Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Sunday, December 9, 2007

Treating Depression: Limitations of the Biomedical Model as Revealed by Social Science Theory - Jaffy Phillips

Major depression* is a serious mental health condition with extensive individual and societal impact. It affects approximately 15 million American adults per year, and is the leading cause of disability inthe U.S. (1). It is also an expensive illness: it is one of fivechronic illnesses that account for almost half of U.S. annual health care spending (2). Given the high individual and social costs of depression, it is important that treatment protocols be maximally effective. It is the thesis of this paper that our current treatment model is limited in its effectiveness by its failure to addres ssocial and environmental aspects of the diagnosis. Recognition and incorporation of these factors by public health and medical professionals would significantly expand our ability to prevent, mitigate and treat major depression. (*Major depression falls within a spectrum of mood and affective disorders including dysthymia, bipolar disorder, and affective aspects of other medical and psychiatric disorders (3). Although this paper confines itself to discussion of major depression, it is likely that the issues identified are relevant to treatment of other affective conditions as well.)

According to the National Association for Mental Illness(NAMI), there are currently three established treatments for major depression: medication, psychotherapy, and electroconvulsive therapy (ECT). Of these, ECT is reserved for only the most severe cases that have not responded to other forms of treatment. Medication, or medication in combination with psychotherapy, is prescribed most often (1,4).

This treatment approach is based in the “biomedical model”, or the belief that “the union of technologic innovation and expertise in basic science can produce cures for most humanafflictions” (5). The presentation of depression as an “illness” underscores the biomedical bias in our understanding of the condition. And it is true that scientific research indicates that depression is at least in part a biological illness caused by an imbalance in brain neurotransmitters, and that susceptibility to depression is influenced by hereditary (genetic) factors (1). Given these findings, it makes sense to treat depression with medication designed to address neurotransmitter imbalances, and many patients do benefit from this approach.

Despite its significant successes, however, treatment based on the biomedical model fails to address several important social and experiential aspects of depressive illness in ways that limit its scope and effectiveness. In the remainder of this paper, Iwill discuss three well-supported areas of social science theory and practice as they relate to the limitations of current treatment protocols and the need for an expanded understanding of depression and its treatment. The theories and concepts presented include: 1)the Diathesis-Stress Model; 2) the Theory of Learned Helplessness; and 3) the concept of stigma.

The Diathesis-Stress Model

The Diathesis-Stress Model is a psychological theory that attributes mental illness to a combination of hereditary factors (diathesis) and environmental stress (6). The research supporting this model points out that while an individual may have a genetic predisposition for depression, this does not necessarily mean that illness will develop. Often, a significant life stress is what triggers the onset of illness in a genetically vulnerable individual.

This theory identifies stress and life circumstances as important factors in the etiology of depression. Given these factors, it would seem likely that interventions designed to reduce situational stress and increase resiliency could play an important role in ameliorating the prevalence and severity of depressive illness.

Unfortunately, the biomedical model does not include the effects of stress and other environmental factors in its understanding of the cause of depressive illness. Drug treatments, when they work and when the side effects are not prohibitive, address the biochemical imbalance (the ‘diathesis’) but do not address aspects of the triggering situation (the ‘stress’). In failing to consider significant life stress as an important causal factor in depression, the biomedical model misses the opportunity to develop educational and other preventive measures that could help increase resiliency and diminish relapse among individuals vulnerable to depression. Consideration of this expanded perspective could also lead to new treatments for those who are not able to take drugs due to side effects and those whose illness is resistant to drug treatment.

Learned Helplessness

The theory of learned helplessness is a cognitive-behavioral theory developed by Martin Seligman in the late 1970’s. According to this theory, people who are faced with situations that they are powerless to change develop feelings of helplessness and exhibit signs of depressed affect. These feelings are linked to attributional assumptions about one’s lack of efficacy that generalize to future situations and reduce self-esteem (7).

Like the diathesis-stress model, this theory points to experience as a significant causal factor in the development of depression. (Helplessness, depressed affect and low self-esteem are key diagnostic criteria for major depression (3).) The theory of learned helplessness, however, also considers the ways that beliefs and future expectations can extend the impact of experience over time. This theory thus highlights a second major limitation of the current treatment model for depression, which is that the current model does not take into account the contribution of learned beliefs to the development and maintenance of depressive symptoms. Medication can lift a patient’s mood as long as it is taken, but does nothing to change the underlying belief structures (which may continue to affect the patient’s mind and mood after medication is discontinued, making him vulnerable to relapse). In failing to take patients’ belief systems into account, the biomedical model misses the opportunity to treat them, and so to reduce both patients’ dependence on medication and the likelihood of relapse.

Stigma

‘Stigma’ is a social science concept that refers to a cluster of negative attitudes and beliefs that people come to associate with certain conditions or attributes. President Bush identified stigma in 2002 as one of three major obstacles for people in need of mental health care (4). According to The President’s New Freedom Commission on Mental Health (4), the stigma associated with mental illness “is widespread in the United States and other western nations” and its effects include: “motivating the general public to fear, reject, avoid and discriminate against people with mental illnesses,” “leading others to avoid living, socializing, or working with, renting to, or employing people with mental disorders,” “low-self-esteem, isolation and hopelessness in the mentally ill,” and“deterring the public from seeking and wanting to pay for care.” The Commission concludes that “responding to stigma, people with mental health problems internalize public attitudes and become so embarrassed or ashamed that they often conceal symptoms and fail to seek treatment” (4).

The social phenomenon of stigma clearly plays a role in depressive illness. It amplifies the affective symptoms (low self-esteem, isolation and hopelessness) and it interferes with treatment efficacy by deterring potential patients from seeking treatment. Interventions designed to reduce stigma and its effects would help to make depression more tolerable for patients, increase social support,and remove a significant barrier to treatment. Unfortunately, the biomedical model does not address stigma in its approach to treating depression. Treatment is designed for those who make it to the physician’s office, but no consideration is given to the social factors and obstacles they face in getting there. This omission is a major shortcoming of the current treatment model for depression. Expanding the model to include these factors would increase the percentage of ill patients presenting for treatment and increase the effectiveness of the care they receive.

Conclusion

In conclusion, the biomedical model has significant limitations when it comes to treatment for major depression. The biomedical model does not address significant individual-level causal factors such as learned beliefs and coping mechanism that influence the onset, course and severity of depressive illness. It also does not address social factors such as the stigma associated with mental illness, which is a significant environmental stressor and barrier to treatment. In failing to address these factors, the biomedical model misses valuable opportunities for prevention and intervention. Interventions designed to help individuals cope with stress and understand the contributions of their thinking to their illness are needed to help individuals develop resiliency. Societal level interventions designed to educate the public and change social norms around depression and mental illness would go a long way towards reducing the detrimental impact of stigma. Expanding treatment protocols into these areas holds the promise of significant benefit for the many individuals suffering from depression as well as for their families and communities.

REFERENCES

1. National Alliance on Mental Illness (NAMI). About Mental Illness: Major Depression. Arlington, VA: National Alliance on Mental Illness. Available at: http://www.nami.org

2. Geyman, John P., MD. Disease Management: Panacea, Another False Hope, or Something in Between? Annals of Family Medicine 2007; Vol. 5; No. 3; 257-260.

3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC: American Psychiatric Association, 2000.

4. The President’s New Freedom Commission on Mental Health. Executive Summary. Rockville, MD: New Freedom Commission on Mental Health, 2003.

5. Bodenheimer, Thomas S. and Grumbach, Kevin. Understanding Health Policy: A Clinical Approach, 4th Ed. United States: McGraw Hill, 2005.

6. Zubin, J. and Spring, B. Vulnerability: A New View of Schizophrenia. Journal of Abnormal Psychology 2007; 86, 103-126.

7. Abramson, Lyn Y., Seligman, Martin E., Teasdale, JohnD. Learned Helplessness in Humans: Critique and Reformulation. Journal of Abnormal Psychology 1978; 87(1), 49-74.

8. MedTerms Dictionary. Definition of Psychotherapy. San Clemente, CA: MedicineNet Inc./WebMD. Available at: http://www.medterms.com

9. Antonuccio, David. Psychotherapy for Depression: No Stronger Medicine. American Psychologist 1995; 50(6), pp. 450-452.

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1 Comments:

  • At December 28, 2012 at 11:58 AM , Anonymous Anonymous said...

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