The Grey Dog

I was once a moody child; I’m still a moody child… sorry, adult. Anyway, I’m also a bit sensitive about the topic. It’s as if being moody means being naughty, or maybe contrary. Not quite right in the head, or something -not well adjusted, at any rate. I take exception to that. I mean, just because I often have trouble mixing with people at parties who only want to make small talk -usually about other people- and then walk away shouldn’t disqualify me from church or anything… Okay, I don’t go to church, but you see what I’m driving at, I hope. Moods are kind of baroque frames around my happiness. They make even run-of-the-mill joy look like ecstasy.

I’m not advocating ignoring the more severe and persistent forms of mood -they may in fact herald something very important. I am saying that not all of us who are occasionally disgruntled, frustrated, or unhappy have some underlying pathology. And to label those occasions as bouts of depression is to dilute the word, mistake the condition, assume everything is the black dog.

I was therefore relieved to find someone who relates to that view:

The author, Dr. Stanley Kutcher, Sun Life Financial Chair in Adolescent Mental Health, at Dalhousie University, Begins by noting that, ‘[…] if the media coverage is to be believed, we are drowning in a sea of mental illness that threatens to overwhelm post-secondary Institutions. […] The prevalence of mental illnesses (defined using clear diagnostic criteria) is not rising in this cohort.

‘Youth self-reports of negative emotions are increasing. But the self-report scales used in studies documenting this have not been calibrated for generational changes in language use. Nor have the results been validated using clear, clinically valid, diagnostic criteria applied by expert clinicians.

‘[…] The above noted self-reports do identify the ups and downs of everyday emotions, but these are not criteria for diagnosis of mental illness. So we can say that youth on campus may report feeling more negative emotions than previously, but this is not the same thing as saying that young people have more mental disorders than previously.’

He cites an interesting example of the lack of application of basic critical thinking and analysis: ‘In late 2017, the study “Mental ill-health among children of the new century: Trends across childhood with the focus on age 14” was published by the National Children’s Bureau in the United Kingdom.

‘This showed that self-reported negative emotions were present in about one quarter of this surveyed group, but this was interpreted as 25 percent of 14-year-old girls in the UK suffer from depression! The fact that parental reports identified about five per cent of this cohort as having significant mood problems was ignored by almost all commentators. This latter number is much more in keeping with known rates of depression in the population.’

I wonder if our expectations of normalcy are to blame. As Dr. Kutcher explains, ‘These concerns are not the result of substantial epidemic increases in the rates of mental illness. They arise, in some part, from poor mental health literacy and unrealistic expectations of the normal emotional states that life challenges elicit.’

He makes some interesting and important points, I think. ‘[…] First, the increased public perception that being well means only having positive feelings is taking over the social discourse on mental health. When the measure of health is simply feeling good, negative emotions become a marker of being unwell. […] Without addressing the life challenges and opportunities that negative emotions signal to us, we can’t develop resilience. Mental health is not a static concept wearing a big smile. There are good days and bad days, good weeks and bad weeks. We still have mental health even if we are having negative emotions.’

‘Second, the use of words originally developed to identify mental illnesses to describe normal negative emotional states has burgeoned. […] Further, the use of terms denoting illness, such as depression, to mean all negative emotions is even more confusing. Now, words like sadness, disappointment, disgruntlement, demoralization and unhappiness are all lumped together as depression.’

He feels that the continued and almost obsessive use of technologies like smart phones for communication-especially by the young- may limit their ability to express complex messages and ideas and hence increase the sense of isolation, of being misunderstood -or perhaps, of even being mislabelled. And since it is adults, by and large, in charge of the classifications, it’s almost a case of two solitudes, two Magisteria, staring at each other -neither the wiser. Neither the winner…

Interestingly, I think I caught a whiff of this while waiting for a bus the other day. Two quite young teenage girls were sitting on the only bench in the little shelter, both clutching their mobile phones like purses. Because the rest of the bench was filled with their back-packs and some school binders, I merely stood outside and leaned against the wooden frame.

“But what did he say, Kitty? Is he, like, mad at you or something?” This from a petite little girl with long, straight dark hair and a big red coat with only a pair of blue boots sticking out from the bottom.

Kitty shook her head and leaned back on the wall of advertising behind her. She also had dark hair, but short and messy. It fit rather well with a large, thick and ragged blue sweater, torn on at least one sleeve to show a thin arm underneath. Her jeans were also fashionably torn, but looking as new as her pink running shoes. “No… Not mad… Just, like, upset. He says I’m moody -and all because I don’t want to, like, talk with him and Mom at the dinner table. I mean, nobody, talks anyway.” She shrugged theatrically and leaned forward on the bench again.

Her friend sighed sympathetically. “Yeah, my mom keeps wanting me to… you know, like communicate with her, too. But I mean, ever since dad left, she’s always either on her phone, or has the TV on.”

Kitty, nodded. “Yeah well, like, my parents think I should see a counsellor at school… They think I’m depressed, eh?” Her friend’s expression tightened, but she stayed silent. “But my dad always has his phone on the table and, like, keeps glancing at the news on his apps or, like, he’s waiting for an important Email, or whatever. And my mom’s a realtor, remember, so she does the same.” Kitty glanced around the wall and saw a bus was coming. “That’s all they talk about, anyway, Jen.”

Jen was staring intently at the ground in front of her. “Well, I think my mom’s depressed, you know, but she won’t go see anybody about it.” She took a little stertorous breath. “She thinks she’s coping… But I think, like, she’s just escaping online and stuff…”

The bus pulled up, and Jen seemed on the verge of tears, so Kitty reached over and hugged her. “We have to be strong for them, you know, Jen…”

That’s all I heard before they quickly gathered their things and walked over to the bus, arm in arm. Kitty must have whispered something else to her, because they both started to giggle before they got on.

I don’t know if it’s the technology, but it did make me wonder whether we really have a handle on mental health yet.


Depression and Inflammation

The practice of obstetrics and gynaecology is normally a kaleidoscope of colours –from the pale red blush of an embarrassed face, the bright green flash of twinkling eyes, to the panoply of skin colours proudly arrayed like just-washed clothes in the waiting room. There is no rank to the colours, no special prize for the one most displayed, no arbitrary preference, but I am wary of grey…

You don’t have to be a psychiatrist to spot the clouds, nor possess a doctorate in psychology to feel the angst. Depression is a fog whose periphery shades and obtunds everything and everyone nearby. Its boundary is indistinct and to approach is to be enveloped. Obscured. Affected. It has the strange property of contagion.

Not to pretend an exact analogy, but I have often wondered about the resemblance of depression to how many of us react to an acute illness like, say, a ‘cold’ or even a headache –so-called ‘sickness behaviour’: fatigue, apathy, loss of focus, withdrawl… All of these are vaguely reminiscent of the psychological behaviour in depression, although I suspect most of us have not really thought about it in those terms. Admittedly, the resemblance is tenuous and terribly non specific, and yet I find the correspondence intriguing –not least because the symptoms are caused by some physical malfunction and seem almost designed to isolate and rest the body to allow healing.

So I was excited to read about the work being done investigating the link between depression and inflammation. One of the more informative evidence based reviews I have found was published in the June 2013 edition of Current Psychiatry and the author was Dr. Maria Almond from the University of Michigan:

The concept of inflammation having a role in what has always been considered a mental maladjustment reminds me of the story of stomach ulcers. Remember, it was not so long ago that ulcers were attributed to stress. It seemed intuitively obvious that it would –and should- be so. And then Helicobacter pylori was discovered in a large percentage of these patients and when treated, seemed to alleviate the symptoms. Mind you, not everone with Helicobacter was symptomatic, but its undisputed role in the disease process changed our thinking about psychosomatic illnesses –opened our minds… Or at least should have.

And then there is the oft refuted contention that cardiovascular diseases may have their origin in infectious –or at least inflammatory- processes. The arterial plaques that can narrow or block important blood vessels and lead to strokes or heart attacks have been commonly attributed to cholesterol levels –too much ‘bad’ cholesterol (LDL) will form these plaques and impede blood flow past them. Observational science at its finest; but seeing them and recognizing their significance, still does not answer the question of why they formed in the first place. There have been attempts to attribute the reason for their formation to inflammation and underlying damage to the arterial wall. But it is a chicken-and-egg observation: did the damage result from inflammation –ie some infectious, or other agent- or did some other cause for damage engender inflammation and attract the cholesterol to form the plaque in an ongoing attempt to heal it?

But as a gynaecologist I admit that I am straying into uncomfortable territory here, so I will merely leave it as a sort of illustration of the There are more things in heaven and earth, Horatio, than are dreamt of in your philosophy type assertion.

The article on depression is exciting because it opens up entirely new ways of thinking of mental illness. It proves nothing, to be sure, and there are no doubt many ways of refuting the evidence it provides –including the fact that the causes of depression are likely as multifactorial as are, say, headaches or abdominal pain. One interpretation is unlikely to explain them all, I agree, but I am still beguiled by the way the observations seem to hint at commonalities. As the article points out:

In our progression toward understanding depression’s pathophysiology, we see factors that point to a relationship between depression and inflammation:

  • depression frequently is comorbid with many inflammatory illnesses
  • increased inflammatory biomarkers are associated with major depressive disorder (MDD) 
  • exposure to immunomodulating agents may increase the risk of developing depression 
  • stress can activate proinflammatory pathways
  • antidepressants can decrease inflammatory response
  • inhibition of inflammatory pathways can improve mood.

I’m not sure how this would explain the increased risk of antepartum –and especially postpartum– depression. Would the ever-changing level of hormones in pregnancy play some role in facilitating an inflammatory process? Or would the physiologic stresses engendered by the increasing needs of the developing foetus play a role? As another observation pointed out in the paper explains:

Acute and chronic stress is associated with increased availability of proinflammatory cytokines and decreases in anti-inflammatory cytokines.3,24 One theory looks to glucocorticoid response to stress as an explanation. Miller et al25 found glucocorticoid sensitivity decreased among depressed women after exposure to a mock job interview stressor and increased among nondepressed controls. Because glucocorticoids normally stop the inflammatory cascade, this finding suggests depressed individuals may not be able to control inflammation during stress.26 At the level of genetic expression, there is increased transcription of proinflammatory genes in response to stress  […]

Heuristic, to be sure, and certainly thought-provoking, but still a long way from convincing. But in Medicine, as in Science, it pays to have an open mind; to look around as you wander along long the well-trodden path. We haven’t seen everything yet; sometimes we have not even left the trail. There is something written by Lao Tzu that I have always remembered from my youthful philosophical journeys: If you do not change direction, you may end up where you are heading. Perish the thought.

Mental Health in prison?

The degree of civilization in a society can be judged by entering its prisons –Dostoyevsky got that right. But in the years since he wrote it, have we learned anything? Have we learned enough? Prisons may have changed over the years to include more individual rights, more facilities and even more education… But for the most part they still seem to function as warehouses: storage bins, where the troublesome -and the troubled– are secreted away so they are off the streets and out of the consciences of the rest of us. Out of sight, out of mind…

But as to who should be in prison, there seems to be some confusion. Some have argued that it should be a form of societal vengeance for any who have violated public normative behaviour -a way of avoiding the egalitarian justice suggested in the ancient babylonian Code of Hammurabi: the ‘eye for an eye’ principle. Some would argue that incarceration of one sort or another should be reserved for those who have both broken the law and are a danger to the public. Still others feel that for more obviously egregious transgressions -whether or not violent: white collar crimes, for example- justice is better served behind bars than with fines or mandated public service. Prison, in other words, is a punishment.

And yet, what if the crime was unintended, or indeed unappreciated? What if there was no criminal intent, no perception of wrongdoing? What if a minor misdemeanor and its subsequent detection led to behaviour that further incriminated, further entangled, and antagonized the system and its enforcers? The case of Ashley Smith and the investigation into her suicide in a prison cell while guards allegedly watched from outside the cell is merely the most recent and publically exposed example in Canada:

Self-injury is increasing in prisons: -especially amongst women inmates. That, surely, is a sign that all is not well in our prison system… A sign that we ignore at our moral peril.

I suppose that this disturbing news could be treated with a simple shrug of the shoulders and an indifferent sigh. As Oscar Wilde said, “One of the many lessons that one learns in prison is, that things are what they are and will be what they will be.” Looking at it this way, however, we learn nothing. We improve nothing. These incidents are telling us something.

That prisons are for criminals would seem self evident; that they should not include those with treatable mental pathology is less so. At first glance, the two may seem inseparable -or at least similar: surely violent criminals, chronic offenders, or even overly greedy white collar convicts have some form of mental illness -something the rest of us don’t have: something alien, unfathomable, pathological

Perhaps they do; perhaps all crime is attributable to some form of mental aberration. But in many ways, that dilutes the need to notice and treat those who have more recognizeable syndromes -syndromes more amenable to therapy. More rescuable. And it implies that such mental states are manageable within the prison system and don’t need separate facilities for successful resolution. The problem is that the primary contact with these troubled individuals is usually not by people trained for mental illness, but by those trained for suppression. Violence begets violence in response; it rarely engenders compassion, or a reasoned, helpful approach that might more successfully mitigate the behaviour. Mental illness unappreciated, is mental illness denied. Revoked. Abrogated.

No, prison is not a place for mental instability, or obvious, diagnosed mental pathology:

I mean, this should be obvious, but is frequently deceptively so. Things are seldom black and white; mental illness is one of the ‘The Great Masqueraders’ as they used to call difficult to diagnose conditions in medical school. Indeed it’s often far from obvious, and may even languish in the background, overshadowed by the actions that occasioned the arrest. We tend to focus on actions, not motives -if that’s what one would call the underlying incentive, the mental aberration that engendered the violation in the first place… We tend to see the criminality of the result, not the intent (once again to ascribe, say, an hallucination or paranoia to something as logical and thoughtful as intent is problematic at the very least).

It is clearly not an easy problem to solve, nor, given the many other issues plaguing prisons -funding priorities, training of staff, and overcrowding, to name a few- is it likely to gain the level of government support it so obviously deserves. And yet it is a priority. The very problem speaks to who we are; who we want to be. Those unfortunate enough to suffer mental illness in the system can never be properly served within the confines of an institution designed to serve other needs -warehouse needs, dare I say.

As Dostoyevsky implies, a society is judged by how it treats the most vulnerable of its members: the old, the poor, the mental disadvantaged… Remember that hymn: God sees the little sparrow fall? Justice is served, not by vengeance, but more by understanding, remediating… Caring.