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Depression and Anxiety

Two Sides of the Same Coin?

Depression and anxiety used to be considered pieces of the same disease. Now they are completely separate, with psychiatry having a whole series of anxiety disorders and, quite apart, “major depression.” This has been a scientific disaster and results in two prescriptions– one for an “antidepressant,” the other for an “anxiolytic” -- rather than one.

How did this happen?

Anxiety was once considered such a fundamental part of all psychiatric illness that it wasn’t a disease of its own at all. Emil Kraepelin, the great German disease-classifier, who around 1890 gave us much of the structure of modern psychiatric diagnosis, thought anxiety so omnipresent that he didn’t consider it a separate disease.

Anxiety then acquired independent disease status with Sigmund Freud’s psychoanalysis, which began to infiltrate psychiatry in the 1920s. Freud had little interest in the classification of disease, even less in depression, a disorder that tended to make patients withdrawn and silent, inaccessible to talk therapies. But anxiety played a huge role in Freud’s theories: It was the motor of conflict within the psyche, and the entry for anxiety in the index of Freud’s collected works goes on for nine pages.

By the Second World War, psychoanalysis had become the dominant ideology within psychiatry, and it was not uncommon for analytically-oriented psychiatrists to ask about the toilet-training of acutely-ill patients.

Yet in the years after 1950 the influence of psychopharmacology – the treatment of psychiatric illness with medications – began to make itself felt. And for good reason. The drugs worked.

So the revolution caused by the new drugs blew away psychoanalysis and it was time to rethink the basic classification of illnesses. This happened in 1980, as a task force of the American Psychiatric Association headed by Robert Spitzer of the New York State Psychiatric Institute, devised a new, third, edition of the Diagnostic and Statistical Manual of the APA. Called DSM-3, it recast the whole ball of wax.

But until this point there had been, in American psychiatry, essentially two different depression diagnoses. The psychoanalysts had favored depressive neurosis, which they considered a neurosis and not a mood disorder. And the non-analysts favored mixed anxiety-depression. This was not unreasonable, because the mixture of anxiety and depression is much commoner than are either pure depression or pure anxiety. And so for half a century, from the decline of “nerves” in the 1920s until 1980, mixed anxiety-depression had been the workhorse of American psychiatry.

But all this suddenly came to an end with DSM-3. In drafting DSM-3 Spitzer had separated the working groups for depressive illness and for anxiety. And you know the way committees work: If you have a separate committee for This, and another committee for That, the chances of getting Mixed This-n’-That are about zero. Spitzer was not himself a psychoanalyst. In fact he heartily disliked psychoanalysis. But he earlier had been in analysis; he had grown up in a milieu that believed implicitly in Freud’s doctrines, and at “PI,” as the Psychiatric Institute was called, psychoanalytic formulations reverberated in the corridors.

So it never really seems to have occurred to Spitzer – who worked in the biometrics department of PI and not in a clinical department – that depression and anxiety required a mixed form because it was so very common in the community.

DSM-3 in 1980 separated depression and anxiety: The depressive illnesses, of which psychiatry previously had several forms, were collapsed into “major depression.” And anxiety found itself tucked away in an entirely different part of the Manual and split into a number of microfragments such as General Anxiety Disorder, Social Anxiety, and so forth.

All of these decisions were mistaken, and completely out of touch with the great international streams of diagnosis that previously had been dominated by the Germans. But the classic texts were, alas, written in German. The anxiety microfragments made no sense to anyone, except the marketing departments of the pharmaceutical companies. And major depression collapsed psychiatry’s two previous depressions – melancholia and what used to be called nervous disease. Anxiety was highly common in both.

So, this was a scientific travesty. DSM-3 rode roughshod over a great body of clinical wisdom that had been accumulated in decades and centuries of experience. It was basically under the influence of whim, and the remaining debris of psychoanalysis, that all the new diagnoses of DSM-3 were created.

Yet clinicians in the trenches in the real world rebelled. They knew that their depressed patients were anxious, and vice versa, and in drafting successive editions of the Manual there were vague stirrings to get mixed anxiety-depression back in. Yet it had no lobby. And in the DSM world you needed a lobby to get your favorite diagnosis included. Post-traumatic stress disorder, the abolition of the hysteria diagnosis, and other innovations in DSM-3 all had powerful lobbies of their own. But mixed anxiety-depression had only the voice of experience behind it.

Finally, in drafting DSM-5, due out in May of this year, the voices in the trenches became loud enough to wake the disease designers. Even without a big lobby, mixed anxiety-depression got back in as a proposed diagnosis.

And then it was withdrawn!

There will be no mixed anxiety-depression in the final, published version because of (a) a sustained publicity campaign against it by the former editor of DSM-4, himself a psychoanalyst; and (b) the failure of clinicians, largely academics, to make the mixed diagnosis in field trials.

Well, the logic went, if the field-trialists didn’t see it in their patients, then it must not exist. But academics tend see only what they have been taught to look for. That’s why they’re academics. They didn’t see the mixed diagnosis because it had vanished from the official roster almost forty years ago. If the field trials had been conducted in 1939 all the trialists would have agreed that their female patients had “hysteria.” This is not the way we do science.