Monthly Archives: June 2021

Photograph courtesy of Niin

Fifty years ago, smoking was commonplace. That's because scientists hadnt yet learned about the harmful effects of cigarette smoke. Once scientists began to realize that tobacco smoke caused a wide range of health problems, they started pushing for an end to traditional cigarettes.

This led to the adoption of the vape as a smoking alternative. While the first electronic cigarette was devised in the 1930s, it wasn't until the 1990s and early 2000s that it started gaining traction. Then, in 2003, Hon Lik created the first commercially successful electronic cigarette.

Since then, vaping has developed into a thriving industry and has served as an alternative to smoking for millions of people around the world. However, despite its clear advantages, vaping isnt right for everyone and isnt the ideal way to enjoy nicotine in all situations. For example, vaping indoors isnt allowed in many public settings. In situations like this, a different way to enjoy nicotine is needed.

Enter nicotine pouches.

They're smokeless, theyre discreet, theyre convenient, and according to the 250% sales increase in 2019, theres a strong demand for them in the United States.

While pouches offer a significant improvement over previous nicotine consumption products, they still have one fatal flawtobacco.

As the industry continues to evolve, consumers are constantly looking for better ways to enjoy nicotine. One of the most recent product categories that arose to meet consumers' desire to avoid tobacco and its inherent properties are tobacco-free nicotine pouches.

What are tobacco-free nicotine pouches exactly? Theyre basically the same thing as traditional nicotine pouches, however, they are made with synthetic nicotine that is not derived from tobacco. As such, they do not contain any tobacco-specific nitrosamines (TSNAs), which are thought to be some of the most potent carcinogens in tobacco products.

In European countries, such as Sweden, tobacco-free pouches have been popular for quite some time. However, until recently, only tobacco leaf-free nicotine pouches, like Zyn and Velo, had been available in the United States.

Today, tobacco-free nicotine pouch brands are becoming increasingly popular in the US as a simpler way to enjoy nicotine without the effects of tobacco.

One of the first brands that rose to meet the growing demand for a truly tobacco-free pouch product in the US was California-based NIIN with its signature line up of Zero Tobacco Nicotine Pouches, available in five long-lasting flavors (Citrus Chill, Wintergreen, Cool Mint, Spearmint and Cinnamon) and two nicotine strengths (3mg and 6mg).

Recognized by their bold, modern branding and signature zero ring emblem, NIIN Primed Pouches are made with synthetic TFN nicotine.

By focusing on innovation and quality, NIIN has created a modern nicotine product that is discreet, convenient, non-combustible, smoke-free, odor-free and mess-free and most importantly, 100% tobacco-free.

To learn more about NIIN Pouches or to inquire about wholesale/distributor opportunities, please visit https://niinpouches.com

This post is sponsored by Niin

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The Evolution of the Tobacco Industry: From Smoking to Vaping to Smokeless - CSPDailyNews.com

Women have long had successful careers in the technology sector, and as an industry, tech has come a long way to creating a better working environment that supports women from all backgrounds. Despite this, theres still work that needs to be done to ensure that women can continue to thrive balancing their lifestyle with career progression.

We often see women being celebrated externally by businesses, particularly around events such as International Womens Day, however sensationalism often plays a role in enabling organisations to simply talk the talk, not walk the walk. To see more of the latter, we need to see action from businesses that challenge the status quo and show women that their work, contributions and value are seen and appreciated.

The first step for any business wanting to create a more welcoming environment for women is to pause and reflect. Taking the opportunity to look objectively at their organisation, how many women it employs, the recruitment process and the way that it supports diversity in the work force is key. It isnt easy to take this self-critical approach, but its necessary in order to make change. Its impossible to move forward otherwise.

Next comes planning and involvement. Establish a committee dedicated to diversity and inclusion to start welcoming womens voices into the mix and hear about their personal experiences throughout their career and in their current role. This is a useful exercise to find out if people feel supported, where they might need more support, and how they would like to see the organisation operate moving forward. While tacking actionable steps may take time, its better to take a small step forward than make no move at all.

Having a diversity and inclusion committee is a great way of supporting people from underrepresented backgrounds, providing them with the space to explore challenges and offer unique insights into navigating and overcoming difficult situations in the workplace. Finding ways to empower employees and encourage them to use their voice to advocate for change, by creating an atmosphere and work environment that allows these discussions to happen, is crucial.

Additionally, it is important to have a range of networks through different D&I groups that are led by people with the appropriate life experiences to offer guidance to employees from underrepresented backgrounds. If any organisation wants to be more inclusive, then you have to give your employees the tools to make change happen and listen.

Across many industries, the pandemic has aided the levelling out of a gendered work life balance. Childcare is no longer exclusively just a female or male issue, as home schooling has required an all hands on deck approach from families. From a gender perspective, this change in work/life balance has been positive across the technology space.

Previously, women mayhave resisted promotional opportunities thinking it meant longer days or more travelling, encroaching on family life. With everyone working from home there is no need to choose between being home for the family or a two-hour commute each day because working is more accessible. By offering flexible hybrid working environments, companies will find that they are able to attract a wider pool of talented candidates, particularly women, who may have otherwise felt excluded. Similarly, from an internal recruitment perspective, more women will be likely to put themselves forward for promotion.

From a junior and graduate level perspective on gender diversity, the tech industry has come a long way to enabling younger people to feel that they can enter the sector right out of university without fear. At CGI, there have been times when there has been a greater influx of female candidates than male candidates. The challenge the industry as a whole still faces is ensuring that junior hires are getting the appropriate level of experience while working from home. To do this, businesses must ensure that women are encouraged to network among their peers, and offer people the chance to continue to learn and develop at home through online courses.

Looking towards senior hiring, the pool of women is much smaller. The industry simply wasnt where it is today 10 or 20 years ago, so there are a smaller number of female candidates applying for roles that require more than 10 years of experience. Its a sign of times gone by, however businesses can look to counteract this by creating a robust pipeline of women climbing the ladder within their organisation or fast tracking more women to senior positions.

As we look to the future of the technology industry, theres still a lot of work to do to create an environment that embraces the wide range of challenges that women face during their careers. So much great work has been done already, and in time, the entire industry is counting on more and more organisations to keep diversifying, keep listening and keep amplifying the voices of women.

Donna Kelly is CGI Vice President and Business Unit lead for South & Midlands Business Unit in the UK, which includes CGIs Metro markets across the region, HR Solutions & Payroll business and Energy & Petrochemicals business. Kelly has substantial experience in the information technology industry and previously worked as a registered nurse.

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The evolution of women in tech - IDG Connect

This article was originally published here

Acad Med. 2021 Jun 22. doi: 10.1097/ACM.0000000000004214. Online ahead of print.

ABSTRACT

The COVID-19 pandemic interrupted administration of the United States Medical Licensing Examination (USMLE) Step 2 Clinical Skills (CS) exam in March 2020 due to public health concerns. As the scope and magnitude of the pandemic became clearer, the initial plans by the USMLE programs sponsoring organizations (NBME and Federation of State Medical Boards) to resume Step 2 CS in the short-term shifted to long-range plans to relaunch an exam that could harness technology and reduce infection risk. Insights about ongoing changes in undergraduate and graduate medical education and practice environments, coupled with challenges in delivering a transformed examination during a pandemic, led to the January 2021 decision to permanently discontinue Step 2 CS. Despite this, the USMLE program considers assessment of clinical skills to be critically important. The authors believe this decision will facilitate important advances in assessing clinical skills. Factors contributing to the decision included concerns about achieving desired goals within desired timeframes; a review of enhancements to clinical skills training and assessment that have occurred since the launch of Step 2 CS in 2004; an opportunity to address safety and health concerns, including those related to examinee stress and wellness during a pandemic; a review of advances in the education, training, practice, and delivery of medicine; and a commitment to pursuing innovative assessments of clinical skills. USMLE program staff continue to seek input from varied stakeholders to shape and prioritize technological and methodological enhancements to guide development of clinical skills assessment. The USMLE programs continued exploration of constructs and methods by which communication skills, clinical reasoning, and physical examination may be better assessed within the remaining components of the exam provides opportunities for examinees, educators, regulators, the public, and other stakeholders to provide input.

PMID:34166234 | DOI:10.1097/ACM.0000000000004214

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Evolution of Clinical Skills Assessment in the USMLE: Looking to the Future After Step 2 CS Discontinuation - DocWire News

From the bottom of the oceans to the skies above us, natural evolution has filled our planet with a vast and diverse array of lifeforms, with approximately 8 million species adapted to their surroundings in a myriad of ways. Yet 100 years after Karel apek coined the term robot, the functional abilities of many species still surpass the capabilities of current human engineering, which has yet to convincingly develop methods of producing robots that demonstrate human-level intelligence, move and operate seamlessly in challenging environments, and are capable of robust self-reproduction.

But could robots ever reproduce? This, undoubtedly, forms a pillar of life as shared by all natural organisms. A team of researchers from the UK and the Netherlands have recently demonstrated a fully automated technology to allow physical robots to repeatedly breed, evolving their artificial genetic code over time to better adapt to their environment. Arguably, this amounts to artificial evolution. Child robots are created by mixing the digital DNA from two parent robots on a computer.

The new design is first sent to a 3D printer that fabricates the body of the robot, then a robotic arm attaches a brain loaded with control software inherited from the parents, along with any new components, such as sensors, wheels or joints, selected by this evolutionary process. A digital replica of every new robot is also created in a computer simulation. This enables a novel type of evolution: new generations can be produced from a union of the most successful traits from a virtual mother and a physical father, combining the benefits of fast but potentially unrealistic simulated evolution with the more accurate assessment of robots in a real physical environment. The new robots therefore inherit traits that represent the best of both types of evolution.

While this technology can operate without a human in the loop, it also allows for collaboration with a human breeder: just as humans have been selectively breeding crops since the dawn of farming, the robot breeder could influence selection of robots with particular traits. One might even imagine breeding farms, producing robots adapted to specific conditions and user requirements. They might be bred for qualities such as battery life or carbon footprint, just as we breed plants for drought-resistance or taste.

Such farms should be subject to the same strict controls and ethical considerations as, say, breeding of genetically modified crops, for example enabling an entire facility to be shut down at the touch of a button, or limiting supplies of raw materials. Furthermore, it is also important to consider the possibility that evolution might result in robots exhibiting malicious or harmful behaviours and put appropriate preventive measures in place.

The idea of digital evolution imitating biological evolution in software to successively breed better and better solutions to a problem over time is not new. It can be traced back to the 1960s when engineers in Germany programmed a computer to evolve the optimal design of a jointed plate subject to turbulent airflow. Since then, evolutionary algorithms operating inside a computer have been used to design everything from tables to turbine blades, by simply telling the evolutionary process what metric it should seek to optimise (for example, the power generated by the turbine blade). In 2006, Nasa sent a satellite into space with a communication antenna designed by artificial evolution.

We are now at a breakthrough moment. While scientists have always been confident that digital evolution could be effective as an optimisation tool, its creativity in producing original and unusual designs that would not have been conceived by a human has been more surprising. The creativity of biological evolution is clearly apparent in the natural world. In the Cuban rainforest, vines have evolved leaves shaped like satellite dishes that amplify the signals propagated by echolocating bats to direct them to its flowers, increasing pollination. In the freezing Southern Ocean, fish manufacture their own anti-freeze proteins to survive.

But numerous examples of creativity in digital evolution have also been observed. Asked to find behaviours for a six-legged robot that would enable it to walk even if it had been damaged, digital evolution discovered multiple ways of walking that used only subsets of the legs, even discovering a way for the robot to move if all its legs had been snapped off, by shuffling along on its back. In another case, it evolved an electronic circuit on a chip where elements of the circuit were disconnected, exploiting electromagnetic coupling effects specific to flaws in the silicon on the actual chip.

Digital evolution now finds application in avenues that we might imagine to be uniquely human, for example in creating music and art (even winning an award in a University of Wyoming art competition where judges were unaware the winning picture was created by an algorithm). While this may sound to the uninitiated like artificial intelligence, digital evolution is a specific subset of that wider field.

The idea of harnessing evolution to design robots is particularly appealing, especially in cases where humans have little knowledge of the environment the robot should operate in for example, undersea mining, clean-up of legacy waste inside a nuclear reactor, or using nano robots to deliver drugs inside the human body. Unlike natural evolution which is driven simply by the goals of survival and reproduction, artificial evolution can be driven by specific targets. Once this evolutionary process is set in chain, and with the technology outlined above, of a computer system instructing a 3D printer to create improved models of the robots for these particular environments, we have the beginnings of a theoretical framework for a self-sustaining robot population that is able to reproduce itself, and evolve without too much input from humans.

Which isnt to say that humans would be redundant. Digital evolution will probably be a collaborative process between human and machine, with humans providing descriptions of what is desired while evolution provides the how. So for example a human might demand an energy-efficient robot made from sustainable materials to move heavy waste inside a reactor, leaving evolution to figure out how this can be achieved. Advances in manufacturing technology that facilitate automated and rapid prototyping in a range of materials including flexible soft plastics have played an important role in enhancing our ability to replicate evolution on practical timescales.

If this all might seem to border on science fiction, there is a serious point. Robots clearly have a role to play in our future, whether in revolutionising healthcare or undertaking tasks too dangerous for humans. We are rapidly using up stores of raw materials on our planet, and current manufacturing processes increase carbon emissions and create serious problems with waste disposal. Perhaps the creativity of evolutionary methods will enable the design of new types of robot, unfettered by the constraints that our understanding of engineering, physics and materials science impose on current design processes.

From another perspective, until we discover extraterrestrial life, biologists have only one system on which to study evolution. Just as the Large Hadron Collider provides us with an instrument to study the intricacies of particle physics, perhaps a reproducing system of robots provides a new instrument to study fundamental questions about life itself.

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Robots may soon be able to reproduce - will this change how we think about evolution? - The Guardian

June 21 (UPI) -- For every animal, sperm perform the same function -- egg fertilization. Yet sperm size varies dramatically from species to species.

Most studies on the topic have focused on how sperm compete and win the race to fertilize an egg, but scientists have struggled to explain the dichotomy.

New research, published Monday in the journal Nature Ecology and Evolution, however, suggests sperm evolution is heavily influenced by the competitive environment -- the location where sperm and eggs meet.

"There is a missing piece of the puzzle -- the location where sperm and eggs meet can also influence sperm size," lead study author Ariel Kahrl, researcher and zoologist at Stockholm University in Sweden, said in a press release.

To measure the influence of fertilization location on sperm size, scientists analyzed the sperm size and fertilization dynamics of more than 3,200 animal species.

The researchers divided animals into different groups based on where the sperm meets the egg.

"In species with internal fertilization -- like mammals, birds and insects -- sperm fertilize eggs inside the female's body, while in species with external fertilization -- like sea urchins and many fish species -- sperm and eggs are released into the water and fertilization happens outside of the female's body," said Kahrl.

The data showed animals that practice internal fertilization have developed both bigger, longer sperm and more quickly evolving sperm. Species that practice internal fertilization also possess greater sperm variability.

The findings echo the conclusions of a previous study that identified the female reproductive tract as the primary driver of sperm evolution.

"When sperm are released externally, selection keeps sperm size small to allow males to produce a lot of sperm," study co-author Rhonda Snook said in the release.

"But when sperm are transferred to the females in internal fertilizers, males may compete better with bigger sperm and females may prefer to fertilize eggs with bigger sperm," said Snook, a professor of zoology at Stockholm.

Researchers also analyzed the reproductive dynamics of a third group of animals, invertebrates that practice spermcasting.

Spermcasting sees male invertebrates release their sperm into the water where it is filtered out by females before internally fertilizing the eggs.

"Spermcasting represents a mix of internal and external fertilizations, which gave us the opportunity to see what part of the fertilization process influenced sperm evolution," senior author John Fitzpatrick, an associate professor in zoology at Stockholm, said in the press release.

Spermcasting animals feature relatively small sperm, like external fertilizing animals, but showcase faster sperm evolution, like internal fertilizing species.

"Our results clearly show that interactions between sperm and females help generate the tremendous diversity in sperm size we see in animals today," said Fitzpatrick. "The greater the potential for interactions between sperm and females, the faster sperm evolve."

The authors of the new study acknowledged that not all internal fertilizing animals have large sperm.

Human sperm, for example, is about the same size as the sperm produced by spermcasting species.

"In animals with large bodies, like humans, sperm are diluted inside the female's reproductive tract," Kahrl said.

"From the sperm perspective, it doesn't matter if dilution occurs inside a female or in the ocean -- dilution keeps sperm small. It's only when sperm are confined in small spaces within the female that sperm become supersized," Kahrl said.

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Sperm evolution heavily influenced by location of eggs - UPI News

Dr Sadowsky is a leading historian of psychiatry, and one I am proud to call him my teacher. As a psychiatry resident, I attended his lectures on history of psychiatry as part of our residency didactics and benefitted greatly from them. Sadowsky was previously interviewed for Psychiatric TimesTM in 2017 by Greg Eghigian, PhD, about his book, Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy, an interview that is well worth revisiting. The present interview is about his new book The Empire of Depression: A New History. I admire Sadowsky for his ability to tackle complex and controversial issues with scholarly rigor and fair-minded appraisal, and I am delighted to have him participate in this series.

AFTAB: I suppose some folks, on hearing the title of your new book, may reflexively think, Whatanother book about depression? Dont we have enough of those already? In your opinion, why was a new history of depression needed?

SADOWSKY: Interestingly, not many of the books about depression are histories. Take The Noonday Demon: An Atlas of Depression by Andrew Solomon, PhD.1 I think it is great, but it has only a single chapter on history, and it is a brief account. In addition, with a few exceptions, most of the history books are focused on antidepressants, but many other treatments have important historiespsychodynamic psychotherapy, cognitive behavioral therapy (CBT), electroconvulsive therapy (ECT), and the many approaches that were taken prior to the 20th century, for example.

A couple of long, detailed histories of depression barely mention ECT. This is weird. I know opinions about ECT are dividedmy book about ECT is also about that controversy. However, whatever you think about ECT, many psychiatrists consider it among the best treatments psychiatry has for serious affective disorder. Imagine for a moment a medical historian in another specialty writing a long history of a particular ailment, and then only briefly noting a treatment many doctors say is among the most effective! Previous histories of depression have also been a bit weak on psychoanalysis, which is a strong interest of mine.

Little existing historiography of depression focused on patient experiences and self-representations. This is not an easy area to research, because a lot of depression treatment takes place in private office practice, a confidential setting, and documentation is not really publicly available. I would have liked to do more, but I hope I pushed the field a little in that direction. I want to add immediately that some historical and other critical studies of psychiatry see patient voices as only a way to criticize psychiatry. It is important to document patient complaints, but some critics of psychiatry go to tortuous lengths to deny any therapeutic benefits. Honoring patient voices also means seeing that many feel helped by treatment.

I also wanted to draw attention to the politics of inequality. Like so many other illnesses, depression hits different populations to different extents. Solomon drew attention to this, but most of the historical work on depression restricts inquiry to the gender ratio, which is an important axis, but not the only one. Class, race, and LGBTQ+ status, for example, also matter for depression, and I hope future historians will develop this further.

Finally, I wanted to make the story more global, less focused entirely on the West, and especially the United States, although I do give the United States a lot of attention. Anthropologists and global mental health workers have looked at the wider world, but historians really have not done so for depression. I would like to have gone further here, too, and I hope others will.

AFTAB: What I love about your book is that it does not settle for easy answers. It embraces the uncertainty, ambiguity, contradictions, and flux inherent in the very subject matter. One of the difficulties with studying depression is its a fluid entity, with variations across both time and space. Is depression the same today as it was in the 17th century when Robert Burton wrote The Anatomy of Melancholy? Is depression the same thing in the United States and, say, Nigeria? These are obviously thorny issues. Can you elaborate on the approach you take to address this? How can we tell a coherent history of something if we are having a hard time pinning down what that something is?

SADOWSKY: The various illness categoriesor, as it may be in some contexts, conceptions that are not illness categoriesare already included in a long-running discussion of the comparability of diagnostic categories and sickness experience across time and space. The discussion is a story itself.

Most of the illness states I compare have a core feature, which is excessive sadness or blue mood, in whatever that particular context considers excessive. But some definitions of depressive illness consider this a common, but not necessary, feature for diagnosis. As you know, DSM-5 does not require depressed mood as a necessary criterion for major depressive disorder (MDD), provided there is loss of interest and 4 other symptoms. I draw (lightly) on the concept of family resemblances Ludwig Wittgenstein, PhD: Things do not need precise overlaps to have similarities that justify comparison.2 For all the imperfections of the DSM, I think if you look at the menu of symptoms for MDD, they do form a constellation of related signs of suffering that have been clumped together in disparate contexts.

Overemphasizing cultural differences has its own risks. I show in chapter 1 the idea that African societies had little or no depression had roots in some frankly racist ideas. Universalizing labels can be a form of cultural imperialism, but overinsistence on difference forecloses possibilities for meaningful comparisons. And some who think depression is a purely modern or Western illness might be surprised at how many cultures, across time and space, have had some conception of excessive sadness as a malady.

Chiara Thuminger, PhD, is a great historian of madness with whom I am collaborating on a new project.

She has set forth 4 principles for comparisons across time and space3:

1. The human mind is biological, a part of a shared evolutionary heritage, so you can expect some measure of universality.

2. The mind and mental life are not confined to the brain, but involve other parts of the body.

3. Mind and brain are situated in and shaped by culture, so universality will always be limited.

4. Every individual has an irreducible quality, uniqueness.

I think these are great principles to keep in mind.

AFTAB: You are clearly dissatisfied with a lot of popular critiques of depression. You write, One thing this book is not is a long lament on the overdiagnosis of depression, and the turning of lifes normal suffering into a medical problem. Tell us more about your dissatisfaction with this line of criticism.

SADOWSKY: Many people look at the high numbers of individuals with a depression diagnosis compared with previous times and take it as self-evident that we are overdiagnosing. It is not. Rising diagnosis rates is a valid reason for concern about overdiagnosis, but it is not proof. In 1950, much of psychiatry was concerned that we were underdiagnosing depression, so from that perspective, we may be finding a lot that we had been missing. We should at least consider the upside: More diagnosis means that more individuals who could use professional help are getting it.

As for medicating the normal pain of living, we should keep in mind that getting treatment for depression, whether in psychotherapy or with antidepressants, does not protect anyone from suffering, although one hopes it is reduced. Life remains hard. And many patients with depression welcome sadness as a relief from feelings of deadness or numbness inside.

In the book, I offer some defense of antidepressants against their most severe critics. But I also think we are probably overreliant on antidepressants. I think the benefits of psychotherapy, particularly long-term insight-oriented therapy, have become underrated in the antidepressant era.

Still, why some advocates of psychotherapy are so adamantly and categorically opposed to any medication use, or to any suggestion of a biological component to depression, is a mystery to me. I have read many hardline critiques of biological and pharmaceutical psychiatry that are focused on whether the evidence for efficacy is robust, or questioning the philosophical underpinnings of the enterprise, or worried about adverse effects, or indicting the pharmaceutical industry. The thoughtful challenges have reinforced my view that we are overreliant on drugs, at least for some populations. Other critiques have struck me as dogma masquerading as critique. But even the smartest of them have not convinced me that antidepressants are worthless, a claim several important voices have made.

The biology of depression is incompletely known, and much of it may remain permanently elusive. However, the idea that depression is purely psychological is, I think, implausible. Yet, so is the view that depression is purely biological. The dichotomy itself is the problem. Mark Solms, PhD, said that mind and brain are 2 ways of looking at the same thing. I find this more helpful. I do not understand how something could affect either the mind or the brain independently of the other. That is not a coherent idea.

I am getting away from your question a little, but it is an important point. Proponents of a life history emphasis in etiology sometimes take it as self-evident that if trauma or neglect is the cause, the better solution must be psychotherapeutic, as opposed to somatic. Psychotherapy might be the better treatment, but it is not self-evident just from the etiology. And the reverse: Individuals who lean toward more organic theories of etiologygenes, brain chemistrysometimes take it as self-evident that the better solution must be something more physical, like a drug or ECT. Again, this could be true, but it is far from self-evident. In any event, I think monocausal approaches to etiology are misguided.

AFTAB: You write at one point, The growing interest in depression led more people, both professional and lay, to learn to label problems as depression, which was a growing idiom of distress before the advent of antidepressants . . . The medications, though, provided new incentives for multiple actorspharmaceutical companies, doctors, patients, and patients familiesto identify cases of depression.4 I suspect you would have been writing a very different history of depression if antidepressant medications had not been developed, or if their use had continued to be severely restricted due to tolerability.

A curious thing, however, is that anxiety disorders are more common in the general community than depressive disorders, and antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are not just antidepressants but also antianxiety medications. We could perhaps imagine an alternative history in which anxiety was the idiom of distress, SSRIs had been marketed as antianxiety rather than antidepressant, and you would perhaps be writing a book about the empire of anxiety, and the continuous historical links between melancholia and anxiety! Is it merely an accident of history that we ended up in the age of depression rather than the age of anxiety?

SADOWSKY: Cross-cultural study has shown that the separation of anxiety and depression is a convention of Western psychiatry (which is rapidly becoming a global or cosmopolitan psychiatry, with both good and bad effects). Many healing systems around the world assume anxiety and depression are aspects of a single thing. And even in the West, the separation is somewhat new, a Kraepelinian innovation.

You present an interesting counterhistory. However, I am not sure the trajectory has been solely drug-driven. When the monoamine oxidase inhibitors and tricyclics were developed, psychiatrists were looking for depression treatments, and they had been doing so for decades. That is partly why these drugs came to be called antidepressants.

One curious thing is that important anxiety medications and antidepressants were introduced around the same time, and yet from a broad cultural point of view, we had first an age of anxietythe immediate postwar periodfollowed by an age of depression, which started sometime in the 1970s and became more visible in the 1980s. In what I consider the most speculative portion of my book, I try to understand those periods as possibly representing wider cultural moods, perhaps rooted in different forms of capitalism. As speculative as that section is, I included it because I thought it was worth thinking about.

AFTAB: You dont spend much time discussing the creation of MDD as a diagnosis in DSM-III. I wonder how different the future course of events would have been in the absence of such a diagnostic category. If you look at DSM-II, depression was fragmented across many different sections under many different diagnoses. In DSM-II, we had diagnoses such as involutional melancholia, manic-depressive illness, depressed type, psychotic depressive reaction, depressive neurosis, and neurasthenic neurosis. I suspect that this DSM-II organization of depression would not have been particularly conducive to the process of empire-building!

SADOWSKY: That is a great question, and I could have given this change more attention in my discussion of the DSM. However, I wonder if the creation of the category (if not the precise name) of major depressive disorder was already in process before DSM-III, reflecting the growing research interest in depressive illness in the years preceding the revision of the manual.

AFTAB: When I look back at the evolution of depression, a pair of developments in recent decades appear to me to be notable, although their historical significance is probably yet to be seen. The first is the notion of treatment-resistant depression (TRD). This has led to more aggressive pharmacotherapy, such as augmenting with atypical antipsychotics, and the relatively recently approved medication esketamine.

The second is that bipolar disorder has been steadily encroaching on the territory of depression, such that even in the absence of mania or hypomania, many psychiatrists classify the presentation as being on the bipolar spectrum. Just as the development of antidepressants led to an increase in the diagnoses of depression, development of medications for bipolar depression have led to an increase in the diagnoses of bipolar disorder. Any preliminary thoughts of these developments as a historian?

SADOWSKY: It is, of course, awful that some depressions are so hard to treat. I am not a clinician, but I wonder if many of those that seem resistant to aggressive medication treatment might respond to intensive psychotherapy, which can be expensive, or to ECT, which has risks of adverse effects (risks which are, in my opinion, generally greater than the risks of antidepressants, although I think in some cases, the risks may be worth it).

As a historian, however, I would ask if the whole category of TRD does not actually represent some progress, since it implies the other kind. A 19th-century alienist could not do much about any severe depressions at all. Many of my colleagues in history of medicine, and especially history of psychiatry, get nervous at any hint of a progress narrative, but I do not mind saying I think we have a better repertoire of treatments for depressive illness now than we did in 1850. All the treatments have downsides, but that is true of medical treatments in general.

I am aware of the rise of bipolar diagnosis, but I have not followed it closely. From a practical point of view, of course, what matters about a label is matching the individual in pain to the best treatment possible, and that is a clinical question. My historians take is: The safest prediction is that changes in diagnostic fashions are going to keep happening, and they will not necessarily be driven by genuine scientific advance. The whole enterprise is not worthless, but we should not assume the present trend represents the final or best word. On this point, I do worry about progress narratives.

AFTAB: In a very memorable passage of your most recent book, you compare history with psychoanalysis: [P]atients are locked into repeatedly telling the same story about themselves about their loneliness or their victimization, for example. The therapy helps patients see that they do not have to repeat the same story. They can tell new stories of their lives. History can have a similar role . . . We do not have to live the same story, time after time.4 Later, in the epilogue, you again refer to history as a means of guarding against compulsive repetition. Can you summarize what history tells us we can do differently going forward when it comes to depression?

SADOWSKY: I will name 2 things. First, we do not need to keep having the same arguments about whether depression is fundamentally biological, or really the result of trauma in life, or the result of social forces. I fear that we will continue to do just that, because of the tenacity with which some individuals hold to the insistence that we must choose. It is my hope that by showing historically how insistence on a single approach leads to dead ends, we might be liberated from it. In the epilogue, I used the image of a quarreling couple, stuck in the same fights for decades on end. A good marriage counselor might be able to remind each partner that the other has things to offer.

I also hope we might be liberated from the cycle of hype and disappointment about new treatments. Most of the major treatments for depression over the last century (psychoanalysis, ECT, CBT, and antidepressants) have been overemphasized by some zealous proponents. Then disappointment (dare I say, depression?) comes when the harms or limitations of the treatments become clear. In turn, we rush to condemn the old treatment as worthless and latch on to something new, which is thought to lack the flaws of the earlier ones. But the old treatments still had something to offer, and the new ones prove to have flaws, although we may not see them right away.

New treatments are going to come, as they should. When they do, let us try not to overdo the hype, the radical rejection of the old ones, or the disappointment in the new that follows. In addition to helping patients overcome repetitions, psychotherapy can help patients to see individuals in and things in their complexity. Sometimes we, as professionals or as whole societies, can act like an individual searching for love, and finding partners we initially idealize, only to come to despise them when they inevitably disappoint us. We would do better to tolerate ambiguity. I hope Empire of Depression might help to foster that toleration.

AFTAB: Thank you!

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric TimesTM.

Dr Aftab is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric TimesTM Advisory Board. He can be reached at awaisaftab@gmail.com or on twitter @awaisaftab. Dr Sadowsky is the Theodore J. Castele Professor of the History of Medicine and Associate Director of the Program in Medicine, Society, and Culture at Case Western Reserve University, Cleveland, Ohio. He holds secondary appointments in the Departments of Bioethics and Psychiatry. He earned a PhD in history from Johns Hopkins University and also studied psychiatric epidemiology at Columbia University. He has authored numerous articles and books, most recently The Empire of Depression: A New History (Polity Books; 2020).

Dr Aftab and Dr Sadowsky have no relevant financial disclosures or conflicts of interest.

References

1. Solomon A. The Noonday Demon: An Atlas of Depression. Simon & Schuster; 2001.

2. Wittgenstein L. Philosophical Investigations. Basil Blackwell; 1953.

3. Thumiger C. A History of the Mind and Mental Health in Classical Greek Medical Thought. Cambridge University Press; 2017.

4. Sadowsky J. The Empire of Depression: A New History. Polity; 2020.

Read more from the original source:

Exploring the Evolution of Depression - Psychiatric Times