How to Classify Misery

Medicine is an inexact science, which is rather a contradiction in terms, but in dealing with patients’ problems doctors can seldom be absolutely certain of anything. That is why medical students are taught to be wary of using the words ‘always’ and ‘never’. Indeed, general practice has been called the art of managing uncertainty because one often sees patients in the early stages of illness when the diagnosis may be unclear.

These comments refer particularly to physical disorders, but with patients whose problems are those of the mind, the so-called mental illnesses, caution to avoid dogmatism is especially needed.

Let us now consider the matter of depression. This is a symptom but the word is often used as a diagnosis, particularly by doctors who sit on committees and issue ‘guidelines’ for the benefit of psychiatrists and general practitioners.

People may be unhappy, miserable, melancholic, or depressed – even seriously so – for all sorts of reasons, but does this feeling ever arise in a vacuum? It seems not. That’s why the old classification of depression into ‘reactive’ (due to adverse life events) and ‘endogenous’ (no apparent cause in external life) has been abandoned and the diagnosis is simply ‘depression’, though it’s now classified into various types according to the perceived degree of severity.

Qualifying the absolutes
From 2009 until recently, depression in the UK has been categorised by psychiatrists as ‘mild to moderate’ and ‘moderate to severe’, but this left ambiguity over the definition of the moderate variety. In response to this difficulty, in a paper discussing recently updated NICE guidance, the lead author, a professor of primary care, no less, Tony Kendrick (beware of people who use diminutives in their first names in official pronouncements) commented approvingly on a new classification of depression as ‘less severe’ and ‘more severe’.

But now we have a difficulty. In normal speech one can talk of degrees of severity, for example: ‘Almost every matador is gored at least once a season in varying degrees of severity.’ This is because to be gored by a bull is always, at least potentially, a serious or severe matter.

But if ‘severe’ is used as the benchmark or standard descriptor, then to talk of ‘more severe’ or ‘less severe’ commits the grammatical solecism of qualifying an absolute. (Other examples are saying something is very unique or that something is becoming more and more ubiquitous.) Why not categorise depression simply as mild, moderate, or severe? I wrote, twice, to Professor Tony Kendrick putting forward this suggestion, but, alas, have not received the favour of a reply.

In America, according to the highly esteemed Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association, one can find the following scheme for degrees of depression:

Mild
Moderate
Moderately severe
Severe

In theory, these subdivisions could be made more precise, such as:

Mild
Mild to moderate
Moderate
Moderate to severe
Severe

Or it could even go like this:

Mild mild depression
Moderate mild depression
Severe mild depression

Mild moderate depression
Moderate moderate depression
Severe moderate depression

Mild severe depression
Moderate severe depression
Severe severe depression

This is, of course, exaggerated, but how do you classify degrees of depression, and should you even try?

The usual way it is done – would you believe it? – is by rating scales such as the Hamilton Rating Scale for Depression, devised in 1960, in which a list of leading questions is presented with suggested answers scored between 0 and 4. At the end of the exercise the scores are totted up and the higher the number the more depressed you are deemed to be!

According to the updated (June 2022) NICE guidance on depression, at least one sensible recommendation follows from the simplified classification: ‘Do not offer antidepressant medication as first-line treatment for less severe depression unless that is the person’s preference.’ Instead, various other treatment options are recommended, as follows:

Guided self help
Group cognitive behavioural therapy
Group behavioural activation
Individual cognitive behavioural therapy
Individual behavioural activation
Group exercise
Group mindfulness and meditation
Interpersonal psychotherapy
Counselling
Short-term psychodynamic psychotherapy

Such a rich choice!

Happy pills
As I mention in my blog on fake treatments for physical ailments, there used to be a wonderful advertisement for a household disinfectant called Domestos: ‘Kills all known germs.’

In the branch of medicine that deals with so-called disorders of the mind, something similar might be claimed for a class of drugs knows as SSRIs: cures all known mental illnesses – as well as a few physical ones. The following is a list of some of the situations for which these drugs can be used:

major depression, panic attacks, social anxiety disorder (otherwise known as shyness), bulimia (binge eating), obsessive-compulsive disorder, menopausal hot flushes, post-traumatic stress disorder, generalised anxiety disorder, agitation in dementia, premature ejaculation, premenstrual depression and bad moods, fibromyalgia, diabetic neuropathy, and ‘off-label’ in anorexia nervosa

SSRI means selective serotonin re-uptake inhibitor. Drugs of this class are claimed to increase the level or activity of a neurotransmitter in the brain called serotonin, and on the hypothesis that depression is caused by a deficiency of this chemical, we have a cure for depression! Unfortunately, however, no reliable objective evidence exists for this simplistic idea which was recently debunked in a review by Professor Joanna Moncrieff and colleagues.

The reaction to this paper, predictably, while not exactly howls of rage, did see some doctors struggling to retain their favoured theory of the cause of depression as a problem with serotonin or other kind of brain disorder. For example, a Professor David Curtis wrote: ‘It is very clear that people suffering from depressive illness do have some abnormality of brain function, even if we do not yet know what this is.’

This is the whole problem: we do not know what is going on in the brain of someone suffering from depression – or any other mental disorder for that matter. Indirectly observed changes in brain function with scans, etc., could be the result, rather than the cause, of depression or other mental disturbance.

Therefore, the concept of depression as a brain disease should be abandoned until proved otherwise.

Text © Gabriel Symonds

Photo credit: Jake Colling on Unsplash

Gabriel Symonds

Dr Gabriel Symonds is a British doctor living in Japan who is interested in helping smokers quit. He has developed a unique simple method without nicotine, drugs, hypnosis or gimmicks that he has used successfully with hundreds of smokers. Further information can be found at www.nicotinemonkey.com

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