Depression

Diagnosing Depression In The Wake Of Robin Williams’ Suicide

The Pros and Cons of Diagnosing

Posted August 30, 2014

The importance of diagnosing depression has been highlighted in the wake of Robin Williams’ suicide. While most discussions, articles, and media outlets focus on the value of diagnosis, there are two sides when considering mental health diagnosis – one that sees it as “the answer” and another that questions the mainstream paradigm in terms of its usefulness, effectiveness, and the harm it may cause. Both of these sides are critical; both sides together create a whole picture. Here are the pros and cons of diagnosis:

Pros: The Light Side of Mental Health Diagnosis

Being able to name and diagnose symptoms may be the first step in healing; for some, it can save their lives. From the perspective of mainstream psychology and psychiatry, as with most medicine, there is no possibility of proper treatment and symptom relief without categorizing symptoms in a way that helps understand the underlying pathology and that allows clinical research to determine the effectiveness of various treatments.

Several individuals I spoke with highlighted the value of diagnosis. One said, “For me a formal diagnosis was a godsend really. It provided an explanation for what was happening to me and opened up opportunities for treatment and medication that are just not available without a psychological diagnosis.” Another said, “For me, getting diagnosed with and medicated for depression and anxiety probably saved my life.” Clearly, the value of diagnosis is not to be taken lightly.

Diagnosis can protect people from ignorant criticism, projection, and shame. According to Professor Richard Bentall, Ph.D., and Nick Craddock, M.D. a diagnosis “can reduce stigma by explicitly acknowledging the presence of illness (and, thus, that the feelings or behavior cannot be dismissed as character weakness or bloody-mindedness).”

In the words of one woman I spoke with, “It let people know that I was not lazy, stupid, bizarre, etc.” A diagnosis can be akin to saying “There is nothing wrong with you as a person morally or intellectually. I see you’re not simply resisting acting functionally or appropriately.”

Diagnosis can legitimize peoples’ symptoms, pain, and suffering. When people “know what is wrong” by having a diagnosis, they often experience significant relief, understanding, and compassion for themselves. A diagnosis removes the mystery of their symptoms, encourages them to take themselves seriously, and lets them know that they are not alone – others suffer similarly.

In the words of one person I spoke with, “Diagnosis in a way legitimized my struggles. It was a real thing!” Another person said, “Finally, I understood so many of my behaviors that have always made me feel misunderstood my whole life.” A third person told me, that her brother’s diagnosis was freeing “because of identifying that there are a lot of other people like him: weird, awesome and sometimes hurting, too.”

Cons: The Shadow Side of Mental Health Diagnosis

Labels marginalize people, treating them like they are broken or not normal. In addition, these labels get internalized in a way that injures the way people see themselves over time. Diagnosis creates labels that can stigmatize individuals. Stigmas are hurtful stereotypes causing people to be viewed as different from others in ways that are undesirable and shameful, reducing them from a whole and worthy person to a tainted, discounted one.” [1] Research tells us that these stigmas also lead to separation, status loss, and discrimination. [2] Specifically, being labeled “depressed” causes some people to think we are unreliable, unstable, untrustworthy, and even dangerous. Further, research by the National Institute of Health found that diagnostic labels get internalized leading people to see themselves in these same negative ways.

Making matters worse, Jerry Kennard, Ph.D. warns that, “The label itself becomes self-fulfilling and can bias the way clinicians and the public see the person. Ordinary aches and pains, grumbles or personal setbacks, may seen as symptoms of the disease. Even the patient can fall into the trap of behaving in ways they think are expected of them.”

Diagnosing individuals creates an “identified patient” to be treated and fixed dismissing the significant family, group, and cultural conditions that are also responsible for the symptoms and require treatment. Most healing paradigms focus on diagnosing, understanding, and treating individuals. However, while some individuals suffer certain symptoms more than others and need more care, this approach can dismiss the role played by other people, communities, or cultures. For example, individuals who are more sensitive to being affected by abuse, toxic atmospheres, or hurtful cultural biases are more readily viewed and labeled as sick while the families, organizations, or cultures they are reacting to are more likely to be viewed as healthy and remain untreated.

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Salvador Minuchin, founder of Family Systems therapy, enlightened a generation of therapists finding that the children he saw were symptomatic not because they were sick but because they were more apt to express their family's problems. While those children were the "identified patients" – seen as sick and sent for treatment – actually it was the whole family that was ill. [3] Identifying one person as the "patient" not only marginalizes them, causing them to feel responsible for the family's troubles, but it ignores a more complete understanding of the illness and how to treat it.

Similarly, some indigenous cultures consider the individual who expresses a symptom to have a special gift or sensitivity for expressing something that belongs to the tribe. From this perspective, folks who suffer mental illness are bearers of information and even healing for their families as well as for the larger culture and the planet. From this point of view, we are responsible for treating those who bear these symptoms as teachers, healers, and messengers of the early warning signs about a collective illnesses requiring treatment in all of us. This could lead us to not only think "How could we have helped them? What were they hiding? What was wrong with them?” but also ask these questions of ourselves.

African shaman Malidoma Somé, Ph.D. puts it this way: “What those in the West view as mental illness, the Dagara people regard as “good news from the other world.” The person going through the crisis has been chosen as a medium for a message to the community that needs to be communicated from the spirit realm.”

Diagnosis supports a “fix” mentality that ignores deeper processes in the background, a process that often leads to the discovery of gifts, life changes, and the uniqueness of the person. When we look at a person as if their symptoms indicate that something is wrong with them we can neglect to see what is “right” or intelligent about their symptoms.For example,Somé noted that a person was sent to a mental institute for “nervous depression” was exhibiting the same symptoms he saw in his village. What struck Dr. Somé was that the attention given to such symptoms was based on pathology, on the idea that the condition is something that needs to stop. This was in complete opposition to the way his culture views such a situation. As he looked around the stark ward at the patients, some in straitjackets, some zoned out on medications, others screaming, he observed to himself, “So this is how the healers who are attempting to be born are treated in this culture. What a loss!”

Not all depressions are the same; treating them as such could be ineffective at best or harmful at worst. While the label “depression” creates the sense that depression is one kind of difficulty requiring anti-depressants as the treatment, not all depressions are the same and thus, "anti-depressing" may not be the most effective form of treatment. For example, many people describe depression as a feeling or energy of going down. That person may slump in their chair, their tone of voice my trail off, their head my hang a bit downward or to one side or the other. In these cases, it is sometimes helpful to support a person to “go down” – relax further, surrender, let go, or even lie down and close their eyes. When they do this, some people find deeper feelings that they were unaware of (e.g., resentments, a sense of floating and ease, tiredness for living the life they are living) or values that are being unlived as they try to cope with a more “normal” life. Treating this kind of person as if they need lifting up or anti-depressing, can miss the meaning behind the depression and the direction they need to go in order to get sustainable relief. On the other hand, some people describe depression with anger in their voice. They sound pissed off at themselves and their lack of energy. In some cases these people are putting themselves down or are being put down by others, a cultural norm, or a group. Unlike the example above, these people may be more served by accessing their “angry energy” in order to fight against this kind of bullying. In this way their “angry energy” is an attempt to anti-depress.

While drug treatment for mental illness can be healing and save lives, it can also be ineffective and unsafe for patients. Research in the field of psychoactive drugs, including those used to treat depression, is regularly tainted by the financial conflict of interests of those who benefit from the pharmaceutical industry. The Institute of Medicine (US) Committee on Conflict of Interest in Medical Research, Education, and Practice asserts that, “Individual and institutional financial interests may unduly influence professional judgments... Such conflicts of interest threaten the integrity of scientific investigations, the objectivity of medical education, the quality of patient care, and the public’s trust in medicine.”

For example, we know that data for drugs prescribed for depression are skewed because unfavorable results regularly don’t get published. Research findings are withheld so frequently that while certain drugs are deemed safe and effective, a more thorough review of the research found the risks outweighed the benefits for almost all antidepressants studied. “Not publishing negative results undermines evidence-based medicine and puts millions of patients at risk for using ineffective or unsafe drugs.” [4] Research published in the New England Journal of Medicine made similar findings; they assert, “Selective reporting of clinical trial results may have adverse consequences for researchers, study participants, health care professionals, and patients.

Conclusion: Both Sides! Now!

A more fair-minded dialogue is needed regarding the diagnosis of mental illness, in particular depression. While some are for and some against diagnosis and medical treatment, neither point of view ought to be dismissed. The diversity in people’s experience of depression as well as the situations, families, and cultures in which they live calls for a diversity of understandings and treatments. Some lives are saved by diagnosis and psychopharmaca. Some people find healing by discovering meaning in their symptoms. Some find relief and change in the healing hand of a friend or healer. And many are assisted by others’ efforts to make changes in their families, communities and cultures. And, of course, some symptoms are best address by the blending of these and other approaches.

[1] Goffman E. Stigma: Notes on the management of spoiled identity, p.3. Englewood Cliffs, NJ: Prentice Hall; 1963.

[2] Link & Phelan, Annual Review of Sociology. Link BG, Phelan JC. Conceptualizing stigma. Annual Review of Sociology. 2001; 27: 363–385.

[3] Minuchin, Salvador, Families and Family Therapy, Harvard University Press (1974).

[4] Whittington CJ., Kendall T. Fonagy P., Cottrell D., Cotgrove A., Boddington E. Selective serotonin reuptake inhibitors in childhood depression: systematic review of published versus unpublished data. Lancet. 2004; 363 (9418): 1341–1345.

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