“I don’t wanna fuck my mother! I don’t give a shit what you say — you’re never gonna convince me!” Credit: Getty Images
It’s not as strange a question as it might sound. Does depression exist? I don’t mean to imply that those with depression should just “pull themselves together”: of course depression symptoms exist (and are sometimes life-ruining). And of course those symptoms often overlap with each other, which certainly implies that there’s a common cause. But is there a thing we can point to in someone’s brain — or some identifiable part of their psychology — that’s called “depression”?
In their understandable desire to get on with trials that might help people who are suffering, many researchers have sidestepped the question of what depression actually is. Instead, they’ve simply agreed on a definition and stuck to it. The Beck Depression Inventory is a questionnaire routinely used to diagnose and define depression: if you’ve ever spoken to your GP about feeling low, you might have come across it. It’s named after Aaron Beck, one of the most important figures in the history of psychiatry (who died aged 100 on November 1st this year). He came up with 21 questions that cover guilt, feelings of failure, weight loss, insomnia, and suicidal thoughts, among other common depressive complaints.
The problem is that the medical profession, and psychiatry researchers, might be relying a little too much on that list of symptoms. Indeed, in an odd, unintentional, circular move, they might have actually turned lists of symptoms into the very definition of depression. An essay by the eminent psychiatrist Kenneth Kendler argues that this is a fundamental mistake: the number of boxes a patient ticks on the list of symptoms that get you a diagnosis isn’t the same as “depression” (nor is their Beck Depression Inventory score) — even if psychiatrists and researchers often act like it is. The Inventory is very often used as the criterion for improvement in studies of treatment: if you achieve a 50% drop in symptoms as measured on his questionnaire, you count as having been positively affected by the treatment. But these criteria are a decent index of many of the common symptoms — not all of them. We know anxiety commonly comes alongside depression, Kendler notes, but it’s not on the standard diagnostic list. If we confuse the disease itself with a useful-but-limited list of its manifestations, we’ll find it harder to truly understand patients’ experiences.
Some researchers have gone a step further: should we stop using the concept of “depression” entirely? One study of thousands of depression patients found over 1,000 unique combinations of symptoms that all still count as “depression”. Maybe it’s time, argue some, to focus on understanding subtypes, or even just specific symptoms, rather than the monolithic entity of “depression” itself.
In some senses — and perhaps ironically — this accords with Beck’s philosophy: he was known for being sceptical of focusing on the ultimate, root causes of mental illness. Which brings us to the other major contribution for which he is remembered: Cognitive Behavioural Therapy. Beginning in the 1960s, Beck reacted against the most popular form of therapy at the time, which was based on Freud’s psychoanalytic theories of the mind. Beck — who himself was originally trained to administer psychoanalytic therapy — began to doubt that depression symptoms were always caused by childhood traumas and unconscious repression. Some of the Freudian theories were rather far-fetched — as Tony Soprano says to his psychoanalytic therapist, after she suggests for the umpteenth time that he might be harbouring some Oedipal desires: “I don’t wanna fuck my mother! I don’t give a shit what you say — you’re never gonna convince me!”
Instead, Beck suggested a much more proximal reason for the disorder: depression patients (and those with other disorders) are suffering from “thought distortions”. For example, they might catastrophise, blowing minor unfortunate occurrences in life out of all proportion. They might overgeneralise, thinking that a fallout with one friend means that they’re hated by everyone they know. As well as focusing his Depression Inventory on these kinds of thought patterns, Beck argued that therapy should target them and train patients out of them, rather than looking for some underlying explanation for all their symptoms.
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SubscribeI have a friend, a doctor, who in private evinces huge suspicion of much of psychology, period. Why? Because, he says, none of it is measurable, and a great deal (most? all?) of it relies on or at least heavily involves subjectivity on the part of the patient, who overwhelmingly has an interest in a diagnosis being made: school children wanting easier exam regimes, people charged with crimes who seek at least partial exculpation, and so on. Also, he says, consider how much of this stuff is identified and characterised ex post facto: your kid won’t sit down? Hey, he has ADHD. So no need to lower his sugar intake or exercise discipline; he has a medical issue. So now a very significant proportion of school kids in the state sector (contrast with the far lower proportion of school kids in the private sector who) have ADD or ADHD. And furthermore, he says, given that this is all totally professionalised, who can possibly challenge any of it? Sure, experts in the field(s) can – and they always do – disagree, but everyone else is shut out of the discussion ab initio. He thinks the profession makes it up as it goes along. Which is not to say there is no such thing as psychology, but he says it has been irredeemably medicalised when it should be treated as a social science, not as a branch of medicine making diagnoses and recommending courses of treatment.
Your friend is very perceptive. Therapists (of all persuasions) have a major interest in perpetuating and extending the definitions of mental illness. It has been called the pathologisation of everyday life, or alternatively the medicalisation of dissatisfaction.
The unforeseen side effect of all this is the trivialisation of severe mental illness.
When my daughter was very young and would have a fall or a minor injury (as children routinely do), I would make it a point to react mildly. As a consequence, she too reacted mildly and would get over being upset very quickly. She continues to have a good disposition and still does get upset (like any normal person) but also pulls herself together. I think much (not all, not all) of depression is like that. Nowadays it is popular to believe you cannot be upset about anything without it becoming a tragedy in your life. The moment you face some difficulty, alarm bells must be rung, which only heightens your own sense of alarm and further amplifies your worries. Moreover, it also likely prolongs and habituates your worries since all humans enjoy attention, including the negative sort. Life is messy and you will be handed raw deals and unfair advantages and disadvantages. No one “deserves” one or the other but to organize crusades to never ever be depressed is the real sickness. For some people, prolonged depression may start to better by first starting to be ok with getting a bit depressed every now and again – navigating the seas of real life.
And your daughter will also have learned to self soothe, rather than always expecting others to do it for her – or going into a funk if they don’t.
Agreed – same with my son who looks upon many of his peer group as psychologically/emotionally weak.
That is interesting; how does your son relate to his peers? Does he respect them?
Good points made by the author. But even better would have been if he had covered the emerging evidence that inflammatory processes in the body (leaking across the blood-brain barrier) explain depression in some people. The problem is that our thinking about depression is stuck in the brain/mind paradigm (the mind causes depression if you are fed up with life or can’t get on with your mum, etc., and the brain causes depression through a weird, never explained, imbalance in neurotransmitters.).
The idea that imbalances in the body itself (specifically immuno-modulated inflammation) might disturb the brain enough to alter mood isn’t really mainstream yet.
When it is, a better understanding of depression will emerge.
Thanks for a very interesting essay. The problem described is one that pervades the whole of psychiatric diagnosis. This was transformed in 1980 with the publication by the American Psychiatric Association of DSM III (Diagnostic and Statistical Manual, third edition). This has been followed by DSMs IV and 5.
DSM III defined all diagnostic categories on the basis of possession of clearly defined numbers and combinations of symptoms. This was in response to a ‘crisis of reliability’ in psychiatric diagnosis. The hope was that research and practice would be placed on a firmer footing if there was at least agreement about when to apply the different diagnostic labels.
Unfortunately, the DSM approach created new problems. One is that symptoms such as depression are noted as either absent or present. If present a level of severity may be assigned. In reality, depression covers a range of emotional states which can vary in quality and this is not captured by a DSM diagnosis. A second problem is that no attention is paid to the contexts in which symptoms arise e.g. social circumstances and past experiences.
The most important issue is that diagnoses can be reliable without being valid i.e. there is no certainty that a diagnostic label is capturing a discrete disease entity. This is important because so much published research is based on DSM-defined patient populations. For example, it is likely that a group of patients who meet DSM criteria for depression will be a heterogeneous group in relation to the causes and nature of their depressed mood. At the same time, there may be depressed patients whose problems are never researched at all because they fail to meet the criteria for a diagnosis.
Because of this, DSM has been described as an ’unintended epistemic prison’. Research has been blinkered and confined to patient groups that hit DSM definitions. Understanding of mental disorders and what to do about them has been hindered rather than advanced. If patient cohorts who are taking part in research are a mixed bag, it is only to be expected that most treatments seem to work a little bit (or only for some people) and nothing seems to work very well.
Fortunately, there has been resistance to DSM from influential bodies such as the National institutes of Mental Health in the USA. Their expectation is that research applications will focus on underlying causal mechanisms rather than DSM-defined disorders. There is also focus on other ways of conceptualising psychiatric problems e.g. use of dimensional ratings rather than assigning patients to diagnostic categories.
The final test of any diagnostic system is the pragmatic one that it should do something useful. It should help us understand patients and their problems and should be a guide to effective treatment. If it fails on these criteria, it should be dropped.
A few of the major issues in modern medicine are: 1) we always want to find the physical seat of the illness (we have carried this idea/concept from the 18th century) 2) we want to group patients ideally in large enough units to be able to label them: this is more for the benefit of organising medicine (health policy, insurance, budgeting etc) 3) if we cannot explain the illness and or the treatment, we prefer to consider that it does not exist.
We confuse evidence based medicine with using ‘scientifically proven effective treatments’ https://pubmed.ncbi.nlm.nih.gov/8555924/
The reality is that every patient is unique in their own context. ‘Medicine’ needs to start accepting this and change its approach. This will make that the ‘innate self repairing mechanisms’ of patients can me more efficiently tuned on again and chronic illness reduce vastly and medicine become affordable again… Much work ahead https://www.raadrvs.nl/documenten/publications/2017/6/19/no-evidence-without-context.-about-the-illusion-of-evidence%E2%80%90based-practice-in-healthcare
Once medicine has realised that its current model is not adapted to patients but mainly to a form of scientific approach that suits the scientific community and ‘rationality’, articles like this one will not be necessary any more…
Or perhaps we need to get back again to causes. People are depressed for different reasons, and their depression is a manifestation of that cause.
If someone is childless; or was brought up to have an exaggerated view of themselves which has failed to materialise; or simply has low self esteem; perhaps those different causes matter and different “remedies” are required.
Otherwise it’s a bit like calling sneezing the illness whether it’s caused by a cold, an allergy or a cocaine habit.
Like the spreading net of depression described here, I get the impression that autism is being diagnosed so commonly under the increasing diagnostic breadth of the ‘spectrum’ that it merely applies to everyone now, thereby trivialising the more extreme forms of autism.
My story is different, but related. A couple decades ago I worked for years with heavy metals, lead and mercury, extensively, (industrial construction) and with zero safety measures as I was making money, paid by the job, and was working 80 hours a week (5.5 years of that) as all I was about was banking $$$. About a decade after I came down with idiopathic peripheral neuropathy in my feet – which is a chronic pain, and is severe, and surprisingly common, mostly diabetic caused though, which I do not have, but heavy metal toxicity also – my cause I believe.
One day I went to a new doctor and he told me that he needed to try the gambit of anti-depressants, and even anti-psychotic drugs as they can have amazing relief for this neural damage. I tried about 5, some dreadful – huge side effects, some did nothing, and hit on bupropion. I have taken 300 mg a day for 10 years now, and it works so much my pain is almost zero mostly – from terrible chronic pain. (chronic means it never stops). If I miss the dose for a day I feel it – a couple days and the pain is dreadful. (It slows the feedback loop, and inappropriate nerve pain seemingly)
If someone you know has neural damage in the feet please google antidepressants and peripheral neuropathy. This from WebMd https://www.webmd.com/diabetes/news/20050719/antidepressants-1st-choice-for-nerve-pain
“Antidepressants: 1st Choice for Nerve Pain. July 19, 2005 — Antidepressants should be used as an initial treatment for the frequently disabling pain caused by nerve tissue damage, according to a”
Just mentioning as most doctors do not try it, or did not… It is like Ivermectin – it is not planned for other things, but works – it is a miracle drug for me, it is not a placebo, as I do hard work on my feet it is a lifesaver, or I could not work…(Nothing to say about depression though as I never had it)
Not to play down your experience but I find this a lot in everyday life. A person has a problem, takes something for it and the change is amazing. But clinical trials show (maybe) that it is just OK. The pharmaceutical companies and medical profession have to rely on the clinical trials when they go ahead with their treatment plans.
The reasons for this effect seem obvious. People have different metabolisms so the drug reacts differently when attacking a problem on one person. Or, for example, one person has a particular exposure to heavy metals that is not repeated with other people. Every situation is different.
Really, drugs are used incorrectly. They should be used perhaps as a last resort but medical people tend to reach for the drugs first, even if they are not needed. Then, not surprising, the drugs don’t work or result in bad side effects.
BUT, to stops drugs being over-prescribed we would need a holistic approach to medicine, where your doctor spends a lot of time finding out about your lifestyle, your work, diet, hobbies, etc, before prescribing anything. This is just wishful thinking because somebody has to pay for the medic’s time.
In the NHS in the UK, there is an overwhelming pressure to treat everybody equally. Everybody gets 10 minutes with the doctor (or did before Covid) and the doctor listens for one minute, reaches for the keyboard and prescribes the NHS-approved therapy. Usually, this therapy is a drug. I once had a slight acid problem and the doctor didn’t ask me anything about my diet. He prescribed a PPI. A couple of months later I developed blood in my urine and had to go for many expensive tests in hospitals. Then I happened to notice that the PPI blurb said that a side effect (1% chance) was blood in urine. I went back to my doctor and he said, “Maybe we’ll try another PPI.”
I just walked out and played with my diet until I felt OK. Blood in urine miraculously disappeared, as did the acid problem.
Homeopathy uses the holistic approach, expensive but worth it.
https://homeopathy-soh.org
Defining conditions by symptoms is going to confuse treatment by lumping together conditions with similar symptoms but different causes. You have to define conditions by causes. To understand causes in the mind you need to understand how the brain holds information and selects the information that causes behaviour. This has been neglected by researchers. I think it will show that the role of consciousness is to allow reflection on information before the information initiates its associated behaviour. That reflection is driven by a sense of uncertainty, anxiety, when patterns are incomplete and a sense of certainty, fulfillment, when patterns are complete. Depression is a failure in pattern completion and therefore continued anxiety from incomplete patterns. A half century ago I was told that to get out of it you had to make a decision, any decision, and act, not the right decision, not a big decision but something inconsequential that initiates behaviour such as which side of the bed to get out of. I think a sequence of such decisions can give some pattern completion and therefore some sense of fulfilment. With a little distance the intractable problems can be put aside until there is a better time to address them. It restores the decion making needed to function.
You obviously have not come across the human givens approach. I suggest you research it now because they do have an understanding of what causes depression, which is much more than a list of symptoms. Depression is a rem sleep disorder, which leads to exhaustion and a self-feeding negative loop that generates a life that is not working and cannot be restored.
Here is a link, which is a good place to start. https://www.hgi.org.uk/useful-info/depression-and-how-to-deal-with-it
I am a human givens therapist myself and have been working successfully with depression for many years. You are quite right to be highly critical of the industry, which seems to feed a depression epidemic and does very little to relieve it.
No need for therapy and psychobabble. Exercise, pray to God, lift your hearts to the heavens and make a pact with the transcendent. Most of what is called depression is just the pathologisation of ordinary human suffering – grief, despair, disappointment, the horror of being human. I used to feel depressed and anxious, gave up alcohol six years ago, gave up degenerate friends, returned to God. Therapy is just a cheap knock off version of confession but without the positive long lasting impact
Mr Ritchie doesn’t even realise he’s confined to the walls of the medical model of understanding our emotions. He medicalises natural feelings which we have in relation to the downsides of life such as bereavement, misery in work, unhappy marriage etc. Does anybody know anybody who is happily married, content at work, has enough money, and is thriving in every way, who got depressed? The pharmaceutical industry invented Depression in the 1970s when sales of valium plummeted because so many people loved it and got hooked, so Depression appeared in order to create a new category of drugs – anti depressants – to be sold by the billion. He also clearly has not read an excellent psychologist called David Smail who summarised the elements within psychotherapy in his book The Nature of Unhappiness as being Comfort, Clarification and Encouragement. Put any old diploma on the wall and provide people with those three sources of emotional nourishment and they’ll pick up.