mean they feel low. People use it to mean they've feel crap and unwell
in their life or head. Doctors use it to describe a syndrome which may
or may not be the medicalisation of misery. Some professionals see it only as a syndrome while others see it as the medicalisation of misery. The biomedical model supposes it is a biologically caused syndrome but this view has changed. Earlier versions of the diagnosis itself used to attempt to differentiate between exogenous and endogenous depression but I don't know much about those. Now the modern cluster of symptoms approach lumps together a lot of different experiences some of which may have biological cause but also involve other factors. There's always the interesting exclusion of grief from depression though grief can become depression after 6 months of grieving, so here a biological syndrome is possibly excluded because of life circumstances. There's also adjustment disorders which I don't quite understand either. These are about not behaving correctly or recovering from after or from a life event.
The psychiatric paradigm is interesting to me. I recalled a study on the
diagnostic criteria for depression. Here's the ICD critieria.
http://www.mentalhealth.com/icd/p22-md01.html
Here's the American one.
http://www.mental-health-today.com/dep/dsm.htm
I'll snip from the American one because I know a little bit more about
it and the study I'm thinking of was an American one.
"
A. Five (or more) of the following symptoms have been present during the
same 2-week period and represent a change from previous functioning; at
least one of the symptoms is either (1) depressed mood or (2) loss of
interest or pleasure.
Note: Do note include symptoms that are clearly due to a general
medical condition, or mood-incongruent delusions or hallucinations.
(1) depressed mood most of the day, nearly every day, as indicated by
either subjective report (e.g., feels sad or empty) or observation made
by others (e.g., appears tearful). Note: In children and adolescents,
can be irritable mood.
(2) markedly diminished interest or pleasure in all, or almost all,
activities most of the day, nearly every day (as indicated by either
subjective account or observation made by others)
(3) significant weight loss when not dieting or weight gain (e.g., a
change of more than 5% of body weight in a month), or decrease or
increase in appetite nearly every day. Note: In children, consider
failure to make expected weight gains.
(4) insomnia or hypersomnia nearly every day
(5) psychomotor agitation or retardation nearly every day (observable by
others, not merely subjective feelings of restlessness or being slowed down)
(6) fatigue or loss of energy nearly every day
(7) feelings of worthlessness or excessive or inappropriate guilt (which
may be delusional) nearly every day (not merely self-reproach or guilt
about being sick)
(8) diminished ability to think or concentrate, or indecisiveness,
nearly every day (either by subjective account or as observed by others)
(9) recurrent thoughts of death (not just fear of dying), recurrent
suicidal ideation without a specific plan, or a suicide attempt or a
specific plan for committing suicide
"
In the study I'm thinking of the researchers asked whether people had a
2 week period of feeling mentally unwell in some way. Then they counted
the symptoms. The results were people had a reasonably high level of
reporting a period of feeling mentally unwell for two weeks. As the
number of symptoms in the diagnostic criteria increased fewer people
were counted. When it reached 5 symptoms - enough for a clinical
diagnosis - there were a lot loss people than those who'd answered that
they felt subjectively unwell for a 2 week period. (The authors didn't
note that the rate of decrease was higher in men, a failing of the
diagnostic criteria in America which often underdiagnoses depression in
people who have 'acting out' symptoms, usually men.
And so there's a clinical question about the syndrome versus the
subjective report of unwellenss. Unwellness isn't the same as
psychological distress in a strict sense but they're inter-related
concepts.
The dual continua model of mental health is something which is not know
about enough. One continuum, the historical psychiatric continuum, is
mental disorder. This is synonymous with psychopathology and the
syndrome which is depression, i.e. the one where 5 symptoms out of 9
make a diagnosis. The other is psychological distress which is akin to
subjective report of unwellness. Importantly there are two paradigms
measures on two scales. It has been a century's work to get the dual
continua model recognised in mental healthcare policy. The recent New
Horizons mental health strategy proposed a new measure, flourishing,
while forgeting about the dual continua model. This represents yet a new
paradigm though it may be a while before it becomes accepoted. In a
sense it's a bit like the social model of disability at the negative
end. People should be able to flourish and reach their true potential.
Depression can get in the way of that however flourishing means that
social and cultural systems must also change because these are also the
reasons why people don't do as well in life as they should. The latter
wasn't mentioned in the concept of flourishing so there's clearly a lot
more thought which needs to go into it.
The relevance of the usual dual continua model, as it was taught to me,
was the recognition that a person can have high levels of
psychopathology yet be doing ok, i.e. they can be mad as a hatter but
happy. Alternative a person with low psychopathology, a 'normal' person,
can be very unhappy.
It also means a person with clinical depression can report high levels
of subjective well being. Without the clinical definitions there would
only be the report of unwellness used to define depression but
depression without low mood still comes with the cognitive, social and
other impairments.
So it's fucking complicated. I've barely managed to scribble down my
thoughts this morning in this short blog post.
The relevance of all this abstract thinking is a bit of a leap. It's
about recognising and dealing with depression in practice.
A middle step is recognising that depression may not need to be treated
how the modern psychiatric system treats it, i.e. by trying to take it
away by drugs, activity or talking therapies. These are all choices made
by society, not absolutes. Depression may have negative social outcomes
but this is because of society's malformation. Psychiatry choses to tell
individual's that the problem is rooted in them and therefore they need
to be changed so they're not like that anymore.
Depression may have a purpose and value. For example depressed people,
in general, may be more critical. They may be 'deeper' too. They may be
funnier, more compassionate, smarter, more creative and perhaps even
wiser than those who don't get this valuable experience in their life.
These ideas of psychosanology - a word I'm using to mean the study of
wellness and the interplay between psychopathology and wellness - are
little studied but observed in pre-mental health systems which did
pretty much the same thing - sprirituality, religion and sage
healing-people.
""The soul would have no rainbow unless the eyes had tears." This is a
piece of native American wisdom which expresses this concept better than
I can.
So really there's not certainty in what the diagnosis of depression is
nor what to do with it in any sense.
My conclusion through all this thinking is the same as I've ranted on
about before. Give people the expertise to make the decisions. Expert
patients enabled and empowered to self-manage is much better than
leaving this to doctors who know nothing about the patient compared to
what the patient can know about the patient, don't have time to keep up
with the latest developments nor to fully interview the patient to get a
proper history and sense of the individual, need to work with guesses
based on what works for most people rather than works for the individual
(and it turns out a lot of treatments don't really work for most people
compared to the placebo effect of the treatment) and may fundamentally
offer the wrong 'treatment' because the 'disease' may not be needed to
be treated in the individual but society needs to change.
Empowering people and giving them the information which doctors have
will give them the capability to recognise and treat their own
coniditons how they want to. A doctor might suggest that they're
clinical experience is impossible for a patient to get. This is true.
The knowledge of the individual patient is as impossible for the doctor
to understand and comprehend. Clinical experience has a value but
complete knowledge of the patient themselves, what they're going
through, how it relates to them, how they express their unwellness and
all manner of other aspects of what's important in mental health is not
available to a doctor or any other person but the individual themselves.
Leave doctors, or whoever, to change society. Society works on averages
and that's what they're experts in. People work on an individual level.
Another counter argument might be insight. This is a word that may be
considered a trick by some patients. It's about awareness of
psychopathology. It's also about awareness of being in a severely unwell
or mentally ill state, for example being in hypermania. There's part of
me that wants to strip the element of psychopathology away per se.
That's just the construct of psychiatry. It's sort of like saying you
don't agree with the dogma of the Church therefore there's something
wrong with you. I prefer the understanding that there are states of
awareness that can be diminished when a person is experiencing certain
mental states. For example someone who's getting high for the first time
on cannabis may not realise they're stoned. They don't know how to
recognise the state. It takes experience to recognise the feelings of
being stoned. People when they experience mania for the first time may
not recognise it and the detrimental effects it can have on a person's
life. This happened in my life. It was assumed I could never learn to
control these moments or manage myself so I'd not get into the sort of
states where I'd end up in a psychiatric ward or doing something worse
outside a psychiatric ward.
I may not be perfect at this but I've learned to self-manage. It's a
hard process. It takes time and I fall often. I've lost a lot in my life
because of my psychiatric mistakes but I'm getting better at fucking up
less. Sadly other people are still a problem. They don't understand my
difference because everyone else who's like me either doesn't talk about
it or no longer experiences it because they take medication. I don't and
I get all the value of life back which medication and psychiatric
treatment takes away. It's fucking hard on me and it's made my life a
total wreck such that I really can't be arsed with all this shit. But I
keep plugging on because I'm resilient (at the moment), which is another
important concept in mental health but one I'll ramble on about at
another point.
And so I don't tell people not to take medication. It is a personal
choice just as not taking medication is a personal choice. Recently I've
begun to take medication - St John's Wort - because I've been
mild-to-moderate depressed (excluding the suicidal feelings but those
are pretty permanent). A few months ago I was a lot worse and didn't
take any SJW but I had the luxury of very little work to do. I was very
isolated, alone and suffering inside. It was torment but I knew I could
always reach for the SJW. I didn't and I got through it. Sure, I now
have a plan to kill myself but it's been one of the positive things and,
perhaps, part of how I recovered. I'm talking SJW while I'm in a much
better place because I have to work and keep up my productivity. I
simply can't do that when I'm tired, sleeping lots, not motivated,
crying and in mental pain. This is where I see depression as a problem
in society. Sick leave is the only system available and that would mean
seeing a doctor and getting them to give me treatment. Sadly my previous
experiences make me think this isn't worth the effort for a number of
reasons. I'm self-employed too and have been for over a year so people
like us just don't get to take sick leave. So I took the drugs and I
feel better. I made all the choices and I've got lots of shit from my
'real' life to sort out. Debts. Taxes. Broken friendships (which weren't
really friendships I think...). Paying for an assisted suicide.
The complexities of depression conceptually and in treatment are all
solved by educating and empowering people. Instead there's a huge debate
where the powerholders, the doctors, have a system which patients don't
believe in and offer treatment which patients may not want. The system
treatments the mentally ill as without capacity by default. It doesn't
actually medical all misery, only what doctors and their doctorine
consider misery. They hand out salvation to those who they judge worthy
like priests at confession. They use the principle of science rather
than religion to justify their dogma.
No comments:
Post a Comment