28 June 2008

"The meaning we make does not always have etiologic implications"

I've always wondered about electroconvulsive therapy (ECT) and while I was looking for information on the topic, I ran across this website run by Dr. Ostroff at Yale. The site contains a link to an interesting essay called "Depression: An Overview with a Focus on ECT."

No, I am not interested in getting ECT, but I was surprised to learn that ECT is such an effective treatment for depression even though it has a reputation as "cruel" punishment or as a last resort. The author suggests that people should consider ECT earlier in their treatment.

But I'm digressing. The real reason I wanted to write the post was because I found the first page of the essay very interesting. It begins:
Depression is an illness and like any illness, it has an impact on biological, psychological and social functioning. Individuals may experience job difficulties, interpersonal difficulties and a variety of physical symptoms that may mimic other conditions. It is common for the patient to attribute the experience of depression to a life event, for example, the failure to get promoted or marital stress. It is human to make meaning of our experiences. It is important for clinicians to remember that the meaning we make does not always have etiologic implications.
I am reminded that coincidence does not imply causation. As a scientist, I am pretty careful to avoid that fallacy in my own work, but this quote cautions me that I can very well make the same fallacy in other areas like in the way I judge people.

As an example, the author tells the story of how he diagnosed a man with Hodgkin's disease. The man became convinced that he had "caught" Hodgkin's disease from walking outside on a damp, cold night because his first symptoms of Hodgkin's started around the same time.

The essay goes on to link the Hodgkin's case to patients with depression.
Like my Hodgkin's patient's experience of cold and coryza that felt like an ordinary flu, patients with depression often experience it as the outcome of immediate life events. Social and psychological events are closer to everyday human experience than neurotransmitter dysfunction in the central nervous system and are readily identified as causative agents.
I don't think the author is trying to say that depression is simply a chemical disorder that should be medicated at every opportunity. Here's my interpretation. Some people are genetically pre-disposed to depression. The other people were healthy individuals who suffered stressful events and the "bad" chemistry has persisted long after the inducing events. The external environment plays a big role, but it's not the entire story.

[Aside: I'm not sure if I believe this view completely. I used to think that everything is just "in your head," but I'm gradually coming around to the view that depression is a complex illness involving interactions between mind and body.]

Towards the end of the essay, the author discusses the implications of meaning and etiologic reasoning on the friends and family of the depressed individual.
Unfortunately, family members of the depressed individual struggle with a concept of illness that is unique to depression. Unlike illnesses that exist in the body in ways that give the appearance of being markedly discontinuous from the patient's emotional environment, such as rheumatoid arthritis or coronary artery disease, depression gives the impression of being related to, if not caused by the patient's emotional milieu...
... Since the depressed individual does not give the impression of being physically ill and a cardinal symptom of their illness is their mood, there is an almost irresistible tendency on the part of their loved ones to try and alleviate their mood. The family wants the depressed member to "snap out of it" or "cheer up" and will go to great lengths to achieve this end. Whereas the coronary patient's family won't let him mow the lawn or shovel snow, and the arthritic's family encourages them to avoid stressing their joints, the depressed patient's family will actively pressure them to change their mood...
... Because the cardinal symptoms of depression often involve emotion states, the family is posed with the problem of understand that emotional states can occur independent of internal or external environmental factors... The family of the depressed patient must understand that the depression is not a reaction to them, but rather a state that arises because of a physiologic problem that requires treatment.
The author notes that misguided family efforts can have significant real-world impact.
If there is a consensus that some external factor caused the depression, there is an overwhelming tendency to eliminate the external factor. I have repeatedly seen families and patients assign etiologic significance to school or work and decide that quitting the situation would eliminate the depression. A significant part of helping the family and patient recover is educating them to not make significant life decisions until recovery is well underway.
This discussion is very useful to me, since I have tried to help depressed people in the past and I will probably be trying to help someone in the future. I have to repeatedly remind myself "the meaning we make does not always have etiologic implications!"

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