Elsevier

Medical Hypotheses

Volume 72, Issue 1, January 2009, Pages 1-7
Medical Hypotheses

Editorial
A model for self-treatment of four sub-types of symptomatic ‘depression’ using non-prescription agents: Neuroticism (anxiety and emotional instability); malaise (fatigue and painful symptoms); demotivation (anhedonia) and seasonal affective disorder ‘SAD’

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Summary

This article will present a model for how ‘depression’ (i.e. depressive symptoms) can be divided into four self-diagnosed sub-types or causes which might then be self-treated using agents available without prescription. (Another, much rarer, cause of depressed symptoms is the classical illness of ‘melancholia’, which when severe cannot be self-treated and typically requires hospitalization.) A self-management option and alternative is now needed due to the an inappropriate emphasis of modern psychiatry on treatment of imprecise syndromal ‘disorders’ which may entail treating ‘depression’ at the cost of making the patient feel and function worse. By contrast, the basic theoretical stance of self-management is that depressed mood should be seen as a result of unpleasant symptoms – and it is the symptoms that require treatment, not the mood itself. Furthermore, drugs (or other interventions) need to be classified in terms of their potential therapeutic effects on these symptoms that may cause depressed mood. The four common causes of depressed mood considered here are the personality trait of Neuroticism; the state of malaise (fatigue, aching etc) which accompanies an illness with an activated immune system; demotivation due to lack of positive emotions (anhedonia); and the syndrome of seasonal affective disorder (SAD). Each of the four sub-types is then ‘matched’ with a first–line non-prescription agent. The ‘stabilizing’ agents such as St John’s Wort and the antihistamines chlorpheniramine and diphenhydramine are used for treatment of Neuroticism; analgesics/pain killers such as aspirin, ibuprofen, paracetamol/acetaminophen and the opiates are used to treat malaise; energizing agents such as caffeine and nicotine are used for the treatment of demotivation; and bright light used in the early morning to treat SAD. Self-treatments are intended to be used after research and experimentally, on a trial-and-error basis; with self-monitoring of beneficial and harmful effects, and a willingness to stop and switch treatments. The model of S-DTM (self-diagnosis, self-treatment and self–monitoring) is suggested as potentially applicable more widely within psychiatry and medicine.

Introduction

The gross imprecision of the diagnosis of ‘depression’ has become farcical in recent decades, when the supposed prevalence of ‘depression’ has risen from a fraction of a percent by about a hundred-fold to anything from ten to twenty-five percent [1], [2]. Nowadays, any person suffering a persistent unpleasant emotional state may be officially diagnosable as depressed, and treated with drugs termed ‘anti-depressants’.

I have previously argued that the disease category of mood (affective) disorder called depression is neither coherent nor useful; and instead it would be preferable to regard ‘depressed mood’ as secondary to a variety of unpleasant emotional states [3]. In other words, depressed mood should be seen as caused by symptoms and emotions – for example anxiety, fatigue or lack of positive emotions (anhedonia) can all lead to depressed mood. Diagnosis and treatment of ‘depression’ should therefore be focused on the emotional states which cause depressed mood, and not upon treating a vaguely-defined – hence over-inclusive – syndrome termed ‘depressive disorder’. In principle there might be an unbounded number of causes of negative, depressed states of unhappiness – in practice, I will focus upon four which are apparently amenable to improvement by therapeutic intervention.

I have also argued that the term ‘anti-depressant’ should not be used, since there are no drugs which have a general action to alleviate depressed mood: what the effective drugs are really doing is to alleviate the causes of depressed mood [3]. There are a variety of different drugs types which can alleviate some symptoms that may lead to depressive symptoms in some people. For example, when anxiety is causing depressed mood then any drug which reduces anxiety (including alcohol, neuroleptics/antipsychotics, benzodiazepines or selective serotonin-reuptake inhibitors – SSRIs) may all (for a while) alleviate ’depression’. But when a person’s depressed mood is not caused by anxiety then these same drugs could be ineffective or may actually worsen the depressed mood.

I believe that a self-management option and alternative [4] is now urgently needed (at least in the UK and USA) due to the incorrect and counter-productive theoretical stance of modern psychiatry [3], the corruption of modern psychiatry by industrial and political influences [2], and the inappropriate emphasis of modern psychiatry on treatment of syndromal ‘disorders’ [3], [4]. This focus on syndromes may lead modern psychiatrists to treat ‘depression’ at the cost of making the patient feel and function worse [5].

This is the rationale and justification for the following article, which represents a personal view – speculative and tentative – of a possible future for psychopharmacology in psychiatry, specifically in relation to negative symptoms of ‘depression’ such as sadness unhappiness, lack of motivation, long-term miserable anxiety, unpleasant mood swings and the inability to feel happiness. My hope is that these ideas are sufficiently accurate and valid to be useful and applicable – but also that they will stimulate discussion and serve as a basis for a process of evolution and improvement.

By extension, this general model of self-diagnosis, self-treatment and self-monitoring (S-DTM) could potentially be extended to other areas of psychiatry and medicine in which symptoms are the focus and where effective treatments are available without prescription. Indeed, as well as being used to alleviate negative states, the model is also applicable to lifestyle/quality of life enhancement [3], [5].

I believe that, one the one hand, the treatment of depression can be more specific and effective than at present; but on the other hand it is also correct that the psychoactive drugs are all imprecise in their effects, and in particular tend to affect different people differently. This means that psychiatric treatment (whether self-treatment or treatment by professionals) is almost inevitably a trial-and-error matter, and should be embarked-upon in an experimental spirit.

Psychiatric drugs (and also some other psychiatric interventions such as electroconvulsive therapy and perhaps bright light) tend to be non-specific in relation to traditional diagnostic syndromes [3]. Different categories of drugs such as ‘antidepressants’ and the neuroleptics/antipsychotics often have over-lapping therapeutic effects, side effects and indications – mainly because many of the most-used drugs were chemically-developed from a relatively small number of coloured dyes which were initially made into antihistamines during the 1940s then further modified over the following decades to make the neuroleptic/antipsychotics, tricyclic and SSRI antidepressants [1], [6], [7].

So, drug recommendations for symptomatic treatment in psychiatry are mainly about suggesting which drug to try first. There needs to be an attitude of trial-and-error; with self-monitoring of the effects of treatment, willingness to change to stop treatment or change to another treatment if the first choice has undesirable side effects or is apparently ineffective.

With these cautions in place, I see no compelling reason why people should not self-treat for psychiatric symptoms using drugs which are available ‘over the counter’ and without prescription. After all, in a country such as the UK or the USA people in their tens of millions already self-treat for headaches and back pains, constipation and diarrhoea, runny noses and blocked noses, hay fever and eczema, high cholesterol, skin infections and duodenal ulcers. And in a world where it is common to assert that anything up to half the population have significant psychiatric symptoms of some sort (e.g. depression, anxiety states, various phobias and compulsions, insomnia) then self-treatment become a practical necessity.

Furthermore, I suggest that symptomatic self-treatment for ‘depression’, when done by careful and informed people, might well be superior to the average treatment on offer from psychiatric professionals. The main constraint is the limited range of drugs available without prescription (especially, see below, in the case of demotivated depression); but this restrictive public policy may change over time or be circumvented by the increased ease of purchasing pharmacological agents without prescription.

The process by which self-diagnosis may be accomplished requires some elucidation. I have previously termed the sequence S-DTM – meaning Self-Diagnosis, self-Treatment and self–Monitoring. The aim is to introduce to self-management a helpful degree of thoroughness and formalization to make the process both safer and more effective than unstructured self-management.

The first step involves developing self-awareness of symptoms. The word ‘phenomenology’ refers to the process of introspection or inward-looking by which a person can become aware of their inner, subjective states – psychiatric symptoms are one of the body states which may be accessible to such introspection [3], [8], [9]. To self-diagnose by introspection requires a skill which may be unfamiliar. For example, it is possible to be anxious but unaware of the anxiety [10], [11]. To become aware of anxiety as a feeling, a person needs to be able to identify their own state of mental angst, muscular tension, rapidly beating heart, sweatiness, ‘butterflies in the stomach’ and so on.

Furthermore, inner states must be identified in terms of a system of classification – because body sensations tend to be experienced as formless and undividedly ’holistic’ unless there is a systematic classification which can describe them. Without some such analytic scheme, it may not be possible for someone to be aware of, and to express even to themselves, much more than a simple dichotomy of feeling either ‘good’ or ‘bad’. Self-treatment, however, requires that different types of ‘feeling bad’ can be distinguished and identified.

In terms of ‘depression’ – the process begins with recognition of a depressed mood, in other words a negative or unpleasant mood state which could be characterized by some kind of unhappiness. Then there is a further introspective process by which the sufferer tries to identify some inner physical, bodily state which may be the main cause of this unhappiness. The assumption is that if this causal symptom can be alleviated or eliminated then the person may become happier.

Happiness is not necessarily entailed by removing the cause of unhappiness, but it is easier and more probable that a currently-unhappy person will become happy if they are relieved of unpleasant symptoms. For example, it is hard to be happy when suffering a headache and relief of the headache may therefore cause a person to become happy who would otherwise have remained miserable.

More exactly, there is an attempt to match-up inner states against a pre-determined classification. Four body states which may cause unhappiness include emotional instability with anxiety (Neuroticism); fatigue and bodily aches and pains (malaise); lack of emotion – especially loss of the ability to anticipate future pleasures (demotivated depression); and sleepy, hungry, irritable mood specifically during the winter season (SAD).

Having identified a particular aversive body state as a probable cause of depressed mood, this symptom is then made the focus for self-treatment; and the symptom is monitored for its response to treatment. A treatment agent or mode is selected as being both safe and potentially able to alleviate the specific symptom, and a trial of this treatment is made. So, if the symptom underlying depressed mood is identified as anxiety and unstable emotions then stabilizing drug is chosen (such as St John’s Wort or chlorpheniramine – see below); and the symptom is monitored to see whether it responds to this treatment.

Section snippets

Self-diagnosis

  • 1.

    Recognition of a depressed, unhappy, low mood.

  • 2.

    Introspective self–diagnosis of the sub-type of symptomatic and emotional cause of depressed mood.

  • 3.

    Matching the symptoms and emotions to one of the four sub-types of ‘depression’.

  • 4.

    Matching the sub-type of depression to the drug class which is most likely to alleviate those symptoms and emotions.

  • 5.

    Researching the scientific literature on the effects, side effects and possible interactions of the drug class – and choose a (probably) safe first-line agent.

Self-treatment

  • 6.

Conclusion

The main benefits of the S-DTM approach to self-management of psychiatric symptoms using non-prescription drugs (Table 1) is that it allows people to avoid contact with modern psychiatry and to maintain control of their own therapy and tailor treatment to their own needs. The main limitations are those of limited (or inaccurate) knowledge, difficulties of introspection and self-monitoring, and the restricted range of treatments available without prescription.

One major advantage of a more

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