Stop comparing depression to diabetes

At the recent gubernatorial candidates forum on mental health, Martha Coakley repeated the oft-heard phrase that depression is like diabetes. Her motivation was good, the idea being to reduce the stigma of mental illness, and to offer “parity” or equal insurance coverage, for mental and physical illness. However, I am concerned that this phrase, and its companion, “ADHD is like diabetes,” will, in fact, have the exact opposite effect.

A recent New York Times op-ed, “The Trouble with Brain Science,” helped me to put my finger on what is troubling about these statements. Psychologist Gary Marcus identifies the need for a bridge between neuroscience and psychology that does not currently exist.

Diabetes is a disorder of insulin metabolism. Insulin is produced in the pancreas. The above analogies disregard the intimate intertwining of brain and mind. For the pancreas, there is no corresponding “mind” that exists in the realm of feelings and relationships.

While there is some emerging evidence of the brain structures involved in the collection of symptoms named by the DSM (Diagnostic and Statistical Manual of Mental Disorders), there are no known biological processes corresponding to depression, ADHD or any other diagnosis in the DSM.

These collections of symptoms, intimately intertwined with feelings and relationships, are problems of behavioral and emotional regulation. The capacity for emotional regulation develops in relationships.  If DSM diagnoses can only be legitimized by comparing them to diabetes — and food allergies, as was recently done by the director of the NIMH (National Institute for Mental Health) — this comparison may increase, rather than decrease the stigma by devaluing relationships and our basic human need for meaningful connection.

The primary treatment for diabetes is a drug. This analogy works if we accept that the primary treatment for mental illness is drugs. The pharmaceutical industry would be pleased with this approach.

But, in fact, the primary treatment for problems of emotional well-being is time. What is needed is time and space for listening, where individuals can have the opportunity to have their feelings recognized and understood. In this time and space, people can make sense of, and find meaning in, their experience.

A model that compares depression to diabetes is an illness model. It promotes a kind of “there is something wrong with you and I will fix it” approach.   It is not simply a question of “therapy vs. medication” as many “evidence-based” research studies suggest. It is a question of a completely different model, a resilience model. Such a model, that values time and space for listening and being heard, seeks to help people reconnect with their most competent selves.

But we will only get there is we stop comparing depression to diabetes.

Claudia M. Gold is a pediatrician who blogs at Child in Mind and is the author of Keeping Your Child in Mind.

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  • JR DNR

    I think that depression and anxiety are symptoms rather than illnesses in themselves, and that many times those symptoms can be improved without medication. That’s also why there was such a “high” standard between feeling “down” for a time and having a mental illness diagnosis in the DSM4 that the DSM5 threw away.

    We cannot deny that there are people with serious, treatment resistant depression whom can live more normal lives with the routine administration of Ketamine. Denying that there is something “biologically” wrong, even if we don’t know what it is exactly, is doing these people a grave disservice.

    “There are no known biological processes corresponding to depression, ADHD or any other diagnosis in the DSM.”

    What about NK immune cells and depression? Or Gamma delta T lymphocytes and PTSD? We know that blood flow to the brain changes during traumatic events associated with PTSD… but we don’t count that as as a “biological process?” Something that causes a brain to develop abnormalities… isn’t a “biological process?”

    • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

      I believe Dr. Gold misspoke a bit when she wrote “there are no known biological processes…” There are clearly biological correlates to a number of DSM disorders. The accurate statement: there are no known biological etiologies corresponding to depression, ADHD, or any other diagnosis in the DSM (except for certain obvious ones, such as drug intoxication and withdrawal disorders). See:
      http://www.kevinmd.com/blog/2014/05/dealing-behavioral-conditions-unknown-etiology.html

      • JR DNR

        The statement in this article sounded like there were no biological causes either identified or ever to be found.

        That’s known as an argument from ignorance.

        • http://blog.stevenreidbordmd.com/ Steven Reidbord MD

          I went back and re-read the post — and you’re right. Apparently being agnostic is harder than it looks.

          • JR DNR

            There was an article over on Medpage on how Physical Therapy was more effective for shoulder pain than injections (drugs).

            That doesn’t mean we deny a biological process for shoulder pain! It’s just that non-medication methods may have a better overall outcome and have less side effects than a medicated method, which I agree with.

  • Acountrydoctorwrites

    If anything, we need to find the courage to turn the analogy around. Yes, we know diabetics (Type 2 Diabetics, that is) run out of insulin, largely because they are insulin resistant and, like someone hollering at someone with impaired hearing, sooner or later they can’t yell anymore. BUT we don’t quite understand WHY people get to that point. Why do some people eat more carbs than their body needs? Why do some people continually take in more calories than they need to maintain weight and activity level?
    Diabetes and depression are both mysterious conditions in the sense that the body’s and brain’s desire and ability to achieve optimal well being is impaired for unknown reasons through relatively unknown mechanisms.

  • John C. Key MD

    I don’t think it is helpful for you to break this analogy down to the mitochondrial level–after all, it’s just a figure of speech! Nobody is seriously trying to compare pathophysiology here. I have used and heard this analogy used for fifty years.

    In fact I think it is a useful, helpful, and comforting analogy to patients and to families, to wit: both conditions are common, shared by much of humanity–you need not feel ostracized. Both are treatable and through careful management and mindful living those with the conditions can live full and rewarding lives. Both conditions can get out of control and require a little intensive treatment from time to time. Finally, if not treated adequately or ignored, both conditions can lead to death.

    In sum it seems to me to be an easy and appropriate way to communicate a new diagnosis to laypeople who may not have a full medical understanding of diseases.

    As Charlie Daniels sang, “That’s the way I see it/I’m a simple man.”

    Lighten up.

  • iphone12

    The problem with the analogy is it is based on the lies perpetuated by psychiatry and the drug companies for several years that depression is due to a serotonin chemical imbalance and taking an SSRI will restore the correct level. In reality, it can’t be measured because it is in constant fluctuation. Whereas, a diabetic’s blood glucose level can definitely be measured which guides how much medication or insulin they need.

    It is also a very insulting comparison as if god forbid, someone is hospitalized for depression in a psych hospital, the chances of them being treated worse than a criminal are very high. vs. someone hospitalized for diabetes in a regular hospital who is treated like a human being.

  • querywoman

    So many doctors look at a person and diagnose depression! The anti-psychiatry types always point out there is no specific depression. However, most people go to a psychiatrists voluntarily seeking help for a mood problem.

  • JR DNR

    I know this is a bit late but thank you for your comment.

  • JR DNR

    Oh look at what was just published this month – one gene that changes the expression of 100 other genes in neurons:

    http://www.eurekalert.org/pub_releases/2014-08/jhm-scr081514.php

    Huh, that’s not related to a brain structure at all, but… a clear biological process brought on by gene expression that causes schizophrenia, major depression, or bipolar in carriers.

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