Depression Can Be Treated,
but It Takes Competence
AUG. 15, 2014
The New York Times
The Opinion Pages
Op-Ed Contributor
By KAY REDFIELD JAMISON
BALTIMORE — WHEN the American artist Ralph Barton killed himself
in 1931 he left behind a suicide note explaining why, in the midst of a
seemingly good and full life, he had chosen to die.
“Everyone who has known me and who hears of this,” he wrote, “will have a
different hypothesis to offer to explain why I did it.”
Most of the explanations, about problems in his life, would be completely wrong,
he predicted. “I have had few real difficulties,” he said, and “more than my
share of affection and appreciation.” Yet his work had become torture, and he
had become, he felt, a cause of unhappiness to others. “I have run from wife to
wife, from house to house, and from country to country, in a ridiculous effort
to escape from myself,” he wrote. The reason he gave for his suicide was a
lifelong “melancholia” worsening into “definite symptoms of manic-depressive
insanity.”
Barton was correct about the reactions of others. It is often easier to account
for a suicide by external causes like marital or work problems, physical
illness, financial stress or trouble with the law than it is to attribute it to
mental illness.
Certainly, stress is important and often interacts dangerously with depression.
But the most important risk factor for suicide is mental illness, especially
depression or bipolar disorder (also known as manic-depressive illness). When
depression is accompanied by alcohol or drug abuse, which it commonly is, the
risk of suicide increases perilously.
Suicidal depression involves a kind of pain and hopelessness that is impossible
to describe — and I have tried. I teach in psychiatry and have written about my
bipolar illness, but words struggle to do justice to it. How can you say what it
feels like to go from being someone who loves life to wishing only to die?
Suicidal depression is a state of cold, agitated horror and relentless despair.
The things that you most love in life leach away. Everything is an effort, all
day and throughout the night. There is no hope, no point, no nothing.
The burden you know yourself to be to others is intolerable. So, too, is the
agitation from the mania that may simmer within a depression. There is no way
out and an endless road ahead. When someone is in this state, suicide can seem a
bad choice but the only one.
It has been a long time since I have known suicidal depression. I am one of
millions who have been treated for depression and gotten well; I was lucky
enough to have a psychiatrist well versed in using lithium and knowledgeable
about my illness, and who was also an excellent psychotherapist.
This is not, unfortunately, everyone’s experience. Many different professionals
treat depression, including family practitioners, internists and gynecologists,
as well as psychiatrists, psychologists, nurses and social workers. This results
in wildly different levels of competence. Many who treat depression are not well
trained in the distinction among types of depression. There is no common
standard for education about diagnosis.
Distinguishing between bipolar depression and major depressive disorder, for
example, can be difficult, and mistakes are common. Misdiagnosis can be lethal.
Medications that work well for some forms of depression induce agitation in
others. We expect well-informed treatment for cancer or heart disease; it
matters no less for depression.
We know, for instance, that lithium greatly decreases the risk of suicide in
patients with mood disorders like bipolar illness, yet it is too often a drug of
last resort. We know, too, that medication combined with psychotherapy is
generally more effective for moderate to severe depression than either treatment
alone. Yet many clinicians continue to pitch their tents exclusively in either
the psychopharmacology or the psychotherapy camp. And we know that many people
who have suicidal depression will respond well to electroconvulsive therapy
(ECT), yet prejudice against the treatment, rather than science, holds sway in
many hospitals and clinical practices.
Severely depressed patients, and their family members when possible, should be
involved in discussions about suicide. Depression usually dulls the ability to
think and remember, so patients should be given written information about their
illness and treatment, and about symptoms of particular concern for suicide risk
— like agitation, sleeplessness and impulsiveness. Once a suicidally depressed
patient has recovered, it is valuable for the doctor, patient and family members
to discuss what was helpful in the treatment and what should be done if the
person becomes suicidal again.
People who are depressed are not always easy to be with, or to communicate with
— depression, irritability and hopelessness can be contagious — so making plans
when a patient is well is best. An advance directive that specifies wishes for
future treatment and legal arrangements can be helpful. I have one, which
specifies, for instance, that I consent to ECT if my doctor and my husband, who
is also a physician, think that is the best course of treatment.
Because I teach and write about depression and bipolar illness, I am often asked
what is the most important factor in treating bipolar disorder. My answer is
competence. Empathy is important, but competence is essential.
I was fortunate that my psychiatrist had both. It was a long trip back to life
after nearly dying from a suicide attempt, but he was with me, indeed ahead of
me, every slow step of the way.
Kay Redfield Jamison, a professor of psychiatry
at the Johns Hopkins School of
Medicine, is the author of “An Unquiet Mind: A Memoir of Moods and Madness” and
“Night Falls Fast: Understanding Suicide.”
A version of this op-ed appears in print on August 16, 2014, on page A19 of the
New York edition with the headline: To Know Suicide.
A FEW years
ago, I awoke at 2:30 a.m. to more than a “rapping, rapping at my chamber door.”
It was a full-force pounding of a body trying to break into my little house in
Washington, D.C. It was the sound and scenario that, as a single woman living
alone, I feared more than spiders in the house.
Because I was writing political speeches at the time, my BlackBerry slept on the
pillow beside me. I grabbed it and looked out my bedroom window at the stoop
below. There he was: tall, dark clothes, big. He backed up and then raced to the
door, pounding his body against it. Then he kicked at it the way actors take
boots to the heads of bad guys in the movies.
I dialed 911 and ran downstairs, my 100-pound Newfoundland with me.
I gave the dispatcher my address, let her know that I lived around the corner
from a police station and said, “Please hurry.” She heard the loud noise and
remained on the line with me.
I put the BlackBerry on speaker and pushed a heavy armchair toward the door. I
watched as the wood expanded with each pound. The white paint splintered some.
The deadbolt held at the top, but the bottom half of the door popped open,
letting in the steam heat from the summer night. I took that chair and slammed
it so the side pushed the door back in line with the frame. I held that chair
with everything my 5 foot 3 inches had. My dog sat right by me on the rug,
ready.
“The police are outside,” the dispatcher said.
I let go of the chair’s arms and thanked the woman for staying on the phone with
me. I answered the questions from the police and looked at the drunk man in the
back of the patrol car, kicking at the seats. When they left, I pushed the
couch, chair, coffee table and even a lamp in front of the locked door. I did
that every night for a week until a steel-gated security door was installed.
And then, I did more.
I considered buying a gun. The threat of violence rattles you like that. What
rolled round my head after that dark morning was: what if I hadn’t heard the
noise, what if it’s different next time? While I held that chair with all of my
strength, I wished that I had had a gun because if he had gotten in, then I
could have pointed it at him, maybe deterred him and if necessary pulled the
trigger.
So I looked at guns. Some had mother-of-pearl handles and looked like something
Mae West would use in a movie. Others were Glocks, shotguns and rifles. I had
gone as far as to dial the number of the Metropolitan Police Department’s
firearms registration division and begin the process. Then I stopped and put my
BlackBerry down.
I remembered who I am.
I am one of the millions of people in this country who live with depression. I
knew that in the gun registration form there would be a version of this
question: Have you ever voluntarily or involuntarily been committed to a
hospital? The answer is yes — voluntarily. But because my hospitalization was
years earlier and I wasn’t in treatment at the time, I could have gotten a gun.
My depression appeared for the first time in the late ’90s, right before I began
writing for politicians. It comes and goes like fog. Medicine can help. I have
my tricks to manage and get through it. Sometimes it sticks around for a day or
a week, and sometimes it stays away for a couple of years. But it never leads me
to sleep all day, cry and wear sweat pants like the people in the commercials.
You’d look at me and never know that sometimes my fight against the urge to die
is so tough the only way I get through it is second by second; I live by the
second hand.
According to the Centers for Disease Control and Prevention, 38,364 Americans
lost that fight in 2010 and committed suicide; 19,392 used a gun. No one ever
attempted to break down my door in the early morning again, but I had an episode
when my depression did come back in full force in the early winter of 2009,
after I made a career-ending decision and isolated myself too much; on a January
night in 2010; and again in May 2012, after testifying in the federal criminal
trial of John Edwards, my former boss. If I had purchased that gun and it had
been in my possession, I’m not sure I would have been able to resist and would
be here typing these words.
The other day, the president and the vice president announced their plans to
curb gun violence in the wake of the shooting in Newtown, Conn. I agree with all
of their measures. But I believe they should be bolder and stop walking on
eggshells about what to do with people like me and those not even close to being
like me but still labeled with the crazy term “mentally ill.” The executive
actions the president signed to increase access and treatment are all good,
although the experts will struggle with confidentiality and privacy issues.
But since most people like me are more likely to harm ourselves than to turn
into mass-murdering monsters, our leaders should do more to keep us safe from
ourselves.
Please take away my Second Amendment right. Do more to help us protect ourselves
because what’s most likely to wake me in the early hours isn’t a man’s body
slamming at my door but depression, that raven, tapping, rapping, banging for
relief.
I have a better chance of surviving if I never have the option of being able to
pull the trigger.
Do
antidepressants work?
Doctors and patients respond to a letter on Wednesday
that
questioned their liberal use.
THE LETTER
To the Editor:
“In Defense of Antidepressants,” by Peter D. Kramer (Sunday Review, July 10),
reflects a high-stakes battle involving pharmaceutical companies, health care
providers and patients.
Billions in profits are at stake for the drug industry, which has sometimes
suppressed negative data about antidepressants. Doctors have financial
incentives to treat depression pharmacologically because quick medication
evaluations are more profitable than more time-consuming psychotherapeutic
treatment. And then there are some practitioners wedded to psychological
treatments who are eager to debunk the supposed superiority of pharmacologic
treatment in part to expand their own practices.
While this battle rages, we must not lose sight of the patient. The arguments
are complex, and a clear answer to whether antidepressants will work for an
individual patient is often not easy to find. The data used and analyzed in the
various studies — highly sophisticated and often not comparable — are not easy
for patients or even practitioners to decipher.
What is a patient to do?
I would suggest to those suffering from depression that they find a provider who
is willing to listen, asks probing questions about how well they are responding,
spends an appropriate amount of time, is willing to switch course if they don’t
improve, and is even willing to consult with another expert colleague.
Fortunately many patients will improve over time.
WARREN R. PROCCI
Pasadena, Calif., July 12, 2011
The writer is president of the American Psychoanalytic Association and a
clinical professor of psychiatry at David Geffen School of Medicine, U.C.L.A.
READERS REACT
As a professional ethicist, I share Dr. Procci’s concerns about the
medical-pharmaceutical complex and how the obsession with ever-greater profits
can hinder, not promote, ethically intelligent patient care.
But as someone who has been using antidepressants successfully for many years, I
can say from experience that some of that concern is misplaced. My life is
richer and infinitely more satisfying because of this medication. I offer my
profound gratitude to the dedicated researchers and conscientious clinicians who
have made this possible.
BRUCE WEINSTEIN
New York, July 13, 2011
Dr. Procci is right that there is a continuing high-stakes battle over the use
of psychiatric drugs, but it is more one-sided than he suggests. These drugs are
greatly overused, mainly because of the pharmaceutical industry’s influence on
the psychiatric profession.
Many have devastating side effects, especially in children and when used long
term. Studies generally show that the benefits are small.
Contrary to the arguments of Dr. Kramer, many sound clinical trials have failed
to find antidepressants effective at all in mild to moderate depression.
Anecdotes of effectiveness are no substitute for clinical trials, since they
can’t take into account the placebo effect or how often a drug is ineffective or
harmful.
Despite the risks and uncertain benefits, the number of Americans taking
psychiatric drugs is soaring, and the heavy reliance on drugs diverts resources
from efforts to find better methods of treatment.
Mental illness is a serious problem, but in the absence of sound evidence, we
should be skeptical about all treatment claims — particularly those promoted by
the pharmaceutical industry.
MARCIA ANGELL
Cambridge, Mass., July 13, 2011
The writer is a senior lecturer in social medicine at Harvard Medical School and
former editor in chief of The New England Journal of Medicine. She is the author
of two recent articles on psychiatric drugs in The New York Review of Books.
Dr. Procci’s advice is for the depressed patient to identify the ethical
caregiver. That is not so simple in a medical care system that denies access,
limits complex consultation, and rewards technology and procedures.
Questions about the efficacy of antidepressants are but one chapter in a larger
moral and social tale without clear answers. Except perhaps one: The medical
system we have today plainly does not work. What to do next is far more
challenging than listening to Prozac.
RONNIE S. STANGLER
Seattle, July 13, 2011
The writer is a professor of psychiatry, University of Washington in Seattle.
I agree with Dr. Procci’s suggestion for the type of doctor whom patients should
seek, but good luck finding one who practices this philosophy of treatment and
is willing to spend so much time with each patient. They do exist, but they’re
few and far between.
Then, try to tell an insurance company that longer sessions are more cost
effective in the long run and conducive to overall health than the 15-minute
sessions with the script writers who ask how you feel on a 1-to-10 scale, then
prescribe accordingly. After that, make up the difference between the insurance
company’s paltry “reasonable and customary” fee schedule and the actual fee.
KIPPI FAGERLUND
Derwood, Md., July 14, 2011
As a practicing psychiatrist, I have found antidepressants to be extremely
effective. However, there are two main obstacles to finding an optimal
medication regimen for patients: Each patient’s brain circuitry is unique, so
what works well for one person may not necessarily do so for another; the
severity of mental illness lies on a continuum, influenced by genes, life
experiences and personality.
It is extraordinarily difficult, if not impossible, to design a clinical study
that can truly take into account all of these differences. Thus, we are left
with studies whose results often conflict.
Perhaps in the distant future, we will have a machine that will analyze each
patient’s brain and create a customized medication regimen, but until then,
clinicians are left with the reality that prescribing medication for depression
remains much more of an art than a science.
LORI SIMON
New York, July 13, 2011
Without antidepressant drugs, there would be no psychiatry. Psychiatrists for
more than 20 years, since serotonin-enhancing drugs were introduced, have, for
financial reasons, elected to become psychopharmacologists, and many have given
up traditional psychotherapy. Instead, they frequently shunt people who require
talking therapy to psychologists.
If as suggested by randomized, controlled studies, the placebo response
approaches that of the drugs, the individual psychiatrist really has no way to
tell whether patients are better because of the drug or simply because they have
been prescribed a drug.
If these drugs were taken away from psychiatrists, or if psychologists could
legally prescribe these drugs, psychiatry would perish.
IVAN R. DRESSNER
Hopatcong, N.J., July 13, 2011
The writer is a clinical associate professor of neurosciences, University of
Medicine and Dentistry of New Jersey.
Dr. Procci’s suggestion that people seek help from clinicians who are willing to
listen to and work with them is entirely reasonable — as far as it goes. But it
does not capture a seismic shift that has been occurring in mental health care.
While the media focus has been on what the professional or the pill is going to
do for the suffering person, the emerging recovery movement has made clear what
individuals can and must do to help themselves — individually and collectively —
and how central self-help and mutual aid are to recovery.
When it comes to dealing with psychiatric challenges, there are no magic doctors
or magic pills. There is no effortless recovery.
With this in mind, I would add the following to Dr. Procci’s advice: Seek other
people in recovery and recovery-oriented clinicians who can help support you
while you learn how to do the work of recovery on your own.
KEN THOMPSON
Pittsburgh, July 13, 2011
The writer is an associate professor of psychiatry at the University of
Pittsburgh.
When my patients respond to treatment for major depression, as a psychiatrist I
am often not sure how much it is from the medication and how much from talking
to an empathic listener. For depressions accompanied by agitation and psychosis,
it is clear that medication, as part of the treatment regimen, is helpful and
essential.
The type of provider that Dr. Procci suggests that patients seek should be a
psychiatrist (at least for the initial evaluation) who is adept at both
psychotherapy and psychopharmacology. If the depression is mild, I agree with
Dr. Kramer that medication should be used sparingly and as a second line.
JEFFREY B. FREEDMAN
New York, July 13, 2011
The writer is a former president of the New York County Branch of the American
Psychiatric Association.
I’m sure psychoanalysis is a good option for some depressives, those who can
afford it. But taking a generic form of Celexa for $4 a month gives me a
fighting chance to face my demons on my own, with some help from my friends.
DEBORAH FINK
Ames, Iowa, July 13, 2011
THE WRITER RESPONDS
I tend to agree with the skeptics who question the efficacy of antidepressants
and condemn their prolific use.
Marcia Angell has long highlighted the ways in which the pharmaceutical
industry, the psychiatric profession and academia have at times colluded to
erode appropriate boundaries.
Another problem is the insurers’ control over access to practitioners and the
kind of care they can render.
Kippi Fagerlund poignantly exemplifies how third-party payers relentlessly limit
treatment options to those seen as quickly “cost effective,” such as brief
medication management visits rather than psychotherapeutic approaches.
Ronnie Stangler rightly sees this as a huge obstacle to quality care. I agree.
The hot crucible of the psychiatrist’s office is far removed from the cool
sterility of research labs and academic offices. Patients in real-world settings
often do find antidepressants singularly helpful. This doesn’t exonerate the
excessive claims of the pharmaceutical industry. It only demonstrates the need
for the individual practitioner to maintain his or her focus on the patient’s
needs.
The bottom line: We doctors must push our professional organizations to
disseminate only the highest quality data, free from conflicts of interest, to
assist us in clinical decision making, and we must seek relief from obsessive
cost-control management of patient care.
And those suffering from depression should insist on being given access to all
available treatments and true information about their efficacy. It is
unconscionable for patients to be held hostage to one form of treatment
supported by such weak data.
June 17, 2009
The New York Times
By BENEDICT CAREY
One of the most celebrated findings in modern psychiatry — that a single gene
helps determine one’s risk of depression in response to a divorce, a lost job or
another serious reversal — has not held up to scientific scrutiny, researchers
reported Tuesday.
The original finding, published in 2003, created a sensation among scientists
and the public because it offered the first specific, plausible explanation of
why some people bounce back after a stressful life event while others plunge
into lasting despair.
The new report, by several of the most prominent researchers in the field, does
not imply that interactions between genes and life experience are trivial; they
are almost certainly fundamental, experts agree.
But it does suggest that nailing down those factors in a precise way is far more
difficult than scientists believed even a few years ago, and that the original
finding could have been due to chance. The new report is likely to inflame a
debate over the direction of the field itself, which has found that the genetics
of illnesses like schizophrenia and bipolar disorder remain elusive.
“This gene/life experience paradigm has been very influential in psychiatry,
both in the studies people have done and the way data has been interpreted,”
said Dr. Kenneth S. Kendler, a professor of psychiatry and human genetics at
Virginia Commonwealth University, “and I think this paper really takes the wind
out of its sails.”
Others said the new analysis was unjustifiably dismissive. “What is needed is
not less research into gene-environment interaction,” Avshalom Caspi, a
neuroscientist at Duke University and lead author of the original paper, wrote
in an e-mail message, “but more research of better quality.”
The original study was so compelling because it explained how nature and nurture
could collude to produce a complex mood problem. It followed 847 people from
birth to age 26 and found that those most likely to sink into depression after a
stressful event — job loss, sexual abuse, bankruptcy — had a particular variant
of a gene involved in the regulation of serotonin, a brain messenger that
affects mood. Those in the study with another variant of the gene were
significantly more resilient.
“I think what happened is that people who’d been working in this field for so
long were desperate to have any solid finding,” Kathleen R. Merikangas, chief of
the genetic epidemiology research branch of the National Institute of Mental
Health and senior author of the new analysis, said in a phone interview. “It was
exciting, and some people thought it was the finding in psychiatry, a major
advance.”
The excitement spread quickly. Newspapers and magazines reported the finding.
Columnists, commentators and op-ed writers emphasized its importance. The study
provided some despairing patients with comfort, and an excuse — “Well, it is in
my genes.” It reassured some doctors that they were medicating an organic
disorder, and stirred interest in genetic testing for depression risk.
Since then, researchers have tried to replicate the gene finding in more than a
dozen studies. Some found similar results; others did not. In the new study,
being published Wednesday in The Journal of the American Medical Association,
Neil Risch of the University of California, San Francisco, and Dr. Merikangas
led a coalition of researchers who identified 14 studies that gathered the same
kinds of data as the original study. The authors reanalyzed the data and found
“no evidence of an association between the serotonin gene and the risk of
depression,” no matter what people’s life experience was, Dr. Merikangas said.
By contrast, she said, a major stressful event, like divorce, in itself raised
the risk of depression by 40 percent.
The authors conclude that the widespread acceptance of the original findings was
premature, writing that “it is critical that health practitioners and scientists
in other disciplines recognize the importance of replication of such findings
before they can serve as valid indicators of disease risk” or otherwise change
practice.
Dr. Caspi and other psychiatric researchers said it would be equally premature
to abandon research into gene-environment interaction, when brain imaging and
other kinds of evidence have linked the serotonin gene to stress sensitivity.
“This is an excellent review paper, no one is questioning that,” said Myrna
Weissman, a professor of epidemiology and psychiatry at Columbia. “But it
ignored extensive evidence from humans and animals linking excessive sensitivity
to stress” to the serotonin gene.
Dr. Merikangas said she and her co-authors deliberately confined themselves to
studies that could be directly compared to the original. “We were looking for
replication,” she said.
