09 avril 2009

Serious illness doesn't bother me for long because I am too inhospitable a host.


Les Joueurs de Cartes, Paul Cézanne, 1892.

The concept of ‘‘depression’’ has been broadened by targeting tendencies to shyness, social anxiety, and moodiness to justify medication treatment. The rise in the number of approved antidepressant drugs parallels the increase in the variations of depression categories and in the numbers of persons diagnosed as depressed. In theearly 1960s two tricyclic antidepressants (imipramine and amitriptyline) and three monoamine oxidase inhibitors (phenelzine, iproniazid, tranylcypromine) were marketed. In 2002, 17 antidepressants were in use in the USA, and several anticonvulsants, atypical antipsychotic agents, and lithium were described as having antidepressant properties. Additional agents are available in Europe and more are in
the pipeline.

In the 1990s prescriptions for antidepressant drugs increased severalfold in industrialized countries, mostly due to the prescribing of selective serotonin reuptake inhibitors. Intensive industry marketing has been argued as a primary factor in this increase. One example of this usage comes from an 8-month survey of 20000 French households. Three percent of persons over age 15 were taking an antidepressant during a 4-week assessment period. Although 62% were diagnosed as depressed by their treating physician, 90% of whom were non-specialists, 46% of those receiving a medication did not meet authorized indications and 25% had no
diagnosis.

The influence of industry is illustrated by the creation of an epidemic of ‘‘depression’’ in pursuit of the sale of the antidepressant Paxil in Japan. Until the late Twentieth Century, ‘‘depression’’ in Japan mostly referred to melancholia and treatment was characterized by lengthy hospital care. Aggressive industry marketing publicizing ‘‘mild depression’’ prompted the government Ministry of Health to create a committee to help educate the public about depression. Celebrities talked openlyabout their depression and in July 2004 the Imperial Household Agency acknowledged that the Crown Princess was being treated with antidepressants and counseling for depression and an adjustment disorder. ‘‘Depression’’ has gone from a bad word to a buzzword. An interesting aspect of the story is a quotation from the Harvard anthropologist Arthur Kleinman, co-editor of Culture and Depression:
I could take you all over the world, and you would have no difficulty recognizing severely depressed people in completely different settings. But mild depression is a totally different kettle of fish. It allows us to re-label as depression an enormous number of things.

Industry marketing practices also influence clinical practice by asserting that all antidepressants have similar efficacy for all types of depressive illnesses, and by claims that the newer, more expensive agents are safer and less likely to elicit sideffects. Encouraging the use of ‘‘the newest’’ agent, combinations of agents, and multiple sequential treatment trials for the widest market homogenizes diagnosis and treatment.

Although most patients with a diagnosis of major depression receive prescriptions for antidepressants, the decisions to treat and the antidepressant selected are not based on clinical features of the episode. The choices are based on characteristics of the patient (age, gender, race, educational level), the prescriber (generalist, specialist, geographic location of the practice), and health care insurance coverage (health management organization, non-insured).

The return of a concept of melancholia as a distinct entity within the depression ‘‘scheme of things’’ has treatment and scientific implications. Defining melancholia as a distinct entity encourages more focused treatments that differ from those prescribed for other forms of depressive disorders. Higher doses of the same treatments alone would not be adequate. An analogy is the diagnosis and treatment of cancer. The clinical features of breast and prostate cancer may suggest each to be a homogeneous condition, but staging and identifying specific cell lines affect treatment choice and outcome. Is a similar, individualized approach useful for depressive illness? Does empirical psychopathology delineate melancholia as a distinct form
or stage of depression?

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