life and the complete absence of pathognomonic characteristics to diagnose depression is problematic.

Typically, patients emphasise suffering and distress whereas psychiatrists diagnose and treat ‘diseases’ (Jacob, 2012a). The patient’s experience of sickness is translated into abnormality of structure and function. It is conceptualised using universal models in terms of disease, learnt maladaptive thinking and behaviour or problematic childhood and adult relationships. Contexts, stressors, personality and coping are dismissed as incidental, whereas the objective symptoms are counted. Medication is prescribed and patients are referred for psychotherapy, if required.

Despite refinement over the past four decades, the operational diagnostic criteria are essentially symptom checklists. Epidemiological studies of depression use diagnostic instruments, which do not address short-term adjustment problems (Jacob, 2009a). The marginalisation of adjustment disorders in clinical practice is due to the elastic concept of depression and the rigid application of the diagnostic hierarchy and criteria. Consequently, normal people under severe stress (adjustment disorders), those who cope poorly with the usual demands of life (dysthymia) and people with depression secondary to disease (severe/psychotic depression) can qualify for a diagnosis of major depression (Jacob, 2009a).

The supposedly atheoretical approach, which in practice undergirds the biomedical model, uses symptom counts for the diagnosis, focuses on cross-sectional presentations and refuses to factor the context (stress, personality, coping, supports). The heterogeneity of the major depression label, the high rates of spontaneous remission and placebo response, and the limited response to medication in milder depression (Kirsch et al., 2008) argue against the sole use of antidepressant treatment. The more recent management guidelines advocate support and psychological interventions for mild and moderate forms of depression (National Institute of Health and Clinical Excellence (NICE), 2009). However, despite NICE guidance for restricting antidepressant use, it continues to increase (Middleton and Moncrieff, 2011).

Nevertheless, clinical utility, feasibility and reliability of the various categories of depression have been tested and the process has involved many iterations, field trials and reviews (American Psychiatric Association (APA), 2012). However, epidemiological, neurobiological, cross-cultural and behavioural research validity, as envisaged by Robins and Guze, early pioneers of operational diagnostic criteria, remain elusive (Kendler et al., 2012). Psychiatry accepts the lack of a ‘gold standard’ for diagnosis and recognises that the current classification and criteria are not set in stone and will remain as work in progress.

Psychosocial distress

Separating human distress from depression is difficult (Heath, 1999). Depression seen in the community is often viewed as a result of personal and social stress, lifestyle choices or as a product of habitual maladaptive patterns of behaviour. Consequently, the general population and general practitioners often hold psychological and social models for depression. Psychiatrists, with their biomedical frameworks, on the other hand, argue for disease models for these conditions. They transfer the disease halo reserved for severe mental illness to all psychiatric diagnoses. While psychiatrists argue that depression is easily recognised using simple screening instruments, general practitioners contend that these screens identify people in distress rather than those with disease. Consequently, many critics have argued against the medicalisation of personal, social and economic distress.

Many investigations have documented the link between poverty and depression/anxiety. They have demonstrated a consistent relationship with low education (Patel and Kleinman, 2003). The postulated links between poverty and poor mental health include experience of insecurity and hopelessness, rapid social change, risk of violence and physical illness (Patel and Kleinman, 2003). Poor mental health worsens the economic situation, setting up a vicious cycle of poverty and mental disorders.

Female gender is also a risk factor for depression (Patel et al., 1999). Social determinants have a significant impact on the health of girls and women in general and on depression in particular. Most studies on depression document that women are at a higher risk for depression when compared with men. Gender injustice is a major issue for women in patriarchal societies (Jacob et al., 2006).

Social exclusion, cultural conflicts and political oppression can also contribute to mental ill health and depression. Interpersonal conflicts and relationship difficulties commonly precipitate and are associated with depression in clinical practice and in the community.

Disease, illness, disorder

The distinction between disease and illness has been emphasised in anthropological and clinical literature. Diseases are defined as conditions with structural and functional abnormalities of the body, while illnesses refer to the patient’s subjective experience of sickness (Eisenberg, 1977). Mental health professionals encounter both diseases and illnesses in their clinical practice. Conditions such as dementia and delirium are diseases, and severe mental disorders such as schizophrenia, bipolar and severe/ psychotic depression demonstrate strong evidence for similar claims. However, many stress-related conditions are illness categories (e.g. mild and moderate depression, generalised anxiety, dysthymia, adjustment and personality disorders) without demonstrable changes in structure and function. The difficulty in bridging the disease–illness divide has resulted in psychiatry side-stepping the controversy and using the concept of ‘disorder’ (APA, 2012).

The definition of ‘mental disorder’ is broad and encompasses both diseases and illnesses focusing on ‘significant dysfunction’ in the ‘individual’s cognitions, emotions, or behaviors that reflects a disturbance in the psychological, biological, or developmental processes underlying mental functioning’ causing ‘clinically significant distress’ (APA, 2012). Its use has been criticised (Kinderman et al., 2012).

Biopsychosocial model

Clinical categories are useful in medical practice, across specialties. Consequently, the disadvantages of categorisation (e.g. overlap between categories, indistinct boundaries, generation of stereotypes, need to force patients into ill-fitting categories, need to follow ill-suited treatment protocols, legal implications of diagnosis, etc.) call for renewed efforts at individualising assessments and treatment to optimise care (Jacob et al., 2012). The biopsychosocial model (Engel, 1977, 1980) soon became the standard perspective in medicine (Smith, 2002) and psychiatry (Engel, 1980). It attempted to integrate multiple and interacting components, including the psychosocial dimensions (personal, emotional, family, community, culture, spirituality), in addition to the biological aspects (disease) of all patients. The model has been espoused for its science, its pragmatism and its humanism, and its opposition to biological reductionism. It has become the mainstream ideology of contemporary psychiatry.

While the biopsychosocial model was a useful antidote to biological reductionism and psychoanalytical dogmatism, it has been reduced to eclecticism (Ghaemi, 2009). The difficulty with integrating the diverse and contradictory strands which predispose, precipitate and maintain depression and mental disorders, often means a very superficial and idiosyncratic approach to causation. Despite its initial claims, the model does not easily lend itself to systematic study and research. While the elicitation of psychological and social issues in causation is possible, their management in actual practice is much more difficult. Psychotherapeutic strategies are time-consuming and require expertise, while social interventions are beyond the mandate and comfort zone of most psychiatrists.

Despite the supposed additive nature of the biopsychosocial model, the disease–distress divide and the divergent biological, psychological and social components often result in complex and mixed messages. If all depression is disease, then how come many patients do not respond to treatment? How do clinical psychiatrists employ cognitive-behavioural therapy or social interventions for which they do not have the mandate, expertise or time? Consequently, the biopsychosocial model is often praised and yet it is the biomedical model that is routinely practiced. Despite its attempts at ‘patient-centred’ medicine, psychiatry continues to be undergirded by the ‘doctor-centred’ biomedical model.

Psychiatry and capitalism

Psychiatry’s major focus on reliability of diagnosis and evidence-based treatment guidelines are major advances. These have also been encouraged and supported by pharmaceutical and insurance industries, which see psychiatric categories as an opportunity to widen the disease net in order to market their products. The focus on the individual and his/her clinical presentation, to the complete exclusion of the context, fits in with capitalism and its free-market philosophy. The individual’s mental state, health and disease are always a consequence of individual concerns (e.g. biology and choice) rather than secondary to structural societal issues. Consequently, while poverty is a well-recognised cause of depression, its solution involves individual treatment, including the need for medication or individual psychotherapy rather than structural changes to society, culture or the economy.

Similarly, issues related to gender justice in patriarchal societies or sexuality in cultures that uphold the heterosexual lifestyle, are also addressed by management at the individual level. Consequently, psychiatry becomes the handmaiden that delivers care for individuals who are diseased or distressed. Psychiatry is then forced to move out of its traditional medical role and biomedical model to manage all mental distress and illness, even that which is produced by psychosocial distress and poor individual coping. However, the provision of such care necessarily involves the use of medical and psychiatric labels to justify such input. Consequently, psychological and social distress receives psychiatric labels that have high inter-rater reliability. However, their disease status is questionable and their response to psychotropic medication is limited. Most general practitioners, clinical psychologists and psychiatrists will acknowledge that individual resilience and social supports have a much greater impact on the outcome of mental distress and illness often labelled as depression.

Psychiatry is caught in classical double binds between: disease and illness, disease and distress, mind and body, cure and care, treatment and healing. The focus on one tends to negate the emphasis on the other. Nevertheless, such conflicts are often unrecognised in clinical practice. The use of diagnostic labels backed by the Diagnostic and Statistical Manual of Mental Disorders (DSM) (APA, 2012) and the International Classification of Diseases (WHO, 1992) naively allows psychiatrists to argue that their practice is scientific. The evidence that all depression is due to biochemical abnormalities remains inconclusive (Moncrieff and Cohen, 2009) and the ability of antidepressants to reverse these changes is also uncertain (Moncrieff and Cohen, 2006).

Issues and critique

Despite a technical language, diagnostic categories, elaborate classificatory systems and support from empirical data and theories – psychiatric categories lack the predictive power required of hard science (Jacob et al., 2012). While its theories are based on available data, much of the theory is forced to fit the data and does not explain many aspects of mental health and illness. Many diverse influences including biology and psychological, social and cultural factors impact human cognition, emotion and behaviour in complex and interconnected ways. The effects of these diverse factors cannot be studied in controlled experimental conditions. Consequently, despite the use of sophisticated operational diagnostic criteria, achieving good inter-rater reliability is a poor substitute for the lack of robust concurrent and predictive validity.

Psychiatry, without the certainty of hard science, faces many challenges (Jacob et al., 2012). Its quest to provide a scientific basis for its diagnostic criteria and classification has resulted in a widening of the disease–illness divide between physician perspectives and patient experience. Recent technological leaps have focused on the body and have made it easier to standardise clinical symptoms, signs, laboratory results and treatments, with much less progress in understanding the mind and social factors (Jacob, 2012a). Biomedical approaches, despite the pretence of their atheoretical nature, play out many dichotomies: subjective versus objective, nature versus nurture, mind versus body, biological versus psychological, disease versus illness, etc. (Jacob et al., 2012). These are not just distinctions but implicit hierarchies with objective valued over subjective, biological over psychological, disease over illness, etc. Framing the issues within such value-laden structural dichotomies distracts us from the task of trying to understand the complex interaction, interdependence and issues related to mental health and illness (Jacob et al., 2012).

These issues are rarely highlighted in current clinical practice and pedagogy. The DSM is considered an authoritative text by the younger generation of psychiatrists (Andreasen, 2007). The original ‘gate-keeping function’ intended to set minimum standards is lost and these texts have become resource and reference material for clinical psychiatry. Its impact on research has annihilated approaches other than biomedicine. Despite the phenomenal effort of the DSM-5 revision, clinical psychiatry should continue to strive for a more holistic understanding of mental health, illness and disease.

Multi-sectoral intervention

The medical, psychiatric, psychological, social and economic causes of depression argue for a multi-factorial aetiology for the condition (Jacob, 2012b). Such a perspective calls for a multi-sectoral understanding of depression and mental health; it argues for a multi-pronged approach to intervention. Within such a framework, pure medical and psychiatric approaches to depression would be restrictive and ineffectual for the vast majority of depression seen in the community. While severe depression demands antidepressant medication and psychiatric treatment, milder forms of the condition respond to psychological support, social solutions, and educational and economic initiatives. Population interventions involving social and economic approaches would be mandatory for improving the mental health of a significant proportion of the population with depression. Educational initiatives to improve resilience, as part of school mental health programs, would also help.

Investments in education and provision of microcredit (very small loans to borrowers who lack steady employment, credit history or collaterals), in addition to reducing poverty, are recommended for their collateral benefits in reducing the risk of mental disorders (Patel and Kleinman, 2003). Population-based strategies for meeting the basic needs of clean water, sanitation, nutrition, immunisation, housing, health and employment, and initiatives for gender justice have been suggested as strategies to reduce distress and suicide (Jacob, 2008). Programs to reduce social exclusion and discrimination, a reduced social class gradient and a more equal society will also help reduce emotional distress and depression (Jacob, 2012b). The social determinants of health apply to mental health as well.

Rhetoric and reality

Psychiatric categories, with high inter-rater reliability, do not automatically translate to valid diagnostic categories. The task calls for wisdom and a broad-based and multi-sectoral response to managing depression and common mental disorders in the population. It also demands a radical departure from the failed strategies of the past with their sole focus on psychiatric treatment. Psychiatry needs to accept that many of its depression, anxiety and common mental disorder categories (e.g. major depression, dysthymia, adjustment disorder, generalised anxiety, etc.) are not diseases but illnesses, caused by psychosocial stress. It mandates psychosocial interventions, often beyond the scope of the discipline. It calls for a multi-sectoral response, which also involves educational, social and economic approaches and interventions.

There is a need to move beyond urgency-driven medical solutions and incorporate public health perspectives, policies and approaches (Jacob, 2007) in managing depression and common mental disorders. The sole focus on medical solutions is an error of the public health movement as it mistakes primary care for public health. Public health is often reduced to a biomedical perspective (Jacob, 2012b). Consequently, much of the efforts of the champions of public health end up in the provision of curative services. Public health requires inputs from diverse disciplines (e.g. politics, finance, law, engineering, social sciences, medicine, religion, etc.) and is much more than biomedical perspectives and solutions (Jacob, 2009b). Such approaches should intervene at the population level in order to bring about the necessary revolution.

Psychiatry and psychiatrists would do well to understand the complexity of the issues, the limitation of their narrow disciplinary perspectives and accept the partial nature of the solutions they offer. Psychiatry needs to acknowledge, both publically and to itself, that despite the four decades of refinement to criteria and classifications, it has a long way to go before finding valid and homogenous categories and effective treatments for personal and social distress. There is a need for a broad-based response to improve the mental health of the population and an urgent need to convert rhetoric into reality.