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A guy walks into a bar. Let's even say for the sake of the argument that he is depressed. This is not about what you think will happen next. This is about the right way to treat his depression; and, if you were to treat that depression, it would be about what he thinks, feels, expects, or doesn't. Such is Paul Biegler's argument in The Ethical Treatment of Depression, published by MIT Press in 2011. The book was originally his PhD dissertation in philosophy and in it he says something new about psychology's debate with psychiatry; in particular about the choice between medication and psychotherapy. Biegler's novel contribution is that he makes the psychological treatment of depression into a moral issue and an imperative.
If Biegler is a lumper with respect to antidepressant medication, all of which he calls ADM, he is a splitter when it comes to concepts like autonomy (instrumental/intrinsic), agency (hierarchical/historical/life plan/reasons responsive), standards of belief (true/justified), information (material/relevant), prudential value (subjective/objective), liberty (positive/negative), hedonism (narrow/preference), and moral theory (theory of the good/theory of the right (consequentialist/non-consequentialist)). These early chapters on autonomy appear to be laying the groundwork for a case against paternalism in medicine but it turns out that Biegler needs a theory of autonomy in order to be able to say that depression undermines it. He makes a clever and credible leap from a notion of autonomy requiring "justified beliefs about material facts" to an autonomous individual's need for "justified beliefs about affect." Next he reviews various perspectives on the important role that affect plays in decision making including William James' theory of the somatic origin of emotions; that interoceptive stimuli converge on the insula; that subliminal pictures of snakes subconsciously activate fear via subcortical pathways to the amygdala; that disconnection syndromes interrupting affective circuits impair decision making (Damasio); and that emotions act as promoters of "action readiness" (Frijda).
The book begins to feel structured like a syllogism in the middle chapter which is about depression as a disorder of affect and thereby also of autonomy. Biegler embraces the idea "that affect and cognition have a mutually reinforcing relationship" such that depression can skew perception, distort thinking, misrepresent reality, warp stressor appraisals, cause false pessimism, and lead to a blinkered acceptance of false cognitions, etc (Beck). Pertinent empirical work documenting various negative information processing biases in depression is reviewed. Biegler's conclusion that depression erodes autonomy depends on a model of depression in which the majority of depressive episodes are triggered by stressors (Kendler) in those with a pre-existing vulnerability to them (Kramer).
Biegler makes use of his conceptual framework on autonomy in the later chapters on the therapeutic goal of understanding those causal stressors and negative information processing biases. He compares the debiasing effects of CBT with the non-equivalent debiasing effects of ADM (Harmer). CBT is preferable to ADM because only CBT promotes awareness of those information processing biases; because the greater awareness of biases that comes from CBT helps to protect against recurrences; and because, unlike ADM, CBT does not blunt sensitivity to negative emotional stimuli.
There was a landmark case against a psychoanalyst in the pre-SSRI era who for years tried to talk a patient out of his depression without prescribing any ADM. Biegler's thesis highlights how far the pendulum has swung in the other direction. Biegler doesn't like paternalism in medicine, he likes informed consent and patient empowerment. He offers the example of diabetes self-management education as a model of autonomy-maximizing treatment and invokes a "parity of reasoning" argument to urge that the DSME model be applied to the treatment of depression. This is not an anti-psychiatry book because, even though he explicitly puts more emphasis on stress than on biology in depression, he never recommends against the use of antidepressants. In that sense The Ethical Treatment of Depression contributes, in my opinion, to a hopeful trend toward more widespread application of insight oriented psychotherapy augmenting or augmented by the use of antidepressants. As Biegler says, "The question arises whether doctors who seek to promote patient autonomy through the provision of psychotherapy should accede to the autonomous requests of patients to receive ADM … in the current climate, the depressed person who autonomously chooses ADM over CBT should undoubtedly have that wish respected."
© 2011 Alan Stearns
Alan Stearns, MD, practices addiction psychiatry in Queens.
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