A Melancholy Breach Science and clinical tradition clash amid new insights into depression
In the past decade, psychiatrists, psychologists and others dealing with depressed patients have experienced an odd mix of optimism and unease.
Their optimism stems from a growing confidence in various combinations of talk therapies and drug treatments to allay mild to extreme forms of depression. Their unease emanates from a harsh exchange between two clinical camps over how best to subdue the sometimes life-threatening symptoms of "major" or severe depression.
An increasingly powerful, research-oriented camp trumpets scientific data supporting a marriage of antidepressant drugs with short-term psychotherapy aimed at altering depression-inducing thoughts and behaviors. A second group of mental health workers, with a perspective grounded in Freudian psycho-analysis, eschews the pursuit of scientific data. Instead, they rely on decades of clinical experience with long-term "psychodynamic psychotherapy" focused on unconscious conflicts and emotions. These therapists grant medication a supporting role at best.
A lawsuit launched in 1982 epitomized this rift. A former patient at a prestigious mental hospital in Rockville, Md., sued the hospital for negligence because it had failed to treat his severe depression with antidepressant drugs. Hospital clinicians had offered the man only intensive, four-times-a-week psychodynamic psychotherapy. The case, known as Osheroff v. Chestnut Lodge, achieved considerable notoriety in the mental health community before an out-of-court settlement in 1987, for an undisclosed amount of money, staved off a jury trial.
Friction between biologically and psychodynamically oriented therapists shows no signs od dissipating in the 1990s, especially as insurance dollars for mental health care dwindle. Another ongoing and related dispute -- involving both mental health workers and organizations of mental patients and their families -- concerns whether major depression and other serious mental disorders primarily represent diseases or stem in critical ways from social and emotional factors.
As these issues continue to generate heated debate, two new investigations shine some precious light on depression's causes and treatments.
Women suffer from all forms of depression at twice the rate of men largely because of cultural and social factors rather than biological predisposition, concludes the National Task Force on Women and Depression in its final report, released last December. The 20-member task force, commissioned by the American Psychological Association (APA), spent three years reviewing research and synthesizing the findings.
Some investigators maintain that the depression gender gap reflects women's greater ease in talking about emotional distress and contacting mental health workers. The APA report, however, accepts the gap as genuine and characterizes it as a product of several risk factors--predominantly social and cultural ones--that promote depression among women. Those factors, according to the report, include physical and sexual abuse, unhappy marriages, poverty and a culturally sanctioned tendency for women to dwell on feelings of depression rather than act to overcome them. Researchers often neglect social factors that influence depression among women, says report coauthor Bonnie R. Strickland, a psychologist at the University of Massachusetts in Amherst.
In addition, hormonal changes related to reproductive events, including menstruation, pregnancy, childbirth and infertility, may further influence women's depression, according to the report. In the case of major depression, the task force grants culture and upbringing equal power with female physiology.
Bouts of major depression last for at least two weeks. Some people suffer only one or a few such episodes, while others spend years …