Professional Voices—Depression: A Drop to Diagnose

By Dr. Richard Juman 11/04/14

Professional Voices returns to The Fix—Today's Column: The onward march of the medicalization of psychiatry and addiction treatment.


What if I told you that a relatively inexpensive and well-researched intervention that produces none of the side effects common to most other forms of psychiatric treatment has always been woefully underutilized? Counterintuitive as it may seem, it is entirely possible to be diagnosed and treated for a psychiatric or addictive disorder without benefit of contact of any kind with a mental health provider—psychiatrist, psychologist, social worker or counselor. And one of the most potent tools available for producing long-term recovery from mental health conditions, individual psychotherapy—a highly evidence-based treatment that produces no deleterious side effects—probably won’t be part of the treatment protocol.

With the recent announcement of the development of a blood test designed to diagnose major depression, the ongoing movement towards the medicalization of psychiatry takes a big step forward. Although the blood test is not yet available, pending further study, it marks an important and dramatic turning point in the movement to diagnose and treat psychiatric and addictive disorders in a fashion similar to that rendered in the treatment of medical illness. 

The study’s authors note that the “objective, laboratory-based diagnostic tool," which actually tests for certain RNA markers that are correlated with depression, can improve care by improving the diagnosis of depression, especially of patients who may “underreport depression symptoms or inadequately characterize them."

They also hope that the test may be able to identify “predisposition to depression,” predict the type of treatment that a given patient would be most likely to benefit from, and then monitor the effectiveness of treatments rendered in a more objective way than the patient’s or clinician’s judgments. In short, the authors note, their study highlights the “potential of using blood as a proxy for the brain." 

The existence of a blood test for depression raises a number of fascinating questions. Obviously, the potential for overtreatment of presumed depression is an important factor to consider in contemplation of tests that diagnose the disorder, or merely the predisposition to it. But the larger issues that surround the announcement connect to various trends, both in healthcare and in the larger society, that have been percolating for years.

It is really a game-changer: the announcement of the development of a potential blood test for a psychiatric disorder that is currently diagnosed exclusively through patient self-reports and clinical observations. The study, which received funding from the National Institute of Mental Health, is a perfect response to a recent directive from NIMH that sent shock waves through the psychiatric community. The occasion was the publication of DSM-5, the recent revision of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders. As the psychiatric and medical community awaited the “Bible” of psychiatry, NIMH Director Thomas Insel seized that opportunity to bemoan that fact that the profession of psychiatry continues to rely on “symptom-based diagnosis." He went on to decry the “lack of validity” demonstrated by the diagnostic practices relied upon by psychiatry, comparing them unfavorably to other medical specialties that rely on “objective laboratory measures."

Commenting that “patients with mental disorders deserve better," he announced that NIMH would be moving its research “away from DSM categories” and towards “precision medicine” in which psychiatric diagnosis is informed by “genetics, imaging, cognitive science and other levels of information to lay the foundation for a new classification system."

Interestingly enough, around the same time, in a previous Professional Voices article, I noted that “psychiatric disorders don’t announce themselves with biological diagnostic data” and that “diagnosis depends, to a certain extent, upon the patient’s own ability to articulate their inner experience."

Can all of that be changing? Will there come a time in which psychiatric and addictive disorders are treated with the same arsenal of data-derived diagnostic tools and “precision” treatment protocols as cancer and heart disease? 

I don’t think so. There are too many aspects of mental health and addiction that are simply too complex and individualized to be well treated by a medication or a procedure, but decidedly still need to be addressed before recovery is possible. For one, substance use produces pleasure or relief of discomfort for many people, so ambivalence about stopping is usually part of the treatment puzzle in a way that just doesn’t come into play in the treatment of most other health issues. On top of that, most mental health and substance use problems exist on a continuum with “normal” human functioning. Many people enjoy a drink or a mood-altering experience from time to time, and most of us understand and experience anxiety, depression and many other mood states and ideations that, taken further, rise to the level of diagnosable mental disorders. This is in sharp contrast to many medical conditions—so while we all get a bit anxious from time to time it is not equally true that we all have a little bit of lung cancer on occasion. Individual human dynamics and existential issues are core elements of the addiction paradigm, with variable stages of motivation, disrupted family constellations, questions about anonymity, cultural influences, social networks, communication deficits, histories of trauma, spirituality, stigmatization, personal identity and role issues, co-occurring disorders and a host of socioeconomic problems all important aspects of treatment and recovery. I don’t envision a time in which targeted biomedical treatments will replace a thorough exploration of the individual complexities inherent in addictive disorders.

We are undoubtedly better off as a result of the development of a wide variety of tools available in the treatment of psychiatric and substance use disorders. Addiction is one of the most costly, painful and devastating problems faced by societies around the world, taking into account the impact of addiction on general health care, car accidents, suicide, overdose, workplace issues, the welfare system and the various components of the criminal justice system. More people in the U.S. now die from drug overdoses, mostly opioids, than from car accidents. 

Unfortunately, our understanding and treatment of addiction remains unsatisfactory, and so we must be vigilant in welcoming innovations that can contribute to improving our outcomes. Few would argue that we aren’t better off with buprenorphine, naltrexone and other pharmacologic and non-pharmacologic interventions as part of our available treatment protocols; that innovations like brain scanning and TMS won’t continue to develop and play a larger role; or even that there aren’t some pretty cool apps out there. But we need to make sure that, in an environment that continues to lean towards a view of addiction as a “brain disease," we don’t “lose sight of the individual into whose life the ‘brain illness’ has intruded." Drug use undoubtedly changes the brain, but attempting to reduce the challenge to something that can be diagnosed and treated in checklist fashion doesn’t resonate with the complexity of the people and families who walk into treatment.

More and more, the default treatment of mental health issues is a psychopharmacologic approach, with 70 percent of Americans taking at least one prescription medication, and around 25% of middle-aged women on an antidepressant. This mirrors general patterns of health care delivery that tend to focus on and treat presenting symptoms, as opposed to underlying issues. And it reflects a more general societal tendency to look for quick fixes rather than deeper solutions that are ultimately more satisfying. Yet the complexity of mental illness and addiction, the weave of trauma, history, biology and symptomatology that combine to create something new in each of our patients, must be recognized. The “illness” that presents itself is inextricably connected a litany of experience, both good and bad, nurturing and traumatic. For many patients, psychotherapy, particularly one that focuses on the patient’s history and uniqueness, and provides for that kind of an exploration in the context of a meaningful relationship with the therapist, is the best way to lasting recovery.

In contrast to other techniques, the gains and development engendered by psychotherapy benefit the patient long after the psychotherapy ends. That is because, in part, the psychotherapeutic relationship, and the focus on core issues that are ultimately the driving force behind patients’ symptoms, have a lasting benefit. And, good to note, good psychotherapy changes the brain, too.

Professional Voices, which returns to The Fix as a weekly feature after a hiatus of 18 months, is focused on the craft of psychotherapy and the challenges inherent in achieving great outcomes. It is written by and for professionals in the addiction and broader mental health treatment field. Each week will feature an article written by a clinician and that is designed to highlight a particular issue, concept, question or theoretical problem that providers are confronted by in actual clinical practice. We will explore societal trends that impact the field or highlight one of its challenges, policy issues that play out in our offices and forces in health care that play a role in our treatments. But mainly we will focus on understanding the “best practices” in clinical care that occur behind closed doors as they are operationalized in treatment. Our interest is in the small details and nuances of psychiatric and psychotherapeutic practice that highlight the work of the best practitioners in our fields.  An emphasis will be placed on reporting, describing and discussing actual clinical material and the psychotherapeutic interventions that highlight the individual nature of treatment. Psychotherapy is both an art and a science, and Professional Voices is designed to explore both aspects of the craft—Richard Juman, PsyD, Editor- Professional Voices on The Fix

[Richard Juman, a licensed clinical psychologist who has worked in the integrated health care arena for over 25 years providing direct clinical care, supervision, program development and administration across multiple settings, is also former President of the New York State Psychological Association.]

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Dr. Richard Juman is a licensed clinical psychologist who has worked in the field of addiction for over 25 years. He has treated hundreds of patients as a clinician and also provided supervision, program development and administration in a variety of settings including acute care hospitals, long term care facilities and outpatient chemical dependency centers. Find him on LinkedIn and Twitter.