Note: This blog post includes a case study for illustrative purposes. Various efforts have been pursued to adhere to ethical guidelines in using case material.
An article in the Wall Street Journal (May 28/29, 2016) woke me up to the latest book by Peter Kramer, M.D., perhaps best known for his 1994 book, Listening to Prozac. The new book, Ordinarily Well: The Case for Antidepressants (2016), both revisits some of the themes addressed in Listening to Prozac, and adds yet again to the defense of biological psychiatry by noting what is the author’s view: that after twenty years, the number of cases of advanced depression appears to have been greatly reduced by the use of anti-depressants. By the way, Dr. Kramer is not against psychotherapy, is for good evidence, and takes note of the fact that some recent studies and meta-studies have questioned the efficacy of anti-depressants.
Here’s a quote from the article:
“[When I was in training in the early 1970s] I saw men and women who suffered depression at the deepest level. On general hospital wards, such patients were not rare. Thin, stooped, immobile suffering souls, they had the classic depressive habitus, the attitude or physique of the disease. They spoke slowly and repetitively. They were hard to interview.”
In the article Dr. Kramer goes on to note that at the time, his clinical supervisors, his training, all directed him to apply psychotherapy as the first line of treatment. Only after a great deal of time and lack of response to psychotherapy were the medications of the day used. Concerning today’s psychiatric ‘landscape,’ he goes on to note that not only he, but a number of experts in depression who he interviewed in preparing his latest book, have noted the diminishing numbers of such immobilized melancholics in our current time. His thesis is that the broad prescribing of anti-depressants – on the whole, the Selective Serotonin Re-uptake Inhibitors (SSRI) – has greatly changed the epidemiology of the worst sort of depression.
After reading the article, I reflected on my encounters with such debilitated individuals and, accounting for only outpatient settings (I am not including day hospitalization treatment), I could only recall two.
Since I began working in an integrated care setting I’ve seen one of those two suffering individuals. That person reminded me that the isolating effect of such an advanced stage of the illness can baffle the sufferer and the helpers. As I reviewed the chart prior to meeting the patient, I saw that over five years each of five different primary care providers – all of them seeing the patient only one time – had noted the patient’s depression. Each had made an attempt to address the depressive illness in the provider’s own way: a prescription for a low dose of an SSRI or a referral to psychiatric care – or both. None had diagnosed Major Depression, Moderate (or Severe): the diagnosis was “Depression,” which coded as 311 under the DSM-IV – Depressive D/O Not Otherwise Specified. Not a diagnosis that usually shouts out the worst of depressive suffering.
Only the most recent encounter gave me some insight into the level of depression. The provider had used an evidence based practice – she had used the Personal Health Questionnaire (PHQ-9) – and the overall score was very elevated and there was also a positive for the suicidal ideation item (#9).
Nonetheless, I was not prepared for the extent of the patient’s retrograde depression: the monosyllabic replies, the latency of response, the effort needed on my part to draw out the simplest details, the blankness of expression, the downturned eyes, the entire lack of the gestural postures that add to our verbal expressions – no shrugs, no shaking the head “no,” just quietly sitting there. No spontaneous narrative. And, no, the patient could not recall feeling much better than this the past couple of years. No fidgeting or tearing up. Nothing.
It took a great deal of time, but I managed to draw out that this person took various responsibilities seriously. Those extended into the future and seemed sufficiently strong commitments that I could relieve myself of concern that the patient would attempt suicide (and there was no intent or plan). Other risk factors were nil or minimal. The patient agreed the medical provider and I could help the patient with a more comprehensive treatment plan (including a higher dosing of the SSRI and telephone coaching by this clinical social worker) and, no, having made it through so far without hospitalization, that option was declined. With this we began our attempt to revive the human being in our care.
Not fancy, but what we do is extend the effort, in each individual’s treatment, to achieve efficacy. The big picture is that our training should include a good grasp of the simple (and the cheap) to change the course of the worst illnesses.