Depression

Of course psychiatry is not asserting explicitly that consciousness is just an illusion; but Gary Greenberg demonstrates that this assertion underlies implicitly what has become standard psychiatric practice: the dispensing of pills to treat purported mental illness. So the title of this book does not do justice to the depth and breadth of its contents. Still, “depression” is the book’s explicit focus throughout. History illustrates that the task of defining mental illness in general is impossible: What are the criteria for (...) distinguishing frank “illness” from “normal” eccentricity and the huge range of human behavior under different social and environmental circumstances? The sociologist David Rosenhan showed—through an undoubtedly unethical experiment—that diagnosing schizophrenia is highly fallible, and that normal behavior is not recognized as non-pathological once such a diagnosis has been rendered. The obvious inference is catastrophic for the profession: “What kind of doctor doesn’t know the difference between sickness and health?”. Homosexuality was officially said to be a mental disorder until 1973; since then it is not. Even as the Diagnostic and Statistical Manual of Mental Disorders offers elaborately detailed guidance, psychiatrists often disagree over the diagnosis to be assigned in any given instance. Greenberg illustrates the profession’s attempts to cope with these circumstances by recounting the history of the several revisions of the DSM. (shrink)

The use of placebo as a control condition in clinical trials of major depressive disorder and anxiety disorders continues to be an area of ethical concern. Typically, opponents of placebo controls argue that they violate the beneficent-based, “best proven diagnostic and therapeutic method” that the original Helsinki Declaration of 1964 famously asserted participants are owed. A more consequentialist, oppositional argument is that participants receiving placebo might suffer enormously by being deprived of their usual medication(s). Nevertheless, recent findings of potential for (...) suicidality in young people treated with antidepressants, along with meta-analyses suggesting that antidepressants add no significant clinical benefit over placebos, warrant a re-evaluation of the arguments against placebo. Furthermore, the nature of placebo treatment in short-term clinical trials is often not well understood, and lack of understanding can foster opposition to it. This paper will show how scientific justifications for placebo use are morally relevant. The fundamental ethical importance of placebo controls is discussed in relation to several aspects of clinical trials, including detection of adverse events, accurate assessment of clinical benefit, advancing understanding of the heterogeneity of depression and anxiety disorders and respecting informed consent requirements. Prohibiting the use of placebo controls is morally concerning in that such prohibitions allow for the possibility of serious adverse public health consequences. Moral worries that research participants receiving placebo are being unduly jeopardised will be shown to be exaggerated, especially in relation to the net benefits for end-users to be gained from the quality of data resulting from using placebo controls. (shrink)

The pathologization of women’s depression covers over the social and institutional causes of that symptomology. Insofar as patriarchal values continue to devalue and debase women and mothers in ways that colonize psychic space, and depression becomes a cover for what I call ‘social melancholy.’ This is not the melancholy of traditional psychoanalysis, but a form of melancholy that results from oppression, domination, and the colonization of psychic space. Social melancholy differs from both Freud’s notion of melancholy in that it is (...) the result of social factors that constitute the depressed subject as ashamed and lacking agency. Crucial to my analysis is a distinction between shame and guilt missing from traditional psychoanalytic accounts of melancholy and depression. (shrink)

It is common today to think about depression as an illness best understood and thus best managed by medical specialists. Indeed, the medical language of depression increasingly provides people with a way of signaling to others that what they suffer from needs no further elaboration. It is what it is: hormonal, genetic, a disease, words whose authority is all the more accepted the more they’re left up to specialists to interpret. Such an approach to managing sadness has its appeals. Insofar (...) as such diagnoses can help people manage symptoms that make their lives unlivable, there is great value in them. And insofar as people suffering from depression feel overwhelmed and out of control of their symptoms, it is.. (shrink)

Data indicate the ubiquity and rapid increase of depression wherever war, want and social upheaval are found. The goal of this paper is to clarify such claims and draw conceptual distinctions separating the depressive states that are pathological from those that are normal and normative responses to misfortune. I do so by appeal to early modern writing on melancholy by Robert Burton, where the inchoate and boundless nature of melancholy symptoms are emphasized; universal suffering is separated from the disease states (...) known as melancholy or melancholia, and normal temperamental variation is placed in contrast to such disease states. In Burton's time these distinctions and characterizations could be secured by the anchoring tenets of humoral theory. Without such anchoring, and in light of the findings and assumptions of today's biological diagnostic psychiatry, we must re-visit each of them. My goals here are to show the need for analytic foundations when claims are made about depression such as those cited above, and to draw attention to some contemporary attempts that may help provide those foundations, particularly, attempts to define disorder or disease. With adjustments, one of these (Cooper 2002) is shown to take us some way toward that goal. (shrink)

Background: Depression (major depressive disorder) is a common and serious medical illness that negatively affects how you feel, the way you think and how you act. Fortunately, it is also treatable. Depression causes feelings of sadness and/or a loss of interest in activities once enjoyed. It can lead to a variety of emotional and physical problems and can decrease a person’s ability to function at work and at home. Depression affects an estimated one in 15 adults (6.7%) in any given (...) year. And one in six people (16.6%) will experience depression at some time in their life. Depression can strike at any time, but on average, first appears during the late teens to mid-20s. Women are more likely than men to experience depression. Some studies show that one-third of women will experience a major depressive episode in their lifetime. Objectives: The main goal of this expert system is to get the appropriate diagnosis of disease and the correct treatment and give the appropriate method of treatment through several tips that concern the disease and how to treat it and we will see it through the application on the expert system. Methods: in this paper the design of the proposed Expert System which was produced to help Psychologist in diagnosing depression disease through its symptoms such as: a loss of energy, a change in appetite, sleeping more or less, anxiety, reduced concentration, indecisiveness, restlessness, feelings of worthlessness, guilt or hopelessness and thoughts of self-harm or suicide. The proposed expert system presents an overview about depression disease is given, the cause of diseases is outlined and the treatment of disease whenever possible is given out. SL5 Object Expert System language was used for designing and implementing the proposed expert system. Results: The proposed depression disease diagnosis expert system was evaluated by psychologist students and they were satisfied with its performance. Conclusions: The Proposed expert system is very useful for psychologist, patients with depression and newly graduated psychologist. (shrink)

There has been recent work on acedia and its relationship to depression, but the results are a mixed bag. In this essay, I engage some recent scholarship comparing acedia with depression, endeavouring to clarify the concept of acedia using literature from theology, philosophy, psychiatry, and even a 16th-century treatise on witchcraft. Along the way, I will show the following key theses. First, the concept of acedia is not identical to the concept of depression. Acedia is not merely a primitive psychological (...) predecessor to depression, but it marks off significantly different ways of being, not least because of one’s spiritual relation to God. As Lucrèce Luciani-Zidane (2009: 13) has said, “acedia is entangled in the heart (or life) of Christian dogma.” Second, however, it is still possible that an instance of acedia can coincide with an instance of depression, if one’s condition, or state, is such that each term can be correctly and truthfully applied. By the conclusion of this piece, I begin to explore what practical implications this view has for practitioners and laypersons. (shrink)

Most mental disorders affect only a small segment of the population. On the reasonable assumption that minds or brains are prone to occasional malfunction, these disorders do not seem to pose distinctive explanatory problems. Depression, however, because it is so prevalent and costly, poses a conundrum that some try to explain by characterizing it as an adaptation—a trait that exists because it performed fitness-enhancing functions in ancestral populations. Heretofore, proposed evolutionary explanations of depression did not focus on thought processes; instead, (...) they emphasized that it facilitates navigation of adverse social circumstances or promotes immune response to infectious agents. According to a new hypothesis, the “analytical rumination hypothesis” (ARH), however, depression’s crucial adaptive trait is rumination—negative, intrusive thought. ARH holds that, (i) social dilemmas trigger depressed mood; (ii) depressed mood induces changes in body systems that facilitate ruminative analysis aimed at solving dilemmas; and, (iii) depressive rumination is a fitness-enhancing trait that was selected for in evolutionary time. Jointly, (i)~(iii) imply that we should not think of rumination as a disorder; instead, it is a trade-off, an eminently rational one. In the same way that fever solves a problem—coordination of the immune system in response to infection—so too does depressive rumination solve a problem, a social dilemma, albeit at the cost of inducing anhedonia and other maladies. But they argue that the cost is worthwhile, something that should be endured “until the problem is solved.” First, we argue that there are two distinct types of rumination, brooding and pondering; the former is associated with a disposition for depression, not the latter. But only the latter has the problem-solving capabilities that ARH requires. Second, recent brain imaging studies of depression reveal resting state hypoactivity in lateral regions and hyperactivity in paralimbic regions; this asymmetric pattern correlates with heightened levels of brooding, self-focused rumination. In other words, on the personal level, patients are trapped within self, isolated from the external world and suffused with negative affect; on the subpersonal level, this pattern is reflected by an asymmetric pattern of lateral vs. paralimbic resting state activity. Third, we proceed to conjecture that rational responses (e.g., pondering) to social dilemmas are those that strike a balance between internal and external considerations in the process of belief formation. Fourth, because the asymmetric resting state activity blocks those who suffer with depression from accessing and processing potentially positive stimuli from the external world, the capacity for rational, analytic response—hence, problem-solving—is constrained. Fifth, it follows that, although there might be conditions for which suffering should be endured rather than pharmacologically alleviated, depression is not one of those. Indeed, in view of the effects of the asymmetric resting state pattern, it is unlikely that depressive rumination would have been useful even for ancestral populations. (shrink)

This chapter has two aims. The first aim is to compare and contrast three different conceptual-explanatory models for thinking about mental illness with an eye towards identifying the assumptions upon which each model is based, and exploring the model’s advantages and limitations in clinical contexts. Major Depressive Disorder is used as an example to illustrate these points. The second aim is to address the question of what conceptual-theoretical framework for thinking about mental illness is most likely to facilitate the discovery (...) of causes and treatments of mental illness in research contexts. To this end, the National Institute of Mental Health’s Research Domain Criteria (RDoC) Project is briefly considered. (shrink)

Leonard L. Heston, M.D. is a Professor of Psychiatry at The University of Washington and is the Director of The Washington Institute for Mental Illness Training and Research. Dr. Heston writes about "a QUIET revolution [which] has been occurring in psychiatry" . Dr. Heston's "new psychiatry" focuses on the "actual study of the brain as a biologic tissue" and avoids "elaborate theorizing, guru-isms, blaming of mothers for unhappiness, backbiting among contending schools, or [popular and simple] prescriptions for instant mental health. (...) Such topics were a product of prescience..." . Heston wishes to distance himself from traditional Freudianism. Most importantly, according to Heston, his biological and scientific psychiatry portends greater hope for the "nearly one person in five [who] will develop a major psychiatric illness...". (shrink)

On the standard view, pessimism is a philosophically intractable topic. Against the standard view, I hold that pessimism is a stance, or compound of attitudes, commitments and intentions. This stance is marked by certain beliefs—first and foremost, that the bad prevails over the good—which are subject to an important qualifying condition: they are always about outcomes and states of affairs in which one is personally invested. This serves to distinguish pessimism from other views with which it is routinely conflated— including (...) skepticism and nihilism—and to allow for the extent to which pessimism necessarily involves more than the intellectual endorsement of a doctrine. (shrink)

Much of the literature on impairment to self-governance focuses on cases in which a person either lacks the ability to protect herself from errant urges or cases in which a person lacks the capacity to initiate self-reflective agential processes. This has led to frameworks for thinking about self-governance designed with only the possibility of these sorts of impairments in mind. I challenge this orthodoxy using the case of melancholic depression to show that there is a third way that self-governance can (...) be undermined: an agent may fail to form the desire she most wants to act on. (shrink)

Young’s paper (2012) offers an interesting and fruitful extension to recent work on Cotard’s syndrome, and in particular, a philosophical investigation of how and why beliefs around death and non-existence frequently co-occur with beliefs around immortality. In this brief response, we discuss a few issues from the paper. Namely, the issue of Cotard delusion being a natural kind, the seeming paradox of death and immortality and its relation to wider culture and literature, and the utility of the concept of misplaced (...) being. (shrink)

he design-based approach is a methodology for investigating mechanisms capable of generating mental phenomena, whether introspectively or externally observed, and whether they occur in humans, other animals or robots. The study of designs satisfying requirements for autonomous agency can provide new deep theoretical insights at the information processing level of description of mental mechanisms. Designs for working systems (whether on paper or implemented on computers) can systematically explicate old explanatory concepts and generate new concepts that allow new and richer interpretations (...) of human phenomena. To illustrate this, some aspects of human grief are analysed in terms of a particular information processing architecture being explored in our research group. We do not claim that this architecture is part of the causal structure of the human mind; rather, it represents an early stage in the iterative search for a deeper and more general architecture, capable of explaining more phenomena. However even the current early design provides an interpretative ground for some familiar phenomena, including characteristic features of certain emotional episodes, particularly the phenomenon of perturbance (a partial or total loss of control of attention). The paper attempts to expound and illustrate the design-based approach to cognitive science and philosophy, to demonstrate the potential effectiveness of the approach in generating interpretative possibilities, and to provide first steps towards an information processing account of `perturbant', emotional episodes. (shrink)

Extant philosophical accounts of schizophrenic alien thought neglect three clinically signifi cant features of the phenomenon. First, not only thoughts, but also impulses and feelings, are experienced as alien. Second, only a select array of thoughts, impulses, and feelings are experienced as alien. Th ird, empathy with experiences of alienation is possible. I provide an account of disownership that does justice to these features by drawing on recent work on delusions and selfknowledge. Th e key idea is that disownership occurs (...) when there is a failure of rational control over one’s mind. Th is produces a clash between the deliverances of introspection and practical enquiry as ways of knowing one’s mind. Th is explanation places disownership on a continuum with more common aspects of our psychological life, such as addiction, akrasia, obsessional thinking, and immoral, selfi sh or shameful thoughts. I conclude by addressing objections, and exploring the relevance of my account to questions in the philosophy of psychiatry concerning the validity of our current taxonomy of symptoms, and the nature of psychiatric classifi cation.. (shrink)

Classifying Madness (Springer, 2005) concerns philosophical problems with the Diagnostic and Statistical Manual of Mental Disorders, more commonly known as the D.S.M. The D.S.M. is published by the American Psychiatric Association and aims to list and describe all mental disorders. The first half of Classifying Madness asks whether the project of constructing a classification of mental disorders that reflects natural distinctions makes sense. Chapters examine the nature of mental illness, and also consider whether mental disorders fall into natural kinds. The (...) second half of the book addresses epistemic worries. Even supposing a natural classification system to be possible in principle, there may be reasons to be suspicious of the categories included in the D.S.M. I examine the extent to which the D.S.M. depends on psychiatric theory, and look at how it has been shaped by social and financial factors. I aim to be critical of the D.S.M. without being antagonistic towards it. Ultimately, however, I am forced to conclude that although the D.S.M. is of immense practical importance, it is unlikely to come to reflect the natural structure of mental disorders. (shrink)

This Article is a response to thoughtful commentaries by Jennifer Radden (2013) and Louis A. Sass and Elizabeth Pienkos (2013) on my paper, which investigates the continuity between melancholia and depression. In the following, I address the challenges presented by the commentators and attempt to clarify and deepen my position. In my paper, I have explored the history of melancholia and depression with special emphasis on the question of their possible continuity—with the knowledge that any such attempt inevitably brings with (...) it a whole cluster of theoretical challenges. Therefore, I tried to remain modest in my conclusions, but I also wanted to contribute to the debate by showing that there might be .. (shrink)

Although the Historical concept of melancholia has undergone numerous metamorphoses, it has maintained a place in psychiatric classification and currently refers to a specific melancholic subtype of major depression (American Psychiatric Association 2000, 419). Although melancholia—as a description of pathological states—constitutes the focus of this paper, it must be pointed out that the range of states encompassed by melancholia cover a far wider spectrum than that covered by the term ‘disease.’ As Jennifer Radden notes, melancholia (and melancholy) referred to “both (...) a normal disposition and a sign of mental disturbance” (Radden 2000, ix), thus covering a wide range of emotional variations that cannot be reduced .. (shrink)

It is a Pleasure to comment on Somogy Varga’s intriguing paper, which offers welcome insight into the historical sources, changing uses, and underlying assumptions pertaining to the concept of ‘melancholia,’ especially in relationship to ‘depression.’ We found Varga’s discussion of the relationship between affect and cognition in past discussions of melancholia and depression to be illuminating, especially given the emphasis on cognitive distortions in contemporary psycho-pathology. His explanation of the gradual evolution of the depression concept from melancholia sheds interesting light (...) on current notions. All in all, we find Varga’s arguments persuasive, and are inclined to agree with him (and others whom he .. (shrink)

Attachment is the way we relate to others. The way we attach to others is developed early in childhood, can be impaired by early traumatic life events, and is disturbed in many psychiatric disorders. Here we give a short overview about attachment patterns in psychiatric disorders with a focus on depression, and discuss two recent empirical studies of our own that have investigated attachment related brain activation using fMRI. In the first study with patients with borderline personality disorder we used (...) a paradigm in which patients produced narratives in response to attachment pictures and measured brain activity while participants were talking. Our results are consistent with the view that BPD pathology might be correlated with traumatic attachment fear related to autobiographic abuse and loss experiences. In the second study we investigated patients with major depression undergoing therapy in a longitudinal design. In this study we used a design with individualized stimuli that were extracted from narratives produced outside of the scanner. We found that patients, as compared to healthy controls, showed differences in a pre-post comparison. The significant correlation of changes in the subgenual cingulate and medial prefrontal cortex with symptom improvement provides evidence that these regions are involved in mediating therapy related effects. (shrink)

The harmful dysfunction (HD) analysis of "disorder" holds that disorders are harmful failures of "designed" (that is, naturally selected) functions. Murphy and Woolfolk (2000) present a series of proposed counterexamples to the HD analysis to support their claim that it fails to provide a necessary condition for disorder. They argue that disorder can exist where there is no failed function, as in failed spandrels and inflamed vestigial organs, and that there can be disorders when everything is working as designed, as (...) in environment--design mismatches and disorders acquired through normal learning processes. They also argue that the HD analysis suffers from methodological problems, including value-ladenness of dysfunction judgments and unwarranted assumptions about the nature of internal mechanisms and their functions. -/- In this paper, each of these objections is critically evaluated. Reanalysis of the proposed counterexamples is argued to reveal strong support for the HD analysis. For example, failed spandrels are considered disorders when and only when they imply failures of designed functions; dysfunctions of vestigial organs involve failures of function at the tissue level, not the organ level; mechanism-environment mismatches are not considered disorders; and conditions acquired through normal learning processes can involve dysfunctions and are considered disordered only when they do. Murphy and Woolfolk's methodological objections are found to be based on a misinterpretation of the HD analysis. It is concluded that Murphy and Woolfolk fail to offer a cogent objection to the HD analysis. (shrink)