MS> N.B.:  "Reactive" depression, if it meets criteria for a real
MS> (DSM-III-R) psychiatric diagnosis, responds to the treatment for
MS> that disorder as well as "endogenous" forms.  Depression is
MS> depression.

Bill Vajk replied:

 BV> Most certainly not true. A patient  may feel that way, but from
 BV> the outside the view should be quite different, and proper
 BV> classification is important for treatment. There's a world of
 BV> difference between endogenous and reactive depression.

There are several different forms of depression.  However, if a
patient's symptoms meet the criteria for the diagnosis, the
diagnosis is made.  The DSM III-R, the product of much research
and collaboration, makes no mention of causation or guesses of
how an episode started.  I would suspect that if a patient feels
as if his depression has been effectively treated, that is all any
practitioner can ask.

 BV> Endogenous depression is highly genetic and is the effect of a
 BV> lifelong imbalance in the neurochemistry of the individual.
 BV> The similarity between endogenous and reactive depression is
 BV> limited to the imbalances, stemming from emotional causes in
 BV> the reactive version, and by definition is self-correcting in
 BV> relatively short order, usually without intervention.
 BV> An individual with reactive depression may experience only a
 BV> single episode in a lifetime. Most with the neurochemistry
 BV> leading to endogenous depression are repeating victims. This
 BV> often leads to behaviors which are exciting by nature in an
 BV> attempt to cause an autonomous rebalancing of the
 BV> neurochemistry. A history of rewarding misbehaviors leads to
 BV> Pavlovian response and a continuation of such behaviors, mostly
 BV> counterindicated in the sense of a "normal" life, sometimes
 BV> long after correction of the neurochemistry. It is in this
 BV> sense that intervention in terms of counseling may be necessary.

If a depressive episode abates in "relatively short order" without
intervention, then it does not meet criteria for Major Depression,
which require a specific minimum duration.  "Endogenous" and
"Reactive" depression are old-fashioned terms which have been
superceded by much more carefully-researched descriptive
terminology.  In point of fact, both psychotherapy (but not
"counseling" which essentially means giving advice) and
pharmacotherapy have been shown to be equally effective for both
Major Depression and Dysthymic Disorder, as well as for Adjustment
Disorder with Depressed Mood.  Given the time courses of the
various illnesses and the differential risks the treatments and
illnesses, different treatments are often indicated for particular
patients.  Your exposition makes me wonder if you treat
psychiatric patients on a regular basis.  My experience is that
individuals who become depressed as a result of life experiences
(i.e., those who suffer from Adjustment Disorders) tend to have
many recurrences, and that this propensity also tends to run in
families.

 BV> The only N.B. that applies to depression these days is that so
 BV> much being discovered it would behooves interested parties not
 BV> directly engaged in research to pay close attention to those
 BV> who are. Please desist from making pronouncements as absolute
 BV> truisms based on old technology.

I would encourage you to do the same.  Neither the current
psychiatric Diagnostic and Statistic Manual nor the Research
Diagnostic Criteria makes any differentiation among depressive
disorders based on any theory of causation.  As someone "directly
engaged in" psychiatric research who also pays close attention to
others who are, I believe that the terminology I am using and my
refusal to impute any causative theory to a patient's depression
regardless whether his family just died in an airline disaster or
not (for example) represents the most current thinking of present
day American scientific (research-based) psychiatry.

-=Mark=-
(Mark A. Stevens, M.D.
 Department of Psychiatry and Behavi{*filter*}Science
 University of Texas, Medical Branch)

--  
Uucp: ...{gatech,ames,rutgers}!ncar!asuvax!stjhmc!386!1!Mark.Stevens

The way I see is, this argument really has no practical implications.  The
distinction exogenous vs. endogenous dates back to Kraepelin an the turn of
this century.  While the debate has been amusing, it has never led to anything
and, fortunately, was eventually dropped, to which DSM III-R is the evidence.

My problem with this subject is more fundamental.  To me, usual diagnoses have
only one utility--they HAVE to be entered on insurance claim forms.  Specificaly , as depression is concerned, most of my patients come to me with very real
and serious (to them) problems.  It would be abnormal of them not to be upset
about these.  It is somewhat arrogant of us, as "experts", to sit in judgement
as to whether their depression can or cannot be explained by previous life evens and, most importantly, how they have been experienced and understood by
patients themselves.  

We've already got to the point that patients come to us, tell us that they are
depressed (their definition as learned, to start with, from us and our
colleagues), we inquire about their symptoms by going through one of DSM III
laundry list and give them a prescription.  Thus, we end up medicating their
problems rather trying to learn from patients how they see them.  In this
regard, I wish that we become less interested in another newly discovered
disorder (now that we've become tired of issues of shame vs. guilt, co-
dependency, untreatable borderline personalities, we discovered a new interest--
multiple personality disorder) but, instead, acquaint ourselves with ideas of
personally and socially constructed reality and hermeneutics and would "think
through" what they mean for processes of diagnosis and treatment.  Until we do
this, holding a hammer (a prescription pad) everything is going to look like
nails.

Dr. Solomon Yusim
Private Practice (Psychotherapy)
and
Baylor College of Medicine
Houston, Texas

The very insurance companies so demanding of specific nomenclature are
also quite interested in just how Johnny broke his leg, although the
physician might not be required to include such information on his
invoice. Whether Johnny broke his leg because he was hit by a car or
because he fell out of a swing is probably unimportant to you as a
physician in determining the techniques you will use. But depression as
a recurring problem should be treated much in the same scope as if Johnny
keeps returning to you with broken limbs. Suddenly you feel bound to look
past the immediate remedies and into the causative factors, no ?

Thank you for your considered article.

Bill Vajk

What I was actually saying is that I don't see depression as a monolithic,
uniform entity.  I see people being upset (depressed) because of many, very
legitimate *to them* reasons.  I would rather talk about reasons than exhaustinconversation after "diagnosing" depression.

Solomon Yusim