Comfortably Numb-er

I noticed while writing this, that the word style="font-style: italic;">numb, if modified
by adding the suffix -er,
becomes an entirely different word.   style="font-style: italic;">Number does not
convey the meaning of more
numb.



According to Answers.com, number
is a adjective, with the root numb.
 The thing is, it only works if spoken; if written, it is
ambiguous.  Ambiguity can be useful, but usually it is just a
nuisance.  



Anyway.   href="http://www.charlesbarberwriting.com/pages/author.html"
rel="tag">Charles Barber wrote a book, href="http://www.charlesbarberwriting.com/pages/comfortablynumb/"> style="font-style: italic;">Comfortably Numb: How Psychiatry
is Medicating a Nation.  Now he has
written an article in the Washington Post: style="font-style: italic;"
href="http://www.washingtonpost.com/wp-dyn/content/article/2008/02/08/AR2008020803272.html">Healing
a Troubled Mind Takes More Than a Pill.



My first thought was "Must be yet another pointless anti-psychiatry
screed. (YAPAPS)"  In fact, I almost skipped it.

  

Feeling depressed? No problem, pop a pill.



That's what more and more Americans are doing these days to quell what
ails their troubled souls. The use of antidepressants in the United
States has exploded in the past couple of decades, and drugs such as
Prozac, Paxil and Zoloft, which didn't even exist 20 years ago, are
household names, almost household staples.



And why not? The television ads make it seem so easy: An agonized man
or woman stares listlessly into space or slumps on a bed or couch,
holding their head in their hands. Then they take a pill and suddenly
morph into a happily engaged and joyous being, back on the job or
walking in a park, awash in sunshine, surrounded by grandchildren, a
golden retriever nipping at their heels, while lush music plays in the
background...

If fact, I agree with a lot of what he says.  But I think that
some context would be helpful in understanding the points that he
makes.  

For example, he implies that drug advertising is inappropriate.
 I happen to agree.  While he is not correct that the
drugs did not even exist 20 years ago, it is true that it is a recent
phenomenon for them to be so pervasive.  But that, by itself,
means nothing.  MP3 players are fairly new, also, but nobody
gets worked up about their popularity.  



There really is nothing to be gained by nitpicking, though.
 What is important is his main point:

In 2006, an astonishing 227 million prescriptions for
antidepressants
were dispensed in the United States -- up 30 million from 2002.
Altogether the United States accounts for about two-thirds of the
global market for antidepressants. Other proven and practical
approaches to managing milder forms of depression, such as diet
changes, exercise or cognitive behavioral therapy, haven't gotten the
attention they deserve in our high-tech zeal for the drugs.



Antidepressants can be highly effective, particularly for the more
severe forms of depression. But when you speak to people with severe
mental illness who have gotten better, you learn about the reality of
the recovery process, which is rarely about a pill -- even if that pill
is effective.

He goes off in a direction I don't like.  He discussed the
medical model, dismissing it as incomplete.  





Such criticisms of models generally are pointless.  Models are
always incomplete.  If a model were 100% faithful to that
which it models, it would not be a model:  it would be the
thing itself.  The whole point of a model is to have a
simplified version that conveys some essential aspect of the thing
itself.



The rel="tag">medical model typically is contrasted
with the href="http://en.wikipedia.org/wiki/Biopsychosocial_model">biopsychosocial
model.  That is the context in which Barber's
article makes the most sense.  



What he is saying is that some people who are treated for depression do
not receive treatment that is sufficiently comprehensive.  He
also is saying that the medication treatment is what tends to get all
the glamor and the glory.  That is also true.
 Psychosocial rehabilitation often is overlooked.
 All of those things are true, and they all are problems.
 However, the problem is not that the model is bad; the
problem is that the medical model sometimes is used inappropriately, to
the exclusion of the biopsychosocial model.  





The biopsychosocial model is not new.  In 1980, a psychiatrist
named George Engel exhorted medical schools and residency programs to
make more use of it.  This was published in the American
Journal of Psychiatry.  The article now is openly
accessible ( href="http://ajp.psychiatryonline.org/cgi/content/abstract/137/5/535">abstract,
PDF).
 Engel's concept of the biopsychosocial model was not new even
in 1980.  He had published an influential article on the topic
in 1977 ( href="http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMed&db=pubmed&cmd=Search&term=%22Science%20%28New%20York%2C%20N.Y.%29%22%5BJour%5D%20AND%20196%5Bvolume%5D%20AND%20129%5Bpage%5D">The
need for a new medical model: a challenge for biomedicine)
The idea has been revisited several times.  For example see href="http://www.annfammed.org/cgi/content/full/2/6/576#R5">this
retrospective in the Annals of Family Medicine.




To further add to the context, it is important to understand the
distinctions between the concepts of response, remission,
recovery, relapse, and recurrence (the 5 Rs).  I'm
not going to belabor this; it is all explained nicely in a href="http://www.nature.com/npp/journal/v31/n9/full/1301131a.html">American
College of Neuropsychopharmacology Task Force Report.
 The basic idea is that patients are said to have responded to
treatment if the symptoms have been reduced by 50%.  Remission
means that any symptoms that remain are present at a level that is
typical of persons in the general nonpatient population.  The
concept of recovery is not as cleanly defined.  One
definition, the one I prefer, is mentioned in the Task Force article:

Another concept of recovery is the successful
integration of a mental disorder into the consumer's life and involves
rebuilding meaningful lives, hope and optimism, self-empowerment,
effective collaboration and direction in clinical care decisions, and
decreasing dependence on the mental health system.

The term consumer, as used here, is chosen in an
attempt to find an empowering, nonstigmatizing substitute for patient.
 



So, getting back to Barber's article, we see:

When you interview patients about how they got
better, they hardly ever cite Prozac or Zyprexa
or lithium. For that matter, they rarely cite a particular doctor or
therapist or treatment program. Rather, they talk about a person who
was kind to them when they were really down; they talk about the child
they wanted to be a good parent to; they talk about God and
spirituality; they talk about something that brought them pleasure even
when they were cloaked in pain.

In the treatment of depression, it is common for about 30% of persons
to attain remission after 6-8 weeks of treatment
with medication.  Often, they attain response but not
remission, much less recovery.  Medical research tends to
focus on response and remission.  There is some, but not
enough, attention given to the attainment of recovery.  



This point seems obvious, but it is important nonetheless: medication
alone is unlikely to bring about recovery, especially after a prolonged
period of severe symptoms.  On the other hand, it is pretty
clear that a person will have to attain response before there can be
any progress to recovery.  Should we wonder which is more
important: response or recovery?  Clearly, recovery is always
the goal, whereas response is a necessary but insufficient milestone.
 



The blind application of the medical model will lead to the assumption
that is essential fine, except for the disease.  Take away the
disease, the person is fine again, and the health care system's job is
done.  That notion is a fair approximation of the truth, for
some illnesses.  Acute sinusitis and bronchitis are examples.
 (But for most persons with those illnesses, they would get
better on their own, without antibiotics or any sort of medical
treatment.)    



Barber's article, then, serves as a good reminder of these points: the
biopsychosocial model, and the 5 Rs.  What makes the article
effective, though, is not the treatment of theoretical concepts.
 That has been done amply.  What makes the article
effective is the way Barber highlights the concepts with human-interest
details:

The critical moment in my own recovery was my
decision -- very unpopular at the time -- to work full-time in a group
home for people with severe developmental disabilities, young men my
age who could not talk. Having been given all the choices, I gravitated
toward a place where there were few options. But I intuitively sensed
that I would find a new path there. Indeed, I found I was good at the
work, and it was therapeutic for me to "get out of my own head" and
serve others.



Ultimately I returned to college, went to graduate school and have
spent my career writing about and working with people with serious
mental illness in shelters, prisons and halfway houses. Both my work
with my clients and my own prolonged and difficult yet ultimately
rewarding journey have taught me lessons about what's involved in
overcoming true psychological distress -- and what isn't.

In this post, I've linked to several articles that discuss concepts
that are central to the effective treatment of mental illness.
 But articles such as those are not comprehensible without the
sorts of stories and experiences that Barber includes in his article.