Tuesday, October 5, 2010

Is It Depression?

"When I use a word," Humpty Dumpty said in a rather scornful tone, "It means just what I choose it to mean--neither more nor less."

Lewis Carroll

I took the title of this post from a drug ad I saw today, a question that, contrary to its originator's intent, yields no clear answers. What kinds of answers does someone seeing a psychiatrist seek, and will she get them? (For complex and controversial reasons, it is epidemiologically more likely to be a she, although that leaves plenty of he's too).

Someone seeing a doctor for chest pain wants to know two main things: one, is this a potentially mortal threat, and two, what can be done for it? The cardiologist can resort to a number of physical exam findings and (more likely these days) tests to answer these questions. What is at issue is: what underlying biological process does the pain reflect?

The psychiatrist's function is not much like this. If presented with someone with depressive symptoms, it is true that there are occult medical syndromes (such as, say, hypothyroidism, vitamin B-12 deficiency, or pancreatic cancer) that could be responsible, but these etiologies are vastly outnumbered by idiopathic depressions. The patient may want to know: is this caused by a "chemical imbalance," or by relationship problems, or by a history of abuse? One may speculate or construct a narrative around this, but is impossible to know for sure.

So if a psychiatrist is usually unable to identify underlying pathophysiology, what can he/she provide? Context. A large part of psychiatry is the proper use of the sick role--people present with ambiguous symptoms that are often the target of stigma in the community at large, and the question is: am I merely weak, or am I losing my mind, or is something else going on? While the psychiatrist has limited appeal to diagnostic tests, he can call upon wide experience with persons exhibiting similar symptoms (for this reason, it is extraordinarily scary to be a neophyte in psychiatry, because one has neither firm science nor experience as backing, only clinical supervision).

The granting of the sick role and the understanding and compassion involved can be quite powerful. The psychiatrist "mans" the gateway of mental disorder, conveying seemingly contradictory messages: you are merely human and therefore vulnerable like the rest of us, and so not beyond the pale, yet to a greater or a lesser degree you are more impaired than the average person. Beyond this, there is really only management of symptoms, as I have written before, in the way that a pain specialist manages symptoms. This may take the form of dynamic understanding, or cognitive reframing, or medications, but none of these is directly treating a clear-cut disease process.

In other words, when someone presents saying "my chest hurts," the appropriate next questions are, "What is really wrong with me and how can it be fixed?" When someone presents with "I am depressed," she has usually diagnosed herself. There is a sense in which one cannot be mistaken about one's own depression any more than one may be mistaken about being in pain (subjectivity prevails here). The questions that follow are: "How does my experience compare with others you have encountered; is there hope for me; and how can this be managed?"


Dr X said...

These days, when patients are diagnosed with identifiable physiological conditions, many learn a great deal by reading up on the internet. But when the symptoms are psychiatric in nature, the internet often perpetuates misinformation.

When patients arrive with the understanding that you're treating an identifiable "chemical imbalance," do you let it pass without comment? To what extent is patient education a part of your approach?

Novalis said...

Ah, "chemical imbalance," which explains everything and nothing. I do try to convey the view that a biological approach, while sometimes necessary, is never sufficient.