Barry Blackwell: The Baby and The Bath Water

Edward Shorter’s reply to Leonardo Tondo’s comment on Edward Shorter’s Comment

         I guess it’s probably time to stop thrashing around in this muddy metaphor about baby and bathwater.  Professor Tondo’s comment raises three issues:

1.  On the difference between suicide attempts and completed suicides:  These are two separate phenomena and should not be discussed as though there were a single scale called “suicide competence,” and suicidality should be arrayed along it in terms of very successful (completed) suicides versus incompetent suicides (“three attempts”).

         Rather, suicide attempts should be considered as attempts at communication (“I’m very unhappy and this is my mode of letting you know”).  Completed suicides, on the other hand, seem to stem largely from melancholia.  There is no attempt at communication; often there is no note.  The suicide-completer is driven by melancholic brain disease that may have little to do with his or her life situation.

         Lumping these quite separate forms of behaviour together ensures that we will understand neither.  It is nothing short of a tragedy that DSM-style psychiatry has virtually abolished melancholia and replaced it with something called “major depression,” which is like lumping trucks and motorcycles together as “motor vehicles.”  (Both are forms of transportation, just as melancholia and neurasthenia both affect mood, but have little else in common.)

2.  Discussions of “antidepressants” and suicide must carefully distinguish between melancholia and neurasthenic depression.  In melancholia, the risk of suicide is non-trivial and the classic TCAs and convulsive therapy are clearly the remedies of choice.  Other “antidepressants,” namely the SSRIs and SNRIs (as though there were a difference between these acronyms!) may be consigned to the limbo where “Carter’s Little Nerve Pills” currently reside.

3.  If there were an underlying problem of psychopharmacology here, it would be the field’s decision to ditch pharmacy-EEG in favor of a single-minded focus on “neurotransmitters.”  Neurotransmitter research has guaranteed that we have not had an innovative new drug class in the last thirty years.  Pharmaco-EEG was capable of distinguishing which classes of medication actually affected the brain.   This might be something to think about . . . .

April 4, 2019