Must Be Happier

It's not easy to define happiness, but someone's got to do it. Over at the Furious Seasons blog, Philip Dawdy does a magnificent job reviewing the debate over the nature of happiness taking place among psychiatrists in this month's issue of the American Journal of Psychiatry.

In the pathology-focused world of psychiatry, happiness is the absence of depression. But how absent should it be? Should we settle for "response," which is defined as at least a 50% improvement, or should we insist on "remission," generally defined as a score of 7 or less on the widely used Hamilton Depression Scale? Ever since Wyeth and Micheal Thase released their study showing (purportedly) that Effexor leads to a higher remission rate than SSRIs, the field has decided that remission is the way to go. And this is the outcome variable that was chosen for NIMH's STAR-D study, which showed that it's very, very hard to bring patients to remission, no matter how many meds you throw at them.

As eloquently argued by Dawdy and in some of the letters in the Journal, remission is an unrealistic goal for most patients, and stacking one medication on top of another may simply cause a succession of side effects. Leaving well enough alone is sometimes the best course of action, and dropping the obsession with finding the very best medication allows a focus on psychotherapy, a lost art form in this era of 15-minute psychiatrists.