Reinventing Depression

Abstract

Remember the mid-1980s? Many psychiatric researchers were very surprised to find a large burden of depression in primary care patients. Of course, with the advent of the SSRIs (selective serotonin reuptake inhibitors) and other safe and effective antidepressants, we in primary care were reassured that we could, indeed, adequately treat these patients, reducing morbidity (and mortality!) with expedition and ease. Twenty years on, and the plot has thickened. In our offices and for our patients, the high prevalence of treatment-resistant depression, the confusion involving differential diagnoses (including bipolar depression and substance abuse disorder), and the interplay of Axis II disorders with Axis I pathology have laid bare some of the halcyon assumptions regarding easy efficacy that marked primary care affective medicine 2 decades ago. If the past informs the present, and is truly prologue to the future, then we could use a history lesson. Callahan and Berrios provide the very best kind—well-written, informative, clearly referenced, and lucidly conceptualized—to tell a story of how we came to approach mental illness in primary care as we do. Their central thesis states that the current model of depression is deterministic and too narrowly defined, overemphasizing the biomedical and failing to take fully into account the contributions of psychosocio-spiritual factors to the patient's experience of emotional suffering. They contend that this narrow model, developed by specialty psychiatry and later endorsed by primary care physicians, prevents many patients from receiving adequate diagnoses and treatment. In addition, it neglects many of the multidisciplinary strengths of the generalist physician and thus lowers the quality of care. To begin, the authors explode 2 favorite myths of modern medicine: that of the old-time doctor (who saw fewer patients, had more time, and was happier with the practice) and that of the old-time patient (who complained less, appreciated the doctor more, and was reluctant to accept medical treatment for emotional suffering). Next, they portray the realities of midcentury primary care and subsequent changes in generalist practices. They then trace the emergence of specialty psychiatry, the development of effective medications for psychiatric disorders, and the rise of criteria-based psychiatric diagnoses. Following the development of fluoxetine as penicillin for the blues, the authors describe the consequences of marketing in a vacuum—the interaction of pharmaceutical companies with physicians or patients in the absence of robust regulatory and academic relationships. The book closes by arguing that only a broader model of mental health and illness will bring to bear the particular strengths of primary care in reducing the overall burden of morbidity and mortality (in a manner similar to the mass strategy associated with such multifactorial illnesses as coronary artery disease and diabetes mellitus). In other words, we don't necessarily need to become better psycho-pharmacologists; we might better serve our patients as better listeners, or counselors, or in some other capacity. As an intriguing aside, the authors propose that the confusion that reigns with regard to the treatment of affective illness in primary care is symptomatic of a more fundamental problem—the failure of generalists to posit and practice a comprehensive vision of their relationship to patients and to society as a whole. Having yielded to the allure of becoming Everydoctor for Everypatient, will generalists suffer a dilution of skills and focus that will ultimately devalue the enterprise entirely? The authors believe this may be the case and argue that the emotionally suffering patient is the canary in the coal mine that signals this unraveling of a coherent role for the generalist in modern medicine. Now and again, a book or paper appears that seems to part the fog, not only showing things as they are but explaining how they arrived to be that way. Reinventing Depression is that kind of book. In a manner reminiscent of Starr's classic The Social Transformation of American Medicine,1 it points the ways to a workable postmodern model of primary care affective medicine by thoroughly illuminating past and present conditions, with all their inconsistencies and serendipities. Serious students of the sociology of medicine, the evolution of primary care as a practice and as a discipline, and the treatment of mental illness will find it time well spent.