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September 5, 2012 2:13 PM   Subscribe

"How, I wonder, can a young woman who has grown up in this harsh environment, waking up early to fetch water, cook, clean, farm till late in the day, be suffering from depression? ... People don't get depressed in Nigeria."
posted by ChuraChura (71 comments total) 73 users marked this as a favorite

 
...many of my classmates, myself included, still look at depression as a largely Western illness. The few cases that we have seen in the clinics in Nigeria have been mostly among the relatively affluent, and so we imagine that it is a luxury for those who can afford to ignore their more pressing immediate problems – what to eat and how to keep a roof over their heads – to indulge in afflictions of the mood.

And here in the West, it's discounted in the exact same manner: "My parents/grandparents grew up during the 30s and no one was depressed because they worked hard! You have everything you want, how can you be depressed? Don't you know there's people starving in Africa who have real problems?"
posted by griphus at 2:24 PM on September 5, 2012 [20 favorites]


What a fantastic article. Thank you for this.
posted by infinitywaltz at 2:25 PM on September 5, 2012 [1 favorite]


Indeed, griphus. Depression is an illness, not a mood.
posted by agregoli at 2:41 PM on September 5, 2012 [5 favorites]


What a powerful and touching piece this is, thank you for posting it.
posted by BigHeartedGuy at 2:49 PM on September 5, 2012


So, what did women with post-partum depression do before there were Western-style hospitals?
posted by Melismata at 2:58 PM on September 5, 2012


This is fantastic, thank you
posted by Blasdelb at 2:59 PM on September 5, 2012


I have a question to whomever is currently mandated with defining "depression": may it be used to describe a non-pathological reaction to things being legitimately shitty?
posted by This, of course, alludes to you at 2:59 PM on September 5, 2012 [6 favorites]


So, what did women with post-partum depression do before there were Western-style hospitals?

I can't speak to post-partum specifically, but the general answer to "what did depressed people do before depression was recognized as an illness" is "develop alcoholism, which also wasn't recognized as an illness."
posted by griphus at 3:01 PM on September 5, 2012 [64 favorites]


The Americanization of Mental Illness.
posted by valkyryn at 3:03 PM on September 5, 2012 [11 favorites]


...may it be used to describe a non-pathological reaction to things being legitimately shitty?

The way "depression" is being used in this article (and the comment thread) is shorthand for "depression the diagnoseable mental illness," which encompasses things like Major Depressive Disorder, Post-Partum Depression, Dysthimia, an aspect of Bipolar Disorder, &c.
posted by griphus at 3:04 PM on September 5, 2012 [4 favorites]


I know some women who got post-partum depression severe enough that they couldn't function were institutionalized.
posted by small_ruminant at 3:07 PM on September 5, 2012 [3 favorites]


In regards to valkyryn's fascinating article, what would be a prophylactic measure against the spree shooter disease? Is this the kind of thing we could even intentionally change?
posted by idiopath at 3:09 PM on September 5, 2012


So, what did women with post-partum depression do before there were Western-style hospitals?

it depends on the culture i suppose. the malaysian malay culture recognised the phenomenon enough that they have a specific term for it: meroyan, and develop a set of societal advice and expectations, that for the most part have helped new mothers cope.
posted by cendawanita at 3:10 PM on September 5, 2012 [7 favorites]


Valkyryn, that article is fascinating. Related (pdf), "The Weirdest People in the World?" How can psychology and economic theories focused on "Western, Educated, Industrialized, Rich, and Democratic" undergrads be accurately generalized to the rest of the world?
posted by ChuraChura at 3:10 PM on September 5, 2012 [4 favorites]


So, what did women with post-partum depression do before there were Western-style hospitals?

Well, some of them just suffered. Almost every family had stories of women who took months or years to recover from childbirth. Some of them remained "invalid" for years, and it was not always due to physical complications.

My great-grandmother never really recovered from the birth of her 15th child, although it was never clear what was wrong with her. She was bed-ridden for 5 years, and was ambulatory later, but never fully functional. Her elder daughters took over care of the house and children. My grandmother, the eldest child, took over care of the youngest from when he was weaned and raised him as if he were her own.

Melancholy was a known condition, it just wasn't called a disease and there was no pallative or cure. Judging from behavior of other ancestors and a now known tendency to depression, people suffering from depression became alcoholics, or constantly moved from one place to another, thinking it would solve their poblems, or they took to their beds and faded away, or not infrequently, they committed suicide.
posted by pbrim at 3:14 PM on September 5, 2012 [19 favorites]


So, what did women with post-partum depression do before there were Western-style hospitals?

My great-grandmother left the family home after her ninth child. Went and took a room in town and let her oldest daughter raise the family for several years. She eventually recovered and returned home.
posted by padraigin at 3:18 PM on September 5, 2012 [2 favorites]


This was a great article.

A lot of people with depression the world over suffer silently because they know their trouble will either be minimized, derided, or treated with outright scorn.

A small, but significant, proportion of these people then go on to hurt themselves or others when faced by an overwhelming stressor. Frankly, a lack of basic psychiatric care is another deficiency of the developing world. Maybe after endemic infectious diseases and starvation are dealt with, the world can address this appropriately.
posted by Renoroc at 3:24 PM on September 5, 2012 [3 favorites]


I hadn't heard Nigerians disclaim depression as a part of their cultural experience before, but I did have the interesting experience of trying to rent a comedy at a Nollywood video store. Perhaps it was a communication issue, but out of many thousands of videos, the proprietors could not suggest one they thought I would find amusing.

Ultimately they settled in the enormously depressing story of a country bumpkin staying with family in the city. He spent a good chunk of the film nearly in tears over misunderstanding social norms. But supposedly it was sort of funny what he had misunderstood, not that anyone laughed (the other characters were basically angry with him).

I'm sure I missed the subtleties of it, but I came away with the idea that situational depression was a distinct possibililty for Nigerians, even if this was somehow kind of funny.
posted by Monsieur Caution at 3:26 PM on September 5, 2012 [10 favorites]


So, what did women with post-partum depression do before there were Western-style hospitals?

As the article I linked points out, there's a body of research which suggests that there might not have been "post-partum depression" before there were Western-style hospitals.* There are some psychological disorders which are known to be unique to particular cultures, called "culture-specific syndromes". But there's an argument to be made that all psychological disorders are culture-specific, and that things like "depression" are only commonplace because we've made them that way. "Going mad" is a highly culturally-fraught thing to do, and it's taken different forms in different places at different times.

So saying that people in Nigeria "don't get depressed" may only be saying that Nigerians process and express their psychology differently than we do. We don't believe in "hysteria" any more, we never believed in koro or "brain fag," but those have all been considered serious, legitimate mental conditions at one time or another. Who's to say that more "objective" "diseases" like depression might not be similar?

This isn't to say that there's nothing going on. It's only to say that what's going on isn't necessarily discernible by any scientific process. The brain is weird and the mind is weirder. Bad stuff can and does happen to both. But the idea that we can box things up into categories as discrete "mental diseases" may be too ambitious by half.

*Note that I can't recall whether post-partum depression was specifically discussed. The article and the research it references are more about the idea that psychological conditions in general may be significantly more culturally bound that we tend to think.
posted by valkyryn at 3:27 PM on September 5, 2012 [3 favorites]


It's been around for quite some time and in all cultures and conditions. But, like all afflictions that modify the will, it raises problems about sin, mind, control and responsibility that are dangerous to consider in societies where society itself is seen as more precious and worth guarding than the individual.
posted by Devonian at 3:57 PM on September 5, 2012 [3 favorites]


there is also a lot of evidence that regular exercise alleviates depression, so a more sedentary society is likely to show a greater incidence of depression.
posted by 5_13_23_42_69_666 at 4:02 PM on September 5, 2012 [3 favorites]


There's plenty of evidence that the specific presentations of mental illnesses are culturally-specific, but I am not aware of any evidence that mental illness itself is. There's a brain doing all this, and it can only work or fail to work in so many ways.

Which is more likely: that non-western countries don't have mental illnesses, or that non-western countries don't diagnose and treat mental illnesses?

If the former seems more likely, do you also believe that Iran has no gay people? Maybe it's just a culturally specific form of sexuality, right?

Or take the child abuse reporting data from the Catholic Church. There was a huge spike in reported incidents in the sixties and seventies. Which seems more likely: that the Church had a sudden influx of abusers because of the moral permissiveness of the Sexual Revolution (an actual claim made by the John Jay report) or that reported incidents only spiked when the victims realized they could be safely heard?
posted by anotherpanacea at 4:17 PM on September 5, 2012 [17 favorites]


Melismata, one of my great-grandmothers was hospitalized for 60+ years because of "hysteria" ( the recorded dx) following the birth of her fourth child. She had been hospitalized briefly between child 2 (my grandmother) and child 3, during which time my grandmother and her older sister were put into an orphanage.

Many children in orphanages during the 19th and early 20th centuries were there because of their mothers' mental illnesses.
posted by Sidhedevil at 4:24 PM on September 5, 2012 [8 favorites]


Dr. Sapolsky's Standford lecture on the biology of depression.
posted by Decimask at 4:32 PM on September 5, 2012 [3 favorites]


In times and places without the various advantages and spare time that 'modern America' has, it seems that severely depressed people simply would not survive, but their deaths would be attributed to something else...

"He got trampled by an elephant. He could've gotten out of the way, but..."
posted by oneswellfoop at 4:36 PM on September 5, 2012 [4 favorites]


There's plenty of evidence that the specific presentations of mental illnesses are culturally-specific, but I am not aware of any evidence that mental illness itself is.

But that's the problem. Mental illnesses are defined by their "presentations."
posted by smorange at 4:51 PM on September 5, 2012


Mental illnesses are defined by their "presentations."

Sure, but so are Higgs Bosons.
posted by anotherpanacea at 4:56 PM on September 5, 2012 [4 favorites]


I have a question to whomever is currently mandated with defining "depression": may it be used to describe a non-pathological reaction to things being legitimately shitty?

If it's a *legitimate* depression, the body has ways of shutting that down.
posted by uosuaq at 4:59 PM on September 5, 2012 [28 favorites]


Right, but whether or not Higgs Bosons "really exist" isn't that important for science; the concept's usefulness is. The question is whether American definitions and categories of mental illness are, on the whole, useful (or even, in some cases, harmful)--and if so, to what extent. But there's no way to know if the whole world adopts American ideas of what mental illnesses are.
posted by smorange at 5:02 PM on September 5, 2012


As the fourth generation in a row to discover the wonders of self-medicating, I can attest that mental illness existed before. Great-grandpa ran out on his family and was a drunken nomad in the area for years, Grandma carried a coktail to bed and started making them again at 10 in the morning every day of the year, Dad was a functional alcoholic but had a bad gambling issue and once jumped out of a moving car to avoid just discussing his issues with a counselor. Me? I have the same not-able-to-deal syndrome that runs in my direct bloodline, but I am so glad there are so many more options out there than just booze.
posted by Vysharra at 5:03 PM on September 5, 2012 [9 favorites]


As the article I linked points out, there's a body of research which suggests that there might not have been "post-partum depression" before there were Western-style hospitals.* There are some psychological disorders which are known to be unique to particular cultures, called "culture-specific syndromes". But there's an argument to be made that all psychological disorders are culture-specific, and that things like "depression" are only commonplace because we've made them that way. "Going mad" is a highly culturally-fraught thing to do, and it's taken different forms in different places at different times.

That article is just more of that pseudo-scientific conservative skepticism. Mental illness isn't culture specific any more than the common cold. Sure, people suffering from psychosis will have culture specific SYMPTOMS, but psychosis is psychosis. And whether depression means you go on a shooting spree or you jump into a gorge or drink yourself to death every night, the disease is still depression.
posted by gjc at 5:33 PM on September 5, 2012 [6 favorites]


Monsieur Caution, it sounds like you were watching the Nigerian version of "cringe" comedy. A lot of modern American comedy is based on awkwardness, and even if it is sort of cruel, there is usually some affection for the characters. America makes a lot of movies about idiot manchildren beset by constant misfortune, and to somebody from another culture, that story could just seem heartbreaking.

There are also a lot of culturally specific things that just don't translate. Not just cultural mores and pop culture references, but even stuff like funny voices and particular accents. Adam Sandler's goofy voices, for instance, might not read as intentionally comedic if you didn't speak the language.
posted by Ursula Hitler at 5:42 PM on September 5, 2012 [1 favorite]


Also, you know how we know there was lots of depression in the past? Lots of suicides in the past. Lots and lots of suicides.
posted by Sidhedevil at 5:53 PM on September 5, 2012 [17 favorites]


My grandmother suffered from depression after the death of her husband. She didn't leave her home for 4 years and my dad (at the age of 12), had to do all the shopping, bill paying, etc. It was called "depression", of course, this being 1950s/1960s England, but it was all the same.
posted by modernnomad at 5:57 PM on September 5, 2012 [1 favorite]


I have a question to whomever is currently mandated with defining "depression": may it be used to describe a non-pathological reaction to things being legitimately shitty?

Yes. I had situationally caused major depression for about seven years when I was in my teens. Post-pardum depression is a specific thing and can be purely biological (hormones do backflips) but also partially caused by trauma during birth; the lines between depression and longstanding post traumatic stress disorder can get very blurry. The adults I have worked with who have debilitating major depression also have a history of extreme childhood trauma; it's impossible to draw causal conclusions from correlational data (and I have a small pool of data) but in terms of my practice I usually deal with the childhood trauma stuff in concert with contemporary stress and problem solving and medication.

Another note is that depression expresses very differently in men and women in Western cultures; women tend to express with "sadness" and men tend to express with "irritation". One running theory is that part of the gender difference in diagnosed depression is due to this difference in gender presentation of symptoms.

We don't believe in "hysteria" any more

Actually, we do, it's just called conversion disorder. Conversion disorder is when physical symptoms, like the loss of functioning in an arm, don't have a physiological cause but do have a psychological cause. It's largely seen in women in Western cultures; it's more commonly gender neutral when looking from Western culture into other cultures, but there is the inborn issue of translating complicated implicit concepts between cultures which impairs defining "universal" mental health.

Needless to say the theory of the "cause" of it being a wandering uterus is thoroughly debunked, but there does seem to be a way in which when a severe psychological issue can't be expressed in psychological terms, it shifts into a physical manifestation. Or, the psychological approach is a different way. We're not sure, since we don't really understand the complex interaction between the brain and the body and how that relates to medicinal and psychological treatments. I would imagine the placebo effect lives there, somehow.
posted by Deoridhe at 6:21 PM on September 5, 2012 [7 favorites]


Conversion disorder is when physical symptoms, like the loss of functioning in an arm,

Huh. I just realized that this is probably what I brushed up against at one very stressful point in college. I could hardly lift my right arm (my dominant arm) because my shoulder hurt so much. There wasn't anything wrong with it, physically - but I wanted to hit stuff. People. A lot. And I "couldn't" (nice kids at good colleges don't hit), so all that desire to hit had nowhere to go. When the stressful thing ended, my arm was back to normal overnight. It only lasted a few weeks, but it was very weird.
posted by rtha at 6:46 PM on September 5, 2012


Sure, but so are Higgs Bosons.

You seem to be supporting smorange's point. If the presentation is all that we can observe, then for pragmatic and scientific purposes, the disease is defined by its presentation. Postulating a common cause for a lot of similar-looking symptom profiles might suggest interesting avenues for research, but your faith in the existence of the common cause is not so scientific.
posted by LogicalDash at 6:53 PM on September 5, 2012 [1 favorite]


I'm just glad the poor woman in the story got some help. How sad it would be if the doctor sat back and decided she couldn't possibly be depressed. People can be depressed for any reason or no reason. "But you have it all!! How could you be depressed??" It's not just about being sad. It's about a colonizing of your whole system.

Depression is such a pernicious disease that one of the symptoms is not believing you could be depressed when it's obvious to everyone else that you are. How can it help people to have an institutional doubting on top of that.
posted by bleep at 7:04 PM on September 5, 2012 [1 favorite]


Huh - interestingly, I just saw this show up in my feedreader: Globally, 1 in 13 suffers from anxiety:

"Depression and anxiety are found in every society in the world—a finding that debunks old theories that only people in the West get depressed."
posted by symbioid at 7:17 PM on September 5, 2012 [4 favorites]


My grandfather was a no-good shiftless layabout. Lazy, lazy man. He couldn't keep a job, or finish anything he started around the house! He would build a fence thus: Pound in one nail up top. Take a cigarette break, drink a beer, polish the hammer, and then pound another nail in. By nightfall, he had four pickets nailed to that fence, five if he was lucky! Such a lazy, lazy man! He cried at the dining room table at night if he had to put in a decent day's work! So wicked! His wife had to work at night as a nurse... at the section 8 ward!... because he couldn't hold down a decent job.

This is Braintree, just south of Boston, in the 1950's and '60s.

It missed my Mom. Something worse missed my Dad. My sister and I got decked with it. Without the "western disease" narrative, without realizing this was something real and biological and actively fucking with me as much as my asthma is, instead of my current life as respected expert in my field...

Slap*Happy is a no-good shiftless layabout. Lazy, lazy man. He couldn't keep a job, or finish anything he started around the house! Just like his grandpa.
posted by Slap*Happy at 7:21 PM on September 5, 2012 [31 favorites]


Well, to be fair, people in "The West" also get labelled with Fibromyalgia, Chronic Fatigue Syndrome, Melancholia, Chronic Lyme Syndrome, Neurasthenia (okay, not so much now) and a bunch of other depressive syndromes that seem exquisitely culture-bound and historically contingent.
posted by meehawl at 8:11 PM on September 5, 2012


I have a question to whomever is currently mandated with defining "depression": may it be used to describe a non-pathological reaction to things being legitimately shitty?

I'm no expert, but I thought the DSM diagnosis for that was "Adjustment disorder". That's what my shrink told me after he said "you're in a really shitty situation...". And then he charged me another $100...
posted by plantbot at 8:44 PM on September 5, 2012 [1 favorite]


Huh. I just realized that this is probably what I brushed up against at one very stressful point in college.

I am not your therapist, and diagnosing over the internet is always bad, but that sounds accurate. I had a similar wonky back (it went out whenever I spent more than fifteen minutes insulting myself; became very useful as a way of me noticing that I was insulting myself, since during that period of time insulting myself seemed normal) in high school. Sometimes it goes away if a specific circumstance changes, but in my case recognizing the internal process was the cure - combined with a change in behavior so I cut myself off from insulting myself when I noticed I was.

One of the interesting effects I had of starting to go over Freud's old cases and details from his work was of trying to see through his eyes, filtered by what he noticed, what truths could lay beyond that he missed due to his perspective. It's a useful thought-experiment anyway, since so much of therapy is figuring out the fiddly bits of someone else's head, but his treatment of young women with conversion disorder and the stories they recounted of sexual abuse (which he later discounted as accurate and refined into his theory of the Electra Complex) always made me wonder if 1) sexual abuse wasn't more rampant than he was willing to accept and 2) if there were peculiarities in the culture at the time which led to a mass breakout of conversion disorder.

I read recently about a large case of conversion disorder at a school in New York, again largely of a population of women and with Torrettes like symptoms, but this time with a few men drawn in as well. The issue of the transfer of mental illness from one person to another is a really critical one, especially if you can discount all physical causes we know of. We have some evidence from FMRIs that people experience the emotional states of others when they observe them, and this could be one of the means by which illness, behavior, and culture expands outwards. This might also explain some of the cultural "leaps" between generations, where behavior one generation was just aping - hoping to make it true - becomes true with the children. Much like children are the creators of language out of pidgins, children may also be creators of culture out of what they perceive of their surroundings.
posted by Deoridhe at 8:51 PM on September 5, 2012 [2 favorites]


I'm no expert, but I thought the DSM diagnosis for that was "Adjustment disorder".

Adjustment disorder literally means, "There is a change in the person's life they are struggling to cope with." It can fit for everyone, which is part of the point of it. It also has no stigma attached to it, which is also very handy.
posted by Deoridhe at 8:58 PM on September 5, 2012 [2 favorites]


But that's the problem. Mental illnesses are defined by their "presentations."

On the other hand, AIUI, there are physiological effects of major depression that are detectable in autopsies— progressive changes to brain structure, kind of thing.

Melancholy was a known condition, it just wasn't called a disease and there was no pallative or cure.

I don't think that's a coincidence, really: until there was something that could be done about depression there wasn't much of a need to describe its species or distinguish them from each other. Depressed? Malnourished? Parasite-ridden? Resentful member of an oppressed population? Doesn't matter which, the diagnosis is the same: try to work through it or die in the gutter (or both).
posted by hattifattener at 9:17 PM on September 5, 2012 [1 favorite]


On the other hand, AIUI, there are physiological effects of major depression that are detectable in autopsies— progressive changes to brain structure, kind of thing.

I don't think that's conclusive of anything, though mine isn't the fashionable opinion these days. I mean, think about it: of course similar physiology is going to accompany similar behaviour. Unless you believe in mind-body dualism, this simply must be true. But what does that show? Just because you can see something "in the brain" doesn't mean it's best conceptualized as caused by what you see in the brain, particularly when your belief in what caused the behaviour influences whether the behaviour will manifest. It may be true, on one level of description, that someone's depression was "caused" by the goings-on in his brain, but it might also be true, on another level of description, to say that is was caused by x, y, and z circumstances or choices in his life. The trouble is, if the latter description is true, our concepts of mental illness may well cause (or prevent, or alter) its manifestation.
posted by smorange at 10:24 PM on September 5, 2012 [2 favorites]


Since we can't assign people mental illnesses, studies of them will perforce be quasi-experimental, not experimental. Which means establishing causality is really, really difficult.
posted by Deoridhe at 10:27 PM on September 5, 2012


I didn't make it clear that I think both the neuroscience and social explanations can be "true," just as a physicist's explanation of phenomena might be as "true" as a chemist's, even if their explanations are totally different. Scientific truth isn't really about what's "really true" anyway; it's about what's useful. And it's not clear that the American conceptualization of mental illness (as a pharmacological problem, mostly) is always the most useful. It may even cause the manifestation of mental illnesses. There's evidence of that; besides, it's not at all a crazy idea--we all make choices, model our behaviour, and live our lives against the backdrop of the narratives of our societies. Human beings are essentially storytellers. Our lives and our identities are the stories we tell ourselves. Why wouldn't our theories of behaviour influence those very lives and identities?
posted by smorange at 10:37 PM on September 5, 2012 [2 favorites]


On the other hand, AIUI, there are physiological effects of major depression that are detectable in autopsies— progressive changes to brain structure, kind of thing.

Link? I'm not aware of any commonly accepted scientifically detectable physiological markers for depression or bipolar.

My grandfather was a no-good shiftless layabout. Lazy, lazy man.

This is sort of the point. In highly individualistic societies that emphasize private property acquisition as the marker of success we might easily pathologize those individuals that seem completely uninterested in such things. Other societies might regard such individuals very differently, if at all.

The very word 'depression' has such powerful economic and psychological overtones in the Western psyche -- it is a kind of ur-villain, a kind of "dissolution of the self" that strikes against all other values -- that it's not even clear what it would mean outside of the Western diagnostic model.
posted by nixerman at 10:37 PM on September 5, 2012 [1 favorite]


I have a question to whomever is currently mandated with defining "depression": may it be used to describe a non-pathological reaction to things being legitimately shitty?

To throw in my anecdotal point: a psychiatrist once told me that disproportionate or never-ending grief about a tragic event would be classified as depression. Obviously, here we get tangled up in what is regarded as a "normal" amount of grief, but yes: depression can be used in that context.
posted by outlier at 12:48 AM on September 6, 2012


>> But that's the problem. Mental illnesses are defined by their "presentations."
> On the other hand, AIUI, there are physiological effects of major depression that are detectable in autopsies— progressive changes to brain structure, kind of thing.


This is true, although:
- it's more qualitative than quantitative (depressed people tend to have a smaller hypothalamus and more blood cortisol)
- we can get all tangled up in the cause-and-effect here
- it's rarely used as a diagnostic method.

So, presentation is in practice how we define mental illness.
posted by outlier at 12:54 AM on September 6, 2012


I have a question to whomever is currently mandated with defining "depression": may it be used to describe a non-pathological reaction to things being legitimately shitty?

Depends how we're describing 'non-pathological', I suppose...

That does remind me of the article valkyryn linked upthread, though, because it does seem that the connection between depression and external influences is perceived differently in different cultures (even Western, first-world, depression-believing cultures). Certainly the cultural understanding of depression where I'm from includes 'reactions to things being legitimately shitty', and isn't so tied up in an understanding of depression based solely on whatever brain chemistry you were born with.

I'm glad of this, because it helped me get medical help when I was depressed. I had a series of shitty things happen in a very short space of time - an awful breakup (trust me, beyond-hellish awful), a family crisis involving both severe illness and unemployment, losing my home, facing unemployment myself, and hospital visits for something else - and even though I am usually a fairly happy person who deals with stress well and has no history of mental illness, my mind just... gave up.

The best way I can describe it is feeling like I'd discovered a secret about how bleak and awful the world really was, and all my previous cheerfulness had been based on a delusion. I had no energy, no interest in anything, couldn't focus, and it was as if all the things I would previously have enjoyed or been interested in faded away to near-invisibility while all the miserable and painful things in the world grew so big they blocked out my vision. I remember thinking to myself that I basically had two choices - either accept that I was never going to live happily in this world now I could really see what it was like, or change my personality totally so that it matched the awful world I saw - and neither of these seemed like something I could do. This felt like cold rationality to me, and all the people I could see enjoying life, they seemed either delusional or secretly cruel and bad inside. I thought about suicide a lot. It was, in short, not a good time in my life.

Eventually something inside me summoned up just enough of a fight against it to get me to a doctor, and the doctor gave me antidepressants. Nothing happened for the first couple of weeks of taking them, and then one day that grey smothering blanket of misery just lifted. It felt like magic, literally. It felt like a spell had been lifted off me. And it was only a good time after that that I could see, looking back, how distorted my thinking had been for the months beforehand.

So in that sense it helped me to have a mental model of depression that included depression induced by external shittiness, because certainly my messed-up mind was trying very hard to convince me this was just a rational reaction to the bad things that had happened. It also helped that almost everyone I knew who had taken antidepressants had done so under similar reactions to external-shittiness-induced misery, and had taken them for six months or a year or so, and then had got better. Had I grown up as part of a culture that I see sometimes presented here - depression is caused by an imbalance in brain chemistry, it's there for life, and if you're sad because something happened to you then that's just 'the blues' - it would have been harder for me to get help, even though I was by the end of it spending hours each day daydreaming about suicide. I don't think all depression is a temporary condition brought on by external stimuli, not at all, but certainly some of it is.
posted by Catseye at 3:30 AM on September 6, 2012 [5 favorites]


> And here in the West, it's discounted in the exact same manner: "My parents/grandparents grew up during the 30s and no one was depressed because they worked hard! You have everything you want, how can you be depressed? Don't you know there's people starving in Africa who have real problems?"

Indeed. I spend most of my working day at the moment looking at letters written to/from doctors in the 18th century, and I find it very striking that people are willing to believe depression didn't exist before about 1968 when it very, very clearly did. I mean, we don't do retrospective diagnosis, and I'm not a doctor anyway so couldn't diagnose even if I was there in person, and mental illness does present differently in different cultures across history - but, there were certainly people suffering from symptoms we'd today associate with 'depression'.

A man in his 40s: "[I have] not got quite free of the Cough and other effects of the Epidemic, besides the other Complaints of Lowness and Oppression of Spirits [with] restlesness in the night not only continued but encreased greatly from great Concern of mind."

A woman in her 50s: "[T]he mind is remarkably dejected, despondent and apt to convert trivial circumstances into insurmountable difficulties; but sometimes she shows signs of violence, or of spasmodic affections, which presently alternate with deep sighs, wailing and tears."

A man in his 20s (away from home for business and writing letters back): "his Letters turned on a Diffrant Strain Complaind of a Melancholy that he found upon him which dayly increas'd inso much as to use his own Expressions his life became a Burden to him, but for his friends sakes he would endeavour to be Preserv'd."

A soldier: "His chief complaint is a langour & Oppression which he suffers from every morning [...] this continues more or less till after dinner & prevents his using exercise by gentle walking or riding in a Chaise, inclining rather to lull in a chair by the fire side."

I wouldn't say life was unrelentingly peachy in the 18th century - nothing has ever made me so glad to be alive today as reading the line "all the ordinary childhood diseases, such as smallpox" - but these are people who could afford an expensive doctor, people at the top ranks of that society. The first man is an Earl. And yet, here they are, getting advice from doctors who saw their ailments as an undoubtedly real illness.
posted by Catseye at 4:33 AM on September 6, 2012 [14 favorites]


whether or not Higgs Bosons "really exist" isn't that important for science; the concept's usefulness is.

I'm not sure where this is coming from, but we don't get any "use" out of the concepts of the Higgs Field and attendant Bosons. This is basic research: there's no industrial use waiting in the wings.

If the presentation is all that we can observe, then for pragmatic and scientific purposes, the disease is defined by its presentation. Postulating a common cause for a lot of similar-looking symptom profiles might suggest interesting avenues for research, but your faith in the existence of the common cause is not so scientific.

You're saying that believing mental illness happens in the brain is not scientific?!?

It's perfectly possible that we'll realize that the thing we now call depression is tied to several different etiologies. But still, all of the kinds of depression we eventually discover are will be mediated by the brain. The physiology of psychology is in its infancy: the only hope it has is if we hold fast to both critical common-sensism and contrite fallibilism.

It's fine to focus on efficacy when your goal is treatment, just as it's fine to ignore quantum mechanics when you're building a bridge. But it cost a little more than $13 billion in absolutely useless research funding to find the Higgs. We'll need to spend even more to discover the actual mechanisms underlying psychopathology.

To return to the fucking article for a moment, Anya's argument is not that Nigerians don't get depressed: it's that the costs of treating depression are much higher than the costs of preventing the major trauma that can lead to depression. In that sense, spending billions on useless medical research is a waste: we should spend the money preventing infant mortality, raising the standard of living so that women do not need to marry right after puberty, and so on.

The fact that this post brought all the Scientologists and psychology skeptics out of the woodwork (despite the fact that the message of the article is completely opposed to the pullquote claim) suggests that the post is framed... well, really badly.
posted by anotherpanacea at 4:35 AM on September 6, 2012 [1 favorite]


Melancholy was a known condition, it just wasn't called a disease and there was no pallative or cure.

I don’t think that’s true, although I can only base that opinion on having read Robert Burton’s 17th-Century Anatomy of Melancholy. In Burton’s introduction to that book he wrote:
It is a disease of the soul on which I am to treat, and as much appertaining to a divine as to a physician, and who knows not what an agreement there is betwixt these two professions? A good divine either is or ought to be a good physician, a spiritual physician at least, as our Saviour calls himself […] They differ but in object, the one of the body, the other of the soul, and use divers medicines to cure; one amends animam per corpus, the other corpus per animam […]. One helps the vices and passions of the soul, anger, lust, desperation, pride, presumption, &c. by applying that spiritual physic; as the other uses proper remedies in bodily diseases. Now this being a common infirmity of body and soul, and such a one that hath as much need of spiritual as a corporal cure, I could not find a fitter task to busy myself about, a more apposite theme, so necessary, so commodious, and generally concerning all sorts of men, that should so equally participate of both, and require a whole physician. A divine in this compound mixed malady can do little alone, a physician in some kinds of melancholy much less, both make an absolute cure.
Moreover, one of the book’s three partitions is solely devoted to all manner of purported cures: dietetical, therapeutic, medicinal & surgical.

Sidhedevil’s observation about suicide as an indicator of depression led me to wonder what Nigeria’s suicide rate might be. It seems that it’s estimated to be relatively low (at least according to the map on the Wikipedia page for List of countries by suicide rate) although good hard data seems to be lacking, and Nigeria isn’t one of the countries included in the WHO’s table of Suicide rates per 100,000 by country, year and sex.
posted by misteraitch at 5:06 AM on September 6, 2012


Well, to be fair, people in "The West" also get labelled with Fibromyalgia, Chronic Fatigue Syndrome, Melancholia, Chronic Lyme Syndrome, Neurasthenia (okay, not so much now) and a bunch of other depressive syndromes that seem exquisitely culture-bound and historically contingent.

There's nothing culture-bound about Chronic Lyme Disease. It's a bacterial infection that can cause measurable neurological damage and death. Sure, there's an environmental consideration: if you don't live where the ticks that carry the disease live, you're less likely to get it, but it's not a damn "cultural construct"; my wife having been recently diagnosed only to realize soon after that apparently everyone either thinks Lyme Disease is as scary as the plague or just dismisses it as a fanciful chimera of American Privilege. It's a disease that's found world wide, wherever the carrier tick species in question is found. And there are specific blood tests that can positively identify it.

Man, it is so turning into the new Dark Ages up in this mother these days! What is up with that? A pox on all your houses!
posted by saulgoodman at 8:12 AM on September 6, 2012 [7 favorites]


You're saying that believing mental illness happens in the brain is not scientific?!?

Of course it happens in the brain, which is why I said "of course similar physiology is going to accompany similar behaviour." However, believing that mental illness is caused by what happens in the brain but not by choices/circumstances isn't scientific. It's convenient because it allows us to ignore social issues. But it's a both/and, not an either/or, thing.
posted by smorange at 9:25 AM on September 6, 2012


However, believing that mental illness is caused by what happens in the brain but not by choices/circumstances isn't scientific. It's convenient because it allows us to ignore social issues. But it's a both/and, not an either/or, thing.

I don't know of any major psychological theory running these days that does not look at interactions of the biological, behavioral, and environmental. (And no, behaviorism is not necessarily an exception to this.) It's baffling to me why the false dichotomy (trichotomy?) among treating biological factors and symptoms, training cognitive adaptation approaches, and advocating personal and social change so dominates these discussions.
posted by CBrachyrhynchos at 9:34 AM on September 6, 2012


The original question was simply: do Nigerians get depression? They do. The rest of it is just pretending that they don't and we'd be better off if we didn't think about it. There is no justification for this, certainly not in the article.
posted by anotherpanacea at 9:36 AM on September 6, 2012


saulgoodman: "There's nothing culture-bound about Chronic Lyme Disease"

I used "Syndrome", not "Disease". Lyme Disease is caused by an endocellular parasite that is quite well characterised in terms of presentation, signs and symptoms, course and prognosis. I can run titres and PCR for its detection, qualification and quantitation, and I can treat with suitable antibiotics.

Chronic Lyme Syndrome is a much more nebulous entity that often cannot be detected with conventional medical tests, cannot be treated well with conventional medical pharmaceuticals, and presents with an amorphous constellation of signs and symptoms. I've treated people with Lyme Disease, and I've treated people with Lyme Syndrome. The former responds well to biological model of treatment, the latter appears to be quite well defended against cure by biological models and I've had better luck reducing symptoms with psychiatric approaches, presupposing a post-infection depressive diathesis (I've seen similar neurasthenic presentations afflict a person in post-EBV or similar debiliating, systemic infections). This approach is often not well liked, either by desperate, depressed patients or the dodgy clinics that cater to them.
posted by meehawl at 10:39 AM on September 6, 2012 [2 favorites]


And it's not clear that the American conceptualization of mental illness (as a pharmacological problem, mostly) is always the most useful.

I don't know how much experience you have in the field, but even on the governmental level, which is where policy is made, supports other than the pharmacological are acknowledged as critical enough that US taxes go to pay for them, usually through programs like Medi-Cal. If that didn't happen, I wouldn't have a job.

I do disagree with a lot of the US and Western conception of mental illness, though it is the training I received (kind of, I'm Jungian which means most Cog-B people think I'm out of touch with reality), but to characterize it as solely a pharmacological problem - especially when there are several mental illnesses for which there is no drug treatment recommended - is not accurate. Accurate for the ads on tv maybe, but not for the feet on the ground.

it's not even clear what it would mean outside of the Western diagnostic model

Depression is easiest understood as ahedonia - that is a loss of pleasure in things which caused pleasure before, and an inability to feel pleasure. It often connects up with a loss of other emotions as well, a feeling of emptiness or hollowness (this is often where 'endured lots of trauma' comes in). I've heard that described in other cultures in other words, personally, and it has nothing to do with Individual Worker as only valuable item (though that configuration makes depression harder to kick for those who divert from the cultural expectations). That is to say, cultural expectations may change how this ahedonia presents (like above when I referenced men being more likely presenting with irritation and anger) but the loss of pleasure itself is more central than how that loss of pleasure expresses itself and so would be found more universally, with different social presentations depending on culture and socialization.


On a more general note - psychology today is really more of a grab-bag than people seem to perceive. I'm one of the most overtly therapeutic out of my job, and I have a Jungian base for conceptualizing my clients (because it works for me), use Person-Centered Rogerian therapeutic means as the basis of establishing and maintaining rapport and as an ethical basis (which is so bloody universal it's starting to leak outside of therapeutic contexts), with Cognitive Behavioral Therapeutic practices (largely the active ones, rather than the making lists ones, though I have taught writing down a Cost-Benefit-Analysis to teach decision making) with an emphasis on only using positive reinforcement (negative reinforcement and punishment are both inappropriate for my clientele), a healthy side dose of Family Systems modified for circumstances where the family is estranged (this I have overtly taught, including drawing out family diagrams where appropriate) and open and regular cooperation with the psychiatrist in our practice as part of supporting the medication side of things.

The Jungian basis thing is outside of normal practice, because I am strange, but the rest is fairly standard even if we don't use the words for it. Maybe people might use less Family Systems than I do, but the effect of the family is always a quiet theme. Cog-B is hugely popular because it is quick and usually effective, especially if the person is largely functional and happy but are having specific small areas of struggle, so you'll see it a lot in practices associated with insurance companies. Since I work with lifelong populations, not the more common "sick for 6mo. to a year crowd", using more long-viewing practices like Jungian and Family Systems, which put a person in the context of their childhood, adulthood, culture, etc... becomes a lot more sensible; with those who have only 12 sessions it would not be Best Practice to emphasize more systemic problems unless they are severely affecting the person's functionality, and then you push for a diagnosis and longer coverage of therapy (see: Adjustment Disorder!).

I see a lot of pushback against longer therapy because of a knee-jerk dismissal of Freud and his daughter, Anna (who have been shown to be wrong about... well, almost everything; but studying his case studies and her codification of his theories is a good way to get perspective of where psychology has been and one way of viewing the human psyche, which makes it still important) but there are people who have lifelong structural issues with how they relate with the world that only a holistic approach can address, and then you figure out which theoretical perspective works best with that person (which is usually when you're talking Freudian (is the problem suppressed desire), Jungian (is the problem diseased self-stories and self-beliefs), Adlerian (is the problem power differentials), Eriksonian (is the problem gaps in psychological development), etc...). There are also people who are lifelong navel-gazers, but we usually become therapists. ;)
posted by Deoridhe at 10:48 AM on September 6, 2012 [9 favorites]


Chronic Lyme Syndrome is a much more nebulous entity that often cannot be detected with conventional medical test

You seem to be overstating how complex it is. There is a simple blood marker that, when coupled with reported symptoms, can pretty solidly establish a diagnosis of the chronic form of Lyme disease. I realize the treatment options aren't very good, and the medical science is inadequate, but that doesn't make Chronic Lyme Disease any less a real bacterial infection than it does, say, neuro-syphillis. Just because there aren't any reliable treatments for a condition doesn't make the condition a non-medical, "cultural" one, does it?
posted by saulgoodman at 1:24 PM on September 6, 2012


saulgoodman: "You seem to be overstating how complex it is. There is a simple blood marker that, when coupled with reported symptoms, can pretty solidly establish a diagnosis of the chronic form of Lyme disease"

Well, I agree with the apocryphal "everything should be made as simple as possible, but not simpler". There's an enormous difference between a disease directly related to an infectious agent that be seen, treated, and definitively eliminated using predictable agents with known, rational mechanisms, versus a protean syndrome with a movable feast character. I suspect we are rather talking at cross purposes, and you are conflating "syndrome" with "disease". Tell me what you think this marker is. You may want to look at something like this first and there's an interesting discussion of the cross-cultural labelling differences between the North American and European approaches to "chronic neuroborreliosis" (which is not the same entity as Chronic Lyme Syndrome).
posted by meehawl at 7:50 PM on September 6, 2012


It's baffling to me why the false dichotomy (trichotomy?) among treating biological factors and symptoms, training cognitive adaptation approaches, and advocating personal and social change so dominates these discussions.
When there's a lot of people talking out of their butts, everything looks black and white.



I sometimes wonder if this "these people don't get depressed" is some kind of weird relative of the "Noble savage" thing.
posted by bleep at 7:59 PM on September 6, 2012 [4 favorites]


versus a protean syndrome with a movable feast character.

I don't know what kind of protean syndrome you mean. My wife, for example, started having severe joint pain a few weeks ago. She'd had some other milder symptoms in the past (and has suffered frequent headaches since her childhood in Connecticut, where the ticks that cause Lyme disease are most common), but we never thought of them as anything more than the general human misery of aging and my wife certainly didn't go diagnosis shopping. We never even suspected anything like Lyme Disease. It was blood testing that turned up the Lyme disease and along with the recent symptoms and medical history confirmed the likely chronic nature of the disease. But look, just because it may be difficult to treat or predict the development of a disease or disorder, that doesn't make it any less an actual medical condition and more a "cultural" thing.

No one with any serious medical credibility disputes that Lyme Disease exists and that if its untreated it can develop into a much harder to treat and persistent form. And the evidence of real neurological damage resulting from Chronic Lyme Disease is overwhelming: it can cause measurable, physical damage to the brain.

Chronic Lyme disease is used in North America and increasingly in Europe as a diagnosis for patients with persistent pain, neurocognitive symptoms, fatigue, or all of these symptoms, with or without clinical or serologic evidence of previous early or late Lyme disease.


From your link meehawl: yeah, that might happen, but it also happens that people are diagnosed with it when there is "clinical or serologic evidence of previous early or late Lyme disease," as in my wife's case where it was only due to the discovery of a potential blood marker for Lyme disease that it came under consideration as a diagnosis at all. Our doctor doesn't even really seem to want to treat it despite having diagnosed it (as we've heard is the case with many doctors in town), because doctors apparently can't be arsed to deal with or care about complicated problems that can't easily be resolved using check-lists and easily repeatable processes.
posted by saulgoodman at 7:24 AM on September 7, 2012


"You seem to be overstating how complex it is. There is a simple blood marker that, when coupled with reported symptoms, can pretty solidly establish a diagnosis of the chronic form of Lyme disease."

The blood marker I'm pretty sure you're referring to is the combination of a preliminary ELISA test that is sensitive but non-specific and a secondary Western-blot that is specific but not very sensitive that is currently the standard test for Lyme disease. Both tests are used to detect the presence or absence of antibodies that are made in response to Borrelia infection. This paper pretty well represents the current consensus on diagnosis strategies for Lyme disease. Specifically, the ELISA test has been demonstrated to often detect antibodies that could not have been produced by Lyme disease and the Western-blot test has been demonstrated to often fail to detect antibodies in patients that are known to have Lyme disease - and this is looking at active Lyme disease with live cells present. Antibodies will persist in the body for decades after infections have been cleared, and these tests have never been demonstrated to be able to distinguish between patients who appear to exhibit Chronic Lyme Syndrome (CLS) and patients who had Lyme disease but don’t. If anything were actually able to do that, then that would be huge news and generate Nature papers and fame for whomever did it.

This paper represents the current medical consensus on Chronic Lyme Syndrome. (PDF) [HTML]

There are a lot of big clues that make physicians really suspicious of CLS as a disease with non-psychological origins, it fits all of the patterns we’ve seen before over and over again. All of the commonly reported symptoms that last more than six months are ones that have been previously individually demonstrated to have purely psychosomatic origins in past culturally mediated epidemics, the commonly reported symptoms are amazingly diverse and follow no other pattern, there are no diagnostic criteria beyond patient reports that separate the affected from the unaffected, otherwise logical physiological interventions like continued antibiotic regimens have been demonstrated to have no meaningful placebo-controlled effect with wildly abundant clarity while psychological interventions have, CLS is faddishly epidemic in regions where Lyme disease is not, most of the reported symptoms have no meaningful relationship to symptoms that actual Lyme disease has, the vast majority of those who self-identify as diagnosed with CLS have no substantiated history of the disease, and reported symptoms by patients over time have followed awfully faddish patterns where suddenly patients across the country discover similar symptoms at the same time.

It is reasonably obvious to any both informed and impartial observer that, at the very least, in addition to any underlying symptoms with non-psychosomatic origins associated with a long term aftermath of Lyme disease there may or may not be, there is a much larger epidemic at work here. Indeed, I would wager that, if such a thing were doable, a particularly unethical researcher could add to the list of symptoms that patients report to their physicians by finding a symptom that has in the past had known psychosomatic and associating it with Chronic Lyme Syndrome on the internet.1 To be fair, while I would be a surprised if there turned out to be something more to the non-psychosomatic after effects of Lyme Disease than the short term and certainly not progressive neurological damage that has already been characterized, it is at least conceivable. That those effects would encompass anything close to the breadth and diversity of CLS however, is absolutely not.

"Our doctor doesn't even really seem to want to treat it despite having diagnosed it (as we've heard is the case with many doctors in town), because doctors apparently can't be arsed to deal with or care about complicated problems that can't easily be resolved using check-lists and easily repeatable processes."

The symptoms you've mentioned that your wife reports are found in more than 10% of the American population and do not correlate Lyme endemic regions. I would hesitate to judge your wife’s physician’s caution, particularly in light of the harm that antibiotics cause and the fact that even the most specific tests also detect past infections that are completely gone and the absence of bacteria can’t be meaningfully treated with antibiotics.

1Incidentally, just went through and googled each of the dozen and a half I could think off of the top of my head and find in my library to look for an example of something that could be used and each of them were already associated with CLS on the internet.
posted by Blasdelb at 10:09 AM on September 7, 2012 [5 favorites]


saulgoodman: "just because it may be difficult to treat or predict the development of a disease or disorder, that doesn't make it any less an actual medical condition and more a "cultural" thing. "

All "diseases" are culturally mediated expressions of expected presentations and responses to biological processes. The changes happen to the body of the person. As doctors we interpret these changes and label them according to our training and biases. The act of labelling them one thing or another drives our treatment strategies. Of course, depending on their emergency and presentation, the cultural aspect may demonstrate more or less variability intra- and inter-cultures. But medicine is not a "one-size-fits-all" thing. Even within largely Anglo-dominated US medical systems, you can find dramatically different presentations and responses to common disease processes, such as COPD or CHF. You begin to see common patterns of best treatment approaches for different categories of patients, and you also see that for many of them, their culture plays a large role in templating their responses. You'd be amazed, for instance, at how much more often black Americans get labelled as "schizophrenic" while white and Asian Americans get labelled as "bipolar".

saulgoodman: "it was only due to the discovery of a potential blood marker for Lyme disease that it came under consideration as a diagnosis at all."

I have a suspicion that the marker you are talking about is an IgG immunoglobulin trace of previous acute burgdorferi or similar exposure (with presumably a low titre, and no follow-up measurement demonstrating a rapid increase in titre levels). But your description of this is too imprecise to be more certain. If you spend a lot of time in specific tick-infested regions then you have a high probability of being positive for this. But these markers are remarkably non-specific for active infection (just as, for instance, around 10% of the population in RMSF areas with show positive IgG without active infection). When I have a high index of suspicion for active Lyme process, there's a whole chain of markers that I test for with varying sensitivities and specificities to enhance my positive predictive value and rule in active disease while ruling out false positives (and false negatives). A single marker, especially something like IgG, is virtually useless for this. Much like many of the single "markers" (humoural or radiological) for depression mentioned up-thread.

saulgoodman: "Our doctor doesn't even really seem to want to treat it despite having diagnosed it (as we've heard is the case with many doctors in town), because doctors apparently can't be arsed to deal with or care about complicated problems that can't easily be resolved using check-lists and easily repeatable processes."

I am a doctor but I am not your doctor. I recognise you feel ill-served by yours. It is plausible that they are following their munificence/beneficence/justice professional obligations. You seem to be arguing against evidence-based medicine, which is a pretty important core principle for dealing with simple diseases with clear etiological agents. As I posted up-thread, there are many, many clinics that specialise in "Chronic Lyme" that are operated by people who feel less obligated to their munificence and that deploy a vast range of frankly dubious and sometimes potentially toxic therapies on people with "Chronic Lyme" not diagnosable by "check-lists and easily repeatable processes". I've treated too many people who've been attending these "Lyme Clinics" for years and are now presenting with heavy metal toxicity or c difficile colitis post-months-to-years of futile antibiotics to advise anyone to go that route.
posted by meehawl at 10:10 AM on September 7, 2012 [5 favorites]


You seem to be arguing against evidence-based medicine

Not at all. I'm arguing against the notion that a diagnosis always needs to be simple and clear cut in order to be a legitimate diagnosis. Medical science can't be done purely in a cookie-cutter, paint-by-the-number fashion. Sometimes real diseases and physiological conditions afflicting real humans are multi-factorial, have very slippery prognoses, and are otherwise messy to deal with, and yet, that doesn't alleviate the patient's need nor the physician's professional obligations to try to remedy the condition.

Actually, my wife's specialist is also concerned about heavy metals exposure as a possible issue in my wife's case. I can appreciate your skepticism and concern about medical charlatanism in this area, but my point is even in principle neither the existence of charlatanism in this area of medical practice nor the many acknowledged medical challenges facing physicians as they attempt to effectively treat real cases of long term Lyme disease alters the fundamental reality of the condition when it's correctly diagnosed. That's my point. Doctors sometimes seem to think that evidence based science means only treating the most obvious and simple to diagnosis conditions and otherwise just writing never-ending prescriptions to manage a patient's symptoms in perpetuity without even attempting to identify any underlying pathology.
posted by saulgoodman at 11:16 AM on September 7, 2012


I've treated too many people who've been attending these "Lyme Clinics" for years and are now presenting with heavy metal toxicity or c difficile colitis post-months-to-years of futile antibiotics to advise anyone to go that route.

That's all fine. I assume you might say the same about Chiropractic providers--but my point is about the fact that we know it's a real condition in some cases regardless. Those cases and patient needs don't disappear even in an ideal world where medical science can always be performed with strict arithmetic precision, or even if you have legitimate complaints about how your profession deals with cases in the gray area diagnostically speaking.

I can tell you as a patient, nothing annoys me worse than having a doctor confirm my physical symptoms, verify they are real, but then stubbornly refuse to attempt to determine a definitive diagnosis, opting rather to throw prescriptions at my symptoms one at a time whenever they occur or recur. This happens a lot nowadays, particularly with GPs who often just act completely clueless about how a patient's medical history might fit together to create a more complex picture and to help make a definitive diagnosis.
posted by saulgoodman at 11:29 AM on September 7, 2012


saulgoodman: "as a patient, nothing annoys me worse than having a doctor confirm my physical symptoms, verify they are real, but then stubbornly refuse to attempt to determine a definitive diagnosis, opting rather to throw prescriptions at my symptoms one at a time whenever they occur or recur"

I understand your frustration, but the reluctance to definitively diagnose often happens because physical symptoms are usually quite poorly specific endpoints for potentially dozens of sometimes quite dissimilar disease processes. Even very few physical exam signs are overly specific for single diseases. That skin colour? It could be a tan, or it could be haemochromatosis. That skin mark? Could be a typical mole, could be neurofibromatosis. That dizziness you're feeling? Could be dehydration, could be acoustic neuroma, could be vestibular neuritis, could be otitis. You're peeing too much at night? Could be prostate hypertophy, could be diabetes, could be prostatitis, could be bladder cancer, could be nephrotic disease, could be adrenal insufficiency, could be pituitary tumour. That rash on your kid's chest? Could be they had a virus a week ago. Could be they have measles. Could be they have meningitis. Could be they are developing toxic skin necrosis as a result of that antibiotic they got for a possible ear infection. Could be their spleen is busy chewing up their platelets. Could be they were just scratching a lot.

Usually a doc will tell you what they think the primary or maybe the secondary diagnosis is, but they are not telling you the short list of 5-15 other diseases they could also attribute to your particular constellation of symptoms. There's a triage and a minimal harm principle going on here: is this something that could injure or kill this person in the next few hours/days if I do not treat, or could the treatment I'm thinking of proposing cause more harm? Very frequently, the "gold standard" test that will produce a definitive diagnosis with >=90% positive predictive value is not available, or is too expensive, or will take 10 days to come back. And because many disease etiologies remain hazy at best, a lot of their identification rests in a definitive response to a curative agent (there's a saying that contains a great deal of wisdom that asthma is a disease characterised by a good response to asthma medications). That's why docs will try those first, because a good response to an asthma inhaler can rule out some of the nastier possible lung pathologies.

Or because there's a ill-defined link between chronic diseases of aging and inflammation, psychiatric states and cardiac-renal neurohumoural regulation, you treat definitively one one domain and ignore the rest, only to find the common endpoint physical symptoms and signs re-present again, later.

That's the attraction of single-agent explanations for complex presentations - if it was all just because of a single bug, or a single gene, or a single deficiency then treating it would be pretty easy. And because there are a few medical conditions that really are that simple, we all get sometimes get lulled into thinking that they could all work that way if we just figured out the secret. Or found the bug, or virus, or marker.

Same with depression, The idea that we're brought this on ourselves, that the fault lies not in the difficult-to-modify nature of our embodied selves but in our potentially modifiable cultural environment is alluring. The idea that, if we returned to some pre-modern state, that these afflictions would recede, that they are somehow a judgement and a critique of our culture, well, I don't believe that.
posted by meehawl at 6:31 PM on September 7, 2012 [8 favorites]


I have a question to whomever is currently mandated with defining "depression": may it be used to describe a non-pathological reaction to things being legitimately shitty?

That would be the APA - American Pscyhological Association and whatever version of the DSM they are using but I believe that all definitions exclude depressed affect due to things actually being shitty. Or at least they used to. I've lost track and wouldn't be terribly surprised if that critical diagnostic criteria were dropped due to things being, well, shitty.
posted by srboisvert at 1:56 PM on September 10, 2012


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