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Suffering, Meaning and Hope: Shifting the Focus from Depression in Primary Care

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Sadness or Depression?

Part of the book series: History, Philosophy and Theory of the Life Sciences ((HPTL,volume 15))

Abstract

The diagnosis of depression is not fit for the purposes of primary care. It is inherently problematic, with regard to both validity and utility, and can be challenged on ethical and evolutionary grounds. It has iatrogenic effects, including reducing the sense of personal agency. These effects are exacerbated by GPs’ deterministic explanatory metaphors, and aggravated in cross-cultural consultations which attempt to integrate experiences of traumatized self-identity within routine technical practices.

We need a theory of the person based not on medical assumptions of passivity but on awareness of personal agency. Two key concepts are coherence and engagement. Coherence involves an understanding of ourselves as consistent beings, persons with the capacity to lead our own lives. We make sense of ourselves in terms of our engagement with the world around us: this is crucial in creating and sustaining our sense of identity and well-being.

To provide high quality primary care for depressive feelings, we cannot limit ourselves to individualized biomedical perspectives. In our clinical encounters we do well to see depressive feelings through our patients’ eyes. We should acknowledge suffering, explore meaning and offer hope. We need to incorporate concepts of agency and coherence within our dialogues with patients, expand social understandings of distress and encourage engagement at the community level.

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Notes

  1. 1.

    Although developed independently, these concepts of coherence and engagement have strong resonance with two bases of personality health - identity cohesion and interpersonal functioning – in DSM-5 ’s alternative dimensional approach to personality disorder (American Psychiatric Association 2013).

  2. 2.

    The struggle itself towards the heights is enough to fill a man’s heart. We should imagine that Sisyphus is happy.

References

  • Akiskal, H. S., & McKinney, W. T. (1975). Overview of recent research in depression: Integration of ten conceptual models into a comprehensive clinical frame. Archives of General Psychiatry, 32, 285–305.

    Article  Google Scholar 

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington: American Psychiatric Publishing.

    Book  Google Scholar 

  • Antonovsky, A. (1987). Unravelling the mystery of health: How people manage stress and stay well. San Francisco: Jossey-Bass.

    Google Scholar 

  • Barbui, C., Cipriani, A., Patel, V., Ayuso-Mateos, J. L., & van Ommeren, M. (2011). Efficacy of antidepressants and benzodiazepines in minor depression: Systematic review and meta-analysis. British Journal of Psychiatry, 198, 11–16.

    Article  Google Scholar 

  • Brown, G. W., & Harris, T. (1978). Social origins of depression. New York: Free Press.

    Google Scholar 

  • Camus, A. (1942). Le Mythe de Sisyphe. Paris: Gallimard.

    Google Scholar 

  • Casey, P., Dowrick, C., & Wilkinson, G. (2001). Adjustment disorders: Fault line in the psychiatric glossary. British Journal of Psychiatry, 179, 479–480.

    Article  Google Scholar 

  • Caspi, A., Sugden, K., Moffitt, T. E., Taylor, A., Craig, I. W., Harrington, H., McClay, J., Mill, J., Martin, J., Braithwaite, A., & Poulton, R. (2003). Influence of life stress on depression: Moderation by a polymorphism in the 5-HTT gene. Science, 301, 386–389.

    Article  Google Scholar 

  • Cowan, W. M., Kopnisky, K. L., & Hyman, S. E. (2002). The human genome project and its impact on psychiatry. Annual Review of Neuroscience, 25, 1–50.

    Article  Google Scholar 

  • Craddock, N., & Forty, L. (2006). Genetics of affective mood disorders. European Journal of Human Genetics, 14, 660–668.

    Article  Google Scholar 

  • Descartes, R. (1649/1967). Treatise on the passions of the soul. In E. S. Halden & G. R. T. Ross (Trans.), Philosophical works of Descartes. Cambridge: Cambridge University Press

    Google Scholar 

  • Dowrick, C. (2009). Beyond depression (2nd ed.). Oxford: Oxford University Press.

    Book  Google Scholar 

  • Dowrick, C., & Frances, A. (2013). Medicalising unhappiness: New classification of depression risks more patients being put on drug treatment from which they will not benefit. BMJ, 347, f7140.

    Article  Google Scholar 

  • Dowrick, C., Gask, L., Edwards, S., Aseem, S., Bower, P., Burroughs, H., Catlin, A., Chew-Graham, C., Clarke, P., Gabbay, M., Gowers, S., Hibbert, D., Kovandzic, M., Lamb, J., Lovell, K., Rogers, A., Lloyd-Williams, M., Waheed, W., & AMP Group. (2009). Researching the mental health needs of hard-to-reach groups: Managing multiple sources of evidence. BMC Health Services Research, 9, 226.

    Article  Google Scholar 

  • Dowrick, C., Chew-Graham, C., Lovell, K., Lamb, J., Aseem, A., Beatty, S., Bower, P., Burroughs, H., Clarke, P., Edwards, S., Gabbay, M., Gravenhorst, K., Hammond, J., Hibbert, D., Kovandžić, M., Lloyd-Williams, M., Waheed, W., & Gask, L. (2013). Increasing equity of access to high quality mental health services in primary care: A mixed-methods study. Programme Grants for Applied Research, 1(2), 1–184.

    Article  Google Scholar 

  • Epstein, R. M. (1999). Mindful practice. JAMA, 282, 833–839.

    Article  Google Scholar 

  • Eriksson, M., Lindström, B., & Lilja, J. (2007). A sense of coherence and health. Salutogenesis in a societal context: Aland, a special case? Journal of Epidemiology and Community Health, 61, 684–688.

    Article  Google Scholar 

  • Faucher, L. (2016). Darwinian blues: Evolutionary psychiatry and depression. In J. C. Wakefield & S. Demazeux (Eds.), Sadness or depression? International perspectives on the depression epidemic and its meaning. Dordrecht: Springer.

    Google Scholar 

  • Fernros, L., Furhoff, A. K., & Wändell, P. E. (2008). Improving quality of life using compound mind-body therapies: Evaluation of a course intervention with body movement and breath therapy, guided imagery, chakra experiencing and mindfulness meditation. Quality of Life Research, 17, 367–376.

    Article  Google Scholar 

  • Fournier, J. C., DeRubeis, R. J., Hollon, S. D., Dimidjian, S., Amsterdam, J. D., Shelton, R. C., & Fawcett, J. (2010). Antidepressant drug effects and depression severity: A patient-level meta-analysis. JAMA, 303, 47–53.

    Article  Google Scholar 

  • Furler, J., Kokanovic, R., Dowrick, C., Newton, D., Gunn, J., & May, C. (2010). Managing depression among ethnic communities: A qualitative study. Annals of Family Medicine, 8, 231–236.

    Article  Google Scholar 

  • Gask, L., Rogers, A., Oliver, D., May, C., & Roland, M. (2003). Qualitative study of patients’ perceptions of the quality of care in general practice. British Journal of General Practice, 53, 278–283.

    Google Scholar 

  • Gibbons, R. D., Hur, K., Brown, C. H., David, J. M., & Mann, J. J. (2012). Benefits from antidepressants: Synthesis of 6-week patient-level outcomes from double-blind placebo-controlled randomized trials of fluoxetine and venlafaxine. Archives of General Psychiatry, 69, 572–579.

    Google Scholar 

  • Goldberg, D., & Lecrubier, Y. (1995). Form and frequency of mental disorders across centres. In T. B. Üstün & N. Sartorius (Eds.), Mental illness in general health care: An international study. Chichester: Wiley, on behalf of the World Health Organisation.

    Google Scholar 

  • Griffiths, F., Boardman, F., Chondros, P., Dowrick, C., Densley, K., Hegarty, K., Gunn, J. (2015). The effect of strategies of personal resilience on depression recovery in an Australian cohort: A mixed methods study. Health, 19(1), 86–106.

    Google Scholar 

  • Hacking, I. (1999). The social construction of what? Cambridge, MA: Harvard University Press.

    Google Scholar 

  • Heath, I. (1999). ‘Uncertain clarity’: Contradiction, meaning and hope. British Journal of General Practice, 49, 651–657.

    Google Scholar 

  • Horwitz, A. V., & Wakefield, J. C. (2007). The loss of sadness: How psychiatry transformed normal sorrow into depressive disorder. New York: Oxford University Press.

    Google Scholar 

  • Keller, M. C., & Nesse, R. M. (2005). Is low mood an adaptation? Evidence for subtypes with symptoms that match precipitants. Journal of Affective Disorders, 6, 27–35.

    Article  Google Scholar 

  • Kendell, R., & Jablensky, A. (2003). Distinguishing between the validity and utility of psychiatric diagnoses. The American Journal of Psychiatry, 160, 4–12.

    Article  Google Scholar 

  • Killingsworth, B., Kokanovic, R., Tran, H., & Dowrick, C. (2010). A care-full diagnosis: Three Vietnamese Australian women and their accounts of becoming “mentally ill”. Medical Anthropology Quarterly, 24, 108–123.

    Article  Google Scholar 

  • Kirsch, I., Moore, T. J., Scoboria, A., & Nicholls, S. (2002). The emperor’s new drugs: An analysis of antidepressant medication data submitted to the US Food and Drug Administration. Prevention and Treatment, 5, Article 23.

    Google Scholar 

  • Kirsch, I., Deacon, B. J., Huedo-Medina, T. B., Scoboria, A., Moore, T. J., & Johnson, B. T. (2008). Initial severity and antidepressant benefits: A meta-analysis of data submitted to the food and drug administration. PLoS Medicine, 5, e45.

    Article  Google Scholar 

  • Kitanaka, J. (2016). Depression as a problem of labor: Japanese debates about work, stress, and a new therapeutic ethos. In J. C. Wakefield & S. Demazeux (Eds.), Sadness or depression? International perspectives on the depression epidemic and its meaning. Dordrecht: Springer.

    Google Scholar 

  • Kokanovic, R., May, C., Dowrick, C., Furler, J., Newton, D., & Gunn, J. (2010). Negotiations of distress between East Timorese and Vietnamese refugees and their family doctors in Melbourne. Sociology of Health & Illness, 32, 511–527.

    Article  Google Scholar 

  • Kokanovic, R., Butler, E., Halilovich, H., Palmer, V., Griffiths, F., Dowrick, C., & Gunn, J. (2013). Maps, models and narratives: The ways people talk about depression. Qualitative Health Research, 23, 114–125.

    Article  Google Scholar 

  • Kouvonen, A. M., Väänänen, A., Woods, S. A., Heponiemi, T., Koskinen, A., & Toppinen-Tanner, S. (2008). Sense of coherence and diabetes: A prospective occupational cohort study. BMC Public Health, 6, 46.

    Article  Google Scholar 

  • Langeland, E., Riise, T., Hanestad, B. R., Nortvedt, M. W., Kristoffersen, K., & Wahl, A. K. (2006). The effect of salutogenic treatment principles on coping with mental health problems: A randomised controlled trial. Patient Education and Counseling, 62, 212–219.

    Article  Google Scholar 

  • Lehtinen, V., Sohlman, B., Nummelin, T., Salomaa, M., Ayuso-Mateos, J. L., & Dowrick, C. (2005). The estimated incidence of depressive disorder and its determinants in the Finnish ODIN sample. Social Psychiatry and Psychiatric Epidemiology, 40, 778–784.

    Article  Google Scholar 

  • Levinson, D. F. (2006). The genetics of depression: A review. Biological Psychiatry, 60, 84–92.

    Article  Google Scholar 

  • Löwe, B., Unützer, J., Callahan, C. M., Perkins, A. J., & Kroenke, K. (2004). Monitoring depression treatment outcomes with the PHQ-9. Medical Care, 42, 1194–1201.

    Article  Google Scholar 

  • MacIntyre, A. (1984). After virtue (2nd ed.). Notre Dame: University of Notre Dame Press.

    Google Scholar 

  • Martel, Y. (2002). Life of pi. Edinburgh: Canongate.

    Google Scholar 

  • McWhinney, I. (2000). Being a general practitioner: What it means. The European Journal of General Practice, 6, 135–139.

    Article  Google Scholar 

  • Mercer, S. W., Neumann, M., Wirtz, M., Fitzpatrick, B., & Vojt, G. (2008). General practitioner empathy, patient enablement, and patient-reported outcomes in primary care in an area of high socio-economic deprivation in Scotland: A pilot prospective study using structural equation modeling. Patient Education and Counseling, 73, 240–245.

    Article  Google Scholar 

  • Miller, D. B., & O’Callaghan, J. P. (2013). Personalized medicine in major depressive disorder – Opportunities and pitfalls. Metabolism, S1, S34–S39.

    Article  Google Scholar 

  • Mitchell, A. J., Vaze, A., & Rao, S. (2009). Clinical diagnosis of depression in primary care: A meta-analysis. Lancet, 374, 609–619.

    Article  Google Scholar 

  • Munafò, M. R., Durrant, C., Lewis, G., & Flint, J. (2009). Gene X environment interactions at the serotonin transporter locus. Biological Psychiatry, 65, 211–219.

    Article  Google Scholar 

  • NICE. (2009). Treatment and management of adults with depression (update), CG 90. London: National Institute for Health and Clinical Excellence.

    Google Scholar 

  • Norton, J., de Roquefeuil, G., David, M., Boulenger, J. P., Ritchie, K., & Mann, A. (2009). Prevalence of psychiatric disorders in French general practice using the patient health questionnaire: Comparison with GP case-recognition and psychotropic medication prescription. Encephale, 35, 560–569.

    Article  Google Scholar 

  • Obeyesekere, G. (1985). Depression, Buddhism, and the work of culture in Sri Lanka. In A. Kleinman & B. Good (Eds.), Culture and depression: Studies in the anthropology and cross-cultural psychiatry of affect and disorder (pp. p134–p152). Berkeley: University of California Press.

    Google Scholar 

  • Parker, G. (2007a). Defining melancholia: The primacy of psychomotor disturbance. Acta Psychiatrica Scandinavica, S433, 21–30.

    Article  Google Scholar 

  • Parker, G. (2007b). What is the place of psychological treatments in mood disorders? International Journal of Neuropsychopharmacology, 10, 137–145.

    Article  Google Scholar 

  • Parker, G. (2013). Opening Pandora’s box: How DSM-5 is coming to grief. Acta Psychiatrica Scandinavica, 128, 88–91.

    Article  Google Scholar 

  • Pinto, E., Reggers, J., Gorwood, P., Boni, C., Scantamburlo, G., Pitchot, W., & Ansseau, M. (2008). The short allele of the serotonin transporter promoter polymorphism influences relapse in alcohol dependence. Alcohol and Alcoholism, 43, 398–400.

    Article  Google Scholar 

  • Price, J., Sloman, L., Gardner, R., Gilbert, P., & Rhode, P. (1994). The social competition hypothesis of depression. British Journal of Psychiatry, 164, 309–315.

    Article  Google Scholar 

  • Ross, W. D. (1953). Aristotle’s metaphysics. Oxford: Clarendon.

    Google Scholar 

  • Ryff, C. D. (2014). Psychological well-being revisited: Advances in the science and practice of eudaimonia. Psychotherapy and Psychosomatics, 83, 10–28.

    Article  Google Scholar 

  • Sáiz, P. A., García-Portilla, M. P., Arango, C., Morales, B., Alvarez, V., Coto, E., Fernández, J. M., Bascarán, M. T., Bousoño, M., & Bobes, J. (2007). Association study of serotonin 2A receptor (5-HT2A) and serotonin transporter (5-HTT) gene polymorphisms with schizophrenia. Progress in Neuropsychopharmacology and Biological Psychiatry, 31, 741–745.

    Article  Google Scholar 

  • Scott, J. G., Cohen, D., Dicicco-Bloom, B., Miller, W. L., Stange, K. C., & Crabtree, B. F. (2008). Understanding healing relationships in primary care. Annals of Family Medicine, 6, 315–322.

    Article  Google Scholar 

  • Seligman, M. E., Steen, T. A., Park, N., & Peterson, C. (2005). Positive psychology progress: Empirical validation of interventions. American Psychologist, 60, 410–421.

    Article  Google Scholar 

  • Shorter, E., & Tyrer, A. (2003). Separation of anxiety and depressive disorders: Blind alley in psychopharmacology and classification of disease. BMJ, 327, 158–160.

    Article  Google Scholar 

  • Simpson, J. (1997). Touching the void. London: Vintage.

    Google Scholar 

  • Skelton, J., Wearn, A., & Hobbs, F. (2002). A concordance-based study of metaphoric expressions used by general practitioners and patients in consultation. The British Journal of General Practice, 52, 114–118.

    Google Scholar 

  • Spinoza, B. (2000). Ethics (G. Parkinson, Ed. & Trans.). Oxford: Oxford University Press.

    Google Scholar 

  • Taylor, C. (1984). Sources of the self. Cambridge: Cambridge University Press.

    Google Scholar 

  • Tsenkova, V. K., Love, G. D., Singer, B. H., & Ryff, C. D. (2007). Socioeconomic status and psychological well-being predict cross-time change in glycosylated hemoglobin in older women without diabetes. Psychosomatic Medicine, 69, 777–784.

    Article  Google Scholar 

  • Turner, E. H., Matthews, A. M., Linardatos, E., Tell, R. A., & Rosenthal, R. (2008). Selective publication of antidepressant trials and its influence on apparent efficacy. New England Journal of Medicine, 358, 252–260.

    Article  Google Scholar 

  • Uher, R., & McGuffin, P. (2008). The moderation by the serotonin transporter gene of environmental adversity in the aetiology of mental illness: Review and methodological analysis. Molecular Psychiatry, 13, 131–146.

    Article  Google Scholar 

  • Verbeek-Heida, P. M., & Mathot, E. F. (2006). Better safe than sorry--why patients prefer to stop using selective serotonin reuptake inhibitor (SSRI) antidepressants but are afraid to do so: Results of a qualitative study. Chronic Illness, 2, 133–142.

    Google Scholar 

  • Wakefield, J. C. (1992a). Disorder as harmful dysfunction: A conceptual critique of DSM-III-R’s definition of mental disorder. Psychological Review, 99, 232–247.

    Article  Google Scholar 

  • Wakefield, J. C. (1992b). The concept of mental disorder: On the boundary between biological facts and social values. American Psychologist, 47, 373–388.

    Article  Google Scholar 

  • Wakefield, J. C., & Schmitz, M. F. (2013). When does depression become a disorder? Using recurrence rates to evaluate the validity of proposed changes in major depression diagnostic thresholds. World Psychiatry, 12, 44–52.

    Article  Google Scholar 

  • Walsh, B. T., Seidman, S. N., Sysko, R., & Gould, M. (2002). Placebo response in studies of major depression: Variable, substantial, and growing. JAMA, 287, 1840–1847.

    Article  Google Scholar 

  • Watson, P. J., & Andrews, P. W. (2002). Towards a revised evolutionary adaptationist analysis of depression: The social navigation hypothesis. Journal of Affective Disorders, 72, 1–14.

    Article  Google Scholar 

  • Whittington, C. J., Kendall, T., Fonagy, P., Cottrell, D., Cotgrove, A., & Boddington, E. (2004). Selective serotonin reuptake inhibitors in childhood depression: Systematic review of published versus unpublished data. Lancet, 363, 1341–1345.

    Article  Google Scholar 

  • Wilson, E. G. (2008). Against happiness: In praise of melancholy. New York: Sarah Crichton Books.

    Google Scholar 

  • Wollheim, R. (1984). The thread of life. Cambridge: Cambridge University Press.

    Google Scholar 

  • Zeldin, T. (1994). An intimate history of humanity. London: Sinclair-Stevenson.

    Google Scholar 

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Authors and Affiliations

  1. University of Liverpool, Liverpool, UK

    Christopher Dowrick M.D., FRCGP

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  1. Christopher Dowrick M.D., FRCGP
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Correspondence to Christopher Dowrick M.D., FRCGP .

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  1. Silver School of Social Work and Department of Psychiatry, New York University, New York, New York, USA

    Jerome C. Wakefield

  2. Department of Philosophy, SPH Laboratory, Université Bordeaux Montaigne, Pessac, Gironde, France

    Steeves Demazeux

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Dowrick, C. (2016). Suffering, Meaning and Hope: Shifting the Focus from Depression in Primary Care. In: Wakefield, J., Demazeux, S. (eds) Sadness or Depression?. History, Philosophy and Theory of the Life Sciences, vol 15. Springer, Dordrecht. https://doi.org/10.1007/978-94-017-7423-9_9

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