Psychiatry may not care about apathy, but that doesn't mean you shouldn't

by John McManamy


YOU KNOW what it’s like. Someone has seemingly pulled the plug and the power drains out. Your get up and go just got up and went. Life, the universe, everything – nothing matters as you shuffle through the clutter on the floor and flop into an unmade bed, your only refuge in a world you have given up on, that has seemingly given up on you.

Apathy is also used to describe indifference, such as to politics or NASCAR racing, but in a psychological context we are talking more like the opposite of motivation, the lack of will to go on and the inability to care about the consequences.

Andrea describes it this way:

I am so lethargic and cannot find anyway out. ... I cannot seem to make myself do anything. All I want or seem to be able to do to get out of bed is get the newspaper and try and read it, smoke, or open a can of something or eat a box of ice cream, watch TV or surf the internet, and now a new addiction - buying things on E-Bay! Getting expensive!!! ...

I make jewelry and used to love it, but now can't complete anything and am in such a mess with my beads I don't think I'll ever get them straightened out. I've gained 40 pounds, don't care about my appearance, can't clean the house, etc etc. I feel I have all the symptoms of depression, plus I can't feel any excitement about seeing loved ones, can't think of anything, or anywhere I want to be but in my bedroom.

The Prize Patrol could probably show up on Andrea's door with a check for 25 million dollars, and she would still feel flat. Or even if she levitated to the ceiling in exultation, it wouldn't be long before she went back to her current life in a darkened room, even if that room happened to be part of a new mansion in the Hamptons.

What We Know About Apathy and Depression

So is apathy part of depression? The  DSM is virtually silent on the topic, as is the depression literature. Depression is generally characterized by too much emotion, but the DSM implicitly acknowledges we can experience too little. One of the two major depression symptoms is loss of interest or pleasure, such as in a hobby. Basically, we stop caring.

What’s missing here is that lack of caring doesn’t necessarily stop at pleasure (see article). We can also become desensitized to grief or to something bad happening, but we’re not likely to see psychiatry weigh in on this any time soon.



The people doing the actual talking are the neuropsychiatrists, and they’re not giving depression any respect. In a groundbreaking article in the Summer 1991 Journal of Neuropsychiatry and Clinical Neurosciences, Robert Marin MD of the University of Pittsburgh argued that it is illogical that depressed people, who experience emotional pain, can suffer from a state of mind that is characterized by a lack of emotion.

Martiin Levy MD of UCLA is even more blunt. "Apathy is Not Depression," he and his colleagues assert in bold in the title of an article in the Summer 1998 Journal of Clinical Neuropsychiatry.

Dr Marin and other neuropsychiatrists perceive apathy in the context of brain damage rather than as a sign of emotional distress or cognitive impairment. They see apathy as the result of neuropsychiatric illnesses such as Alzheimer’s, dementia, Parkinson's, or Huntington’s, or else an event such as a stroke, involving disruptions to frontal-subcortical pathways that are fueled by dopamine and acetylcholine

Dr Marin would like to see apathy regarded as a syndrome (sort of like an illness). He also views apathy as a symptom when it is associated with the likes of Alzheimer’s. There is already a precedent in sleep, which constitutes a number of DSM disorders, as well as being listed as a symptom for depression and mania.

Can Dr Marin’s views be reconciled to depression? Yes, when the lack of caring factor is taken into account. In this context, apathy would be a symptom of depression. As a separate entity, it could be that apathy co-occurs with depression, much like anxiety and depression hook up as the Bonnie and Clyde of the brain. One can even make a case for apathy-driven depression.

Obviously there’s much to discuss, but first psychiatry needs to join the conversation.




Caring About Apathy

Clearly apathy and depression are related. A review article by Robert van Reekum MD et al of the University of Toronto in the Winter 2005 Journal of Neuropsychiatry reports on studies that found both apathy and depression endemic in populations with neuropsychiatric diseases and brain damage. Few were just one or the other. Depression and apathy were a package deal.

In a poster presented at the 2000 American Psychiatric Association’s annual meeting, Robert Morton MD et al of the University of Oklahoma reported on their study that examined 126 depressed or bipolar outpatients for apathy. They found that 79 percent met Dr Marin’s criteria for this state of mind.

Certainly, apathy rates a mention in a future DSM (not that it will ever happen), if for no other reason than to put on notice the people who treat us. At the 2005 American Neuropsychiatric Association annual meeting, James Duffy MD of the University of Connecticut urged its inclusion in the next edition. "Patients who are apathetic do not take care of themselves as well as patients who are not apathetic," he argued. But he was talking in the context of neuropsychiatric illnesses.

So far, apathy has no champion from the depression quarter, which explains why you won't see apathy in the DSM, not that anyone cares.



But you need not sit helpless waiting for psychiatry to get its act together. Whether apathy is part of depression or not, there are tests to tease it out, which is all that counts. The Apathy Evaluation Scale, devised by Dr Marin, asks questions such as whether you like to see a job through to the end and whether you need to be told what to do, and so on. Feel free to ask your therapist to administer it to you.

Small studies and clinical experience have found that apathetic patients have responded to meds that activate dopamine and/or enhance what is called cholinergic function (vital to cognition). These include: Symmetrel and Parlodel (for Parkinson’s), Aricept and Exelon (for Alzheimer’s), amphetamine, Wellbutrin, Ritalin, and selegiline (an MAOI for Parkinson’s). In the development pipeline are a new generation of dopamine agonists.

Now for the yellow caution flag: Many of the above meds represent clear and present dangers for certain patients, and may not be appropriate. None except Wellbutrin and selegiline have been extensively tested on depressed populations and certainly not with apathy in mind. Dr Marin would like to see apathy as a new domain of psychiatry. But it is an uncharted territory, especially when depression is involved. Watch out for quicksand.

See also: No Pleasure, No Reward.

Reviewed June 29, 2016


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