Comments (Martin M. Katz)

In a relatively brief, inviting Preface, Tom Ban recounts the history of research in European psychopathology during the 20th century. He details the contributions o f many of its leading figures and covers ground unfamiliar to many American psychiatrists. These early workers arrive at different formulations of depression, different diagnostic systems and different treatments. Of specific interest is the development of “phenomenologic psychopathology” referencing the roles of Karl Jaspers and Kurt Schneider, noting that they reopened the science in a more enlightened context. The new antidepressants have clearly shaken the approaches to treatment. Such earlier theoretical concepts have been set aside as clinicians adopt a more practical trial and error approach with the new drugs and show less concern for lessons in this historical sphere. Ban is more at home in that context because the approach which relies less on ideas about etiology, provides the foundation for the methodology he will use in the book to “deconstruct major depression, (to) open the path in the study of the biology and genetics of the different depressive subtypes” In so doing he hopes to achieve a “personalized medicine” capable of individualizing the treatment approach for each depressed patient. Ban’s approach will attempt to provide psychiatrists with a new context within which to work. One can look forward to a more complete blueprint for this strategy in the text that follows.

Martin M. Katz
 July 25, 2013


Reply (Paul Devenyi)

This is a reply to this comment

Peter Martin was a very talented research fellow in the institution I used to work. I am pleased to see that he developed into a very talented and highly respected psychiatrist. His response  is eloquent, making many good points. I don't believe he is violently opposed to what I said, but he certainly has a more optimistic view about the future of addictions and their treatments, than I have. I highly respect that.

The comparison between alcoholism and type 2-diabetes is often made. Yes, insulin resistance is the underlying disease along with several other factors (genetic, immunological). If, as in Martin's example, we compare the control of diabetes as a chronic disease with that of alcoholism, the latter is so far behind that similar outcomes in diabetes would give our health care system the shivers.

I agree with Peter that "loss of control" defines addictions more than for example cirrhosis defines alcoholism; when addiction reaches the "loss of control" stage, we can really talk about a disease. I am glad Peter is optimistic that "addiction may be modified throughout a patient life using pharmacological and behavioral strategies". I think pharmacological approaches failed so far perhaps behavioral ones might produce some success.

As to "pre-morbid characteristics" being predisposing factors, I never came to term with "addictive personality". I still think addiction will be largely determined by the family a patient comes from, by cultural determinants and values of his social milieu and the peer group he associates with. Genetic factors underlying addictions have been proposed, but the evidence so far has been weak.

I still believe that "social engineering" represented by educators, the media, police, judges, social agencies, etc. could have more impact on the prevalence and perhaps the outcome of addictions, than the medical profession.

As to Peter's alcoholic who is "placed on an island where there is no alcohol, will he/she be cured or will other behaviors emerge that replace the alcohol?" As Peter, I don't know the answer either. My guess is that even after many years if escaping from the island, he/she will drink in an uncontrolled fashion again. In the meantime, if the island has a medical school, he/she may become a psychiatrist.

Peter, thanks again for your reply and I am heartened by your overall optimistic approach that an old cynic as I, doesn't have.

Paul Devenyi
October 3, 2013

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