Drugs, monopolies, gin and tonics, and electric guitars

Yeah, as the title suggests I'm a bit scattered today.  But I want, primarily, to post a quick follow-up to yesterday's post on the DSM  (was it yesterday? time seems unreal sometimes) and its mention of ketamine.

DSM kerfuffle, Part the First

This month the fifth edition of the of the Diagnostic and Statistical Manual of Mental Disorders (DSM) came out, and the release is generating more press than one might expect from the publication of a thick, dry tome that resides mostly in the offices of psychiatrists, psychologists, and insurance companies. Typically, given the media's weakness for controversy, the coverage tends to focus on the controversies surrounding the new DSM.

This piece at The Guardian covers some of the issues, in particular the objections of the British psychological establishment to the latest DSM. In anticipation of the publication of the new DSM the Division of Clinical Psychology (DCP),  part of the British Psychological Society, released a statement detailing the members' objections to the new DSM. I want to talk today about those objections. Tomorrow, time willing, I will address the concerns from within the psychiatric community, and discuss a maddening and ill-reasoned screed from a psychiatrist who worked on the previous edition of the DSM. For now, let's deal with the psychologists.

Neurobiology of Depression

Psychologists in England recently declared war on psychiatry and the "bio-medical model" of mental illness. I'll have more to say soon on this, as well as on the controversies around the new Diagnostic and Statistical Manual of Mental Disorders.  For now, however, I will just say the the psychologists are fighting a rear-guard retreat, though they don't yet seem aware that this is the case. The accumulating evidence that depression, in particular is indeed a medical—that is, a physiological—condition  is becoming overwhelming.

A recent development on this front: the work of Eric J. Nestler, MD, Ph, who is working on developing a model for human depression in mice.  A short video, in which he discusses his work:

"Months oozed by"

Several years ago one of my favorite things on the internet was the blog Hyperbole and a Half, by the wonderful Allie Brosh.  It was primarily the sensibility that attracted me: dark humor edging toward twisted, unflinching honesty, and all this wrapped around a generous core. By generous I mean: the most generous humor is often at one's own expense rather than at the expense of others. It was one of the most delightful things on the internet.

I lost track of Hyperbole as I descended deeper into my own depression. As it turns out,  Allie Brosh also lost track of Hyperbole as she descended into her own depression. She is back now, after a very long absence, and her latest and long-awaited post may be one of the better descriptions of depression we will ever see.

The post has too many important things to say, and I won't quote extensively. But she is quite good on the difficulty of dealing with people who don't understand your depression:

But people want to help. So they try harder to make you feel hopeful and positive about the situation. You explain it again, hoping they'll try a less hope-centric approach, but re-explaining your total inability to experience joy inevitably sounds kind of negative; like maybe you WANT to be depressed. The positivity starts coming out in a spray — a giant, desperate happiness sprinkler pointed directly at your face. And it keeps going like that until you're having this weird argument where you're trying to convince the person that you are far too hopeless for hope just so they'll give up on their optimism crusade and let you go back to feeling bored and lonely by yourself.

And the part that rings truest for me, given my own complicated relationship with the possibility/promise of death:

No, see,  I don't necessarily want to KILL myself. . . I just want to become dead somehow.

That is the thought I went to bed with every night for a year and half. I didn't want to kill  myself; I just wanted to never wake up again. Assuming I could get to sleep. . . .

I'm in a position now to appreciate some of the wonderful things in the world, and Hyperbole and a Half is certainly among them. Head on over and look around; her Best Of listing on the right should keep you out of trouble for a few hours. If you like velociraptors, pirates, sharks and boats, you will like what you find.

Depression: as real as diabetes

This is a very good (but perhaps longish--52 minutes) video with Robert Sapolsky addressing our current understanding of depression and the way various risk factors interact. He gives, a well, as quick summary of the origins of the "chemical imbalance" theory that was once so influential.

In brief, depression is the result of genes + stress; these two interact via brain chemistry.   What I especially appreciate is his understanding that admonishing us to "pull ourselves out of it" is useless. We don't need pep talks. We need treatment for a condition that is, as he says, as real as diabetes.  I would even go so far as to say that telling a depressed person to "pull yourself out of it" is needlessly cruel, despite there being at least one entire  book devoted to that sort of brow-beating and victim-blaming.

Sapolsky is an interesting scholar, having carved out a niche for himself between neurobiology and primatology! He is, in particular, an expert on stress, which plays a huge role in major depression.

Plus ça change??

If I were gay I think I would try to convince this guy to leave his wife for me:

Dear Prudence,
I’m a man in his mid-40s who has been happily married for 10 years. I particularly enjoy my wife’s dry, some would say sarcastic, sense of humor. Her wit not only attracted me to her as a partner, but it was one of the things that got me through a difficult time in my career, enabling me to see the humor in absurd and uncomfortable situations. About 18 months ago my wife’s mother passed away suddenly and my wife began seeing a counselor. After a few appointments, the counselor prescribed an antidepressant medication, Paxil, and my wife’s has been taking it ever since. As a result, my wife's personality has changed. Not dramatically, but enough so that she has become a glass-half-full, constantly cheerful type of person. I have no idea if this is common or perhaps if she was always depressed and her dark humor existed for her to deal with it. I'm glad she's happy now but I thought we were happy before and frankly, I miss my old wife! The new rainbows-and-sunshine person I'm living with gives me a headache and I find myself less attracted to her. I feel like a jerk and don't know what to do. Help!

—Dark Side

Comfort in, dump out

How not to say the wrong thing to someone in a crisis:

Draw a circle. This is the center ring. In it, put the name of the person at the center of the current trauma. . . . Now draw a larger circle around the first one. In that ring put the name of the person next closest to the trauma. . . .  Repeat the process as many times as you need to. In each larger ring put the next closest people. Parents and children before more distant relatives. Intimate friends in smaller rings, less intimate friends in larger ones. When you are done you have a Kvetching Order. . . .

Here are the rules. The person in the center ring can say anything she wants to anyone, anywhere. She can kvetch and complain and whine and moan and curse the heavens and say, "Life is unfair" and "Why me?" That's the one payoff for being in the center ring.

Everyone else can say those things too, but only to people in larger rings.

When you are talking to a person in a ring smaller than yours, someone closer to the center of the crisis, the goal is to help. Listening is often more helpful than talking. But if you're going to open your mouth, ask yourself if what you are about to say is likely to provide comfort and support. If it isn't, don't say it. Don't, for example, give advice. People who are suffering from trauma don't need advice. They need comfort and support. So say, "I'm sorry" or "This must really be hard for you" or "Can I bring you a pot roast?" Don't say, "You should hear what happened to me" or "Here's what I would do if I were you." And don't say, "This is really bringing me down."

If you want to scream or cry or complain, if you want to tell someone how shocked you are or how icky you feel, or whine about how it reminds you of all the terrible things that have happened to you lately, that's fine. It's a perfectly normal response. Just do it to someone in a bigger ring.
Comfort IN, dump OUT.

Read through to the last line.

From the LA Times