Contrary to the APA’s assertion, depression is not an illness. In fact, depression is an adaptive mechanism which has served the species well for millions of years. When things are going well in our lives, we feel good. This good feeling is nature’s way of telling us to keep doing what we’re doing. When our lives are not going well, we feel down or depressed. This is nature’s way of telling us to make some changes.
This is very similar to pain. Pain is a signal that tissue is being damaged and that urgent action is needed. For instance, if you touch a hot stove, the pain induces an immediate reaction to pull your hand away. Usually this is accomplished with minimal damage to the skin. Without pain, we would not respond as quickly to these kinds of situations, and we would incur a great deal more tissue damage than is actually the case.
Depression or despondency is not as acute a sensation as pain. It is more generalized and it signals – not imminent tissue damage – but problems of a more general nature. In order to feel good, the following six factors must be present in our lives.
- good nutrition
- fresh air
- sunshine
- physical activity
- purposeful activity
- good relationships
When any of these factors are missing, or are present to only a slight degree, we begin to feel despondent or depressed. When many of these factors are missing to a large degree, we sink into despair. Over the years, I have worked with hundreds of people who were depressed. To all of these people – without exception – I could say, “If I were in your shoes, living the life you are living, I would be depressed too.”
Many of these individuals lived on a diet of soda pop, cigarettes, and salami sandwiches. Others drank enormous quantities of alcohol. Few ate vegetables regularly. Many stayed indoors almost all the time. Physical activity was almost always minimal. Purposeful activity – i.e. activity directed towards some kind of goal – was seldom present, and good honest, open relationships almost non-existent.
The point here is not to disparage or castigate people who are depressed, but rather to point out that depression is essentially and fundamentally a function of what we are doing – how we are living our lives. It is not an illness. It is the body’s natural feedback system. It is nature’s way of trying to induce in us some motivation to make changes in our lifestyle – to eat better; to abstain from toxic substances; to get out in the fresh air and sunshine; to identify goals and pursue them and to talk to friends and family honestly and openly about the things that trouble us. If we do these things consistently and regularly – if we integrate these things into our daily routines, then we will start to feel good. If we don’t do these things, we will feel depressed. Or as Peter Breggin, MD, puts it in Antidepressants Cause Suicide and Violence in Soldiers: “The principles for overcoming depression are exactly the same principles required for living a good and happy life.”
Everybody experiences an occasional down day. But we also know what to do about it – get out for a walk; start a project; talk to a friend or loved one, etc. Chronically depressed people, however, are individuals who have been neglecting these areas for years. They spend the vast majority of their lives indoors, watching television and eating snack food. They are often over-weight, have no goals other than the next TV show, and although they may have many acquaintances, they do not share their concerns and worries in an open and honest manner.
Of course, not all depressed people are deficient in all these areas. Some depressed people eat well, but never share their worries or concerns with anybody. Others share their worries, but have no purposeful activities. Others have purposeful and rewarding jobs, but never get outdoors and never engage in physical activity and so on.
To feel consistently good, we need to have all of these factors present in our lives to a substantial and significant degree. Nor is this such a daunting proposition. A person who eats moderately from the five main food groups; who controls his intake of sugar and alcohol; who doesn’t smoke; who has a job or hobby that provides challenges and a sense of fulfillment; who gets outdoors most days for exercise or even for a brisk walk; and who has at least one other person with whom he is open and honest, will feel generally positive. A person whose life is lacking in one or more of these areas will feel generally negative. This latter is not an illness – it is not an instance of something going wrong in our bodies. Rather it is an instance of something going right. Depression is a message from the organism calling for change. Induction of negative feelings is the only language the organism has to express the need to make changes.
Severe losses can, of course, precipitate depression even in otherwise very orderly and functional lives. Even when all six factors are present to a substantial degree, the loss of a loved one will usually result in profound feelings of depression. Similarly, the loss of one’s career, health, home, etc., will generate some measure of depression regardless of previous lifestyle. People who have been living functional and productive lifestyles, as described above, however, will normally come to terms with the loss in a reasonable time frame. They will talk about the loss to the people in whom they confide; they will continue to eat well and to exercise, and will continue with the various purposeful activities they have always pursued. Gradually the sense of loss will recede and the ability to enjoy life will return. When it seems as if life is coming apart at the seams, it is our routines that save us – provided we have established good functional routines which incorporate the six factors mentioned above.
However, for people whose lifestyles are deficient, or only marginal, in terms of the six factors mentioned earlier, a major loss can put them “over the edge,” and they sink into a state of chronic long-term despondency. In this regard it is worth noting that all human lives are, sooner or later, touched by major tragic losses. What matters is: how equipped are we, in habits and lifestyle, to handle these losses. When a person goes to a mental health center and asks for help with depression, the first priority should be a detailed assessment of the person’s lifestyle, habits, relationships, history, etc., to determine the source of the depressive feelings. From this assessment, a remedial program should be developed and active support and assistance provided to the client in the implementation of this program.
In practice this almost never happens. The client who mentions depression is routinely shuffled off to the psychiatrist. He gets a prescription for an antidepressant and is told (falsely) that his depression is an illness like diabetes, and that he must take his pills in the same way that a diabetic must take insulin. If supportive or adjunctive therapy is provided at all, it usually takes the form of patronizing pats on the back or reminders to take the “medication.”
Despite decades of highly motivated research on the part of pharmaceutical companies and university departments funded by pharmaceutical companies, no evidence has ever been presented that depression is caused by a physical problem in the brain. Yet this assertion is routinely presented to clients and their families as justification for the drug prescription. Elliot Valenstein, Professor Emeritus of Psychology and Neuroscience at the University of Michigan, having reviewed the various biological theories of depression, summarizes the results as follows in his book Blaming the Brain:
Although the often-repeated statement that antidepressants work by correcting the biochemical deficiency that is the cause of depression may be an effective promotional tack, it cannot be justified by the evidence.
The fact is that anti-depressants are mood-altering drugs (essentially in the same general category as alcohol, cocaine, amphetamines, etc.). All of these drugs have in common that they alter people’s moods. They make people feel better. That’s why people take them! But it doesn’t mean they are a good idea. There are two ways to get drugs in the United States. You can go to the street corner and buy them illegally; or you can go to a physician and tell him you are depressed, or anxious, or both. Either way, you’ll get something that will give you a temporary “fix” for whatever negative feelings are troubling you. But you will not get any real help with your problem.
In recent years many hospital and clinics have been offering free depression screenings. If you go in for one of these screenings, it’s obvious that you have been experiencing some depression, and the interviewer will quickly establish (through insultingly simplistic questionnaires) that, yes, you are indeed depressed, and that you would benefit from one of the many wonderful antidepressants currently available and wouldn’t you like an appointment to see our psychiatrist. These “free” screenings are almost invariably paid for by a pharmaceutical company. They are a form of marketing and have been a major factor in the promotion of psychotropic drugs. The hospital staff who participate in these charades are well-intentioned, but in fact are mere cogs in an enormous drug-marketing scheme.
The purpose of the DSM is to promote the false notion that depression is really an illness, and to legitimize the prescription of mood-altering drugs. The manual lists several different kinds of depression. Acute, severe depression is called Major Depressive Disorder. Persistent though less severe depression is called Dysthymia. Depression that comes and goes and is interspersed with periods of mild mania is called Cyclothymic Disorder. And so on. And, of course, if a client doesn’t meet the criteria for any of these – there’s always Depressive Disorder Not Otherwise Specified: a residual category to broaden the scope of the diagnostic net. In fairness to the APA, all of the several diagnoses require a fairly significant level of severity. In practice, however, the precise criteria are routinely ignored. In fact, most of the staff working in the mental health system have only a vague notion of the criteria. A client who says he’s depressed is assigned a diagnosis and is given anti-depressant drugs.
There are, of course, small numbers of mental health staff who although constrained by regulatory agencies to work within the DSM context, nevertheless ignore the implications of the sickness model and provide real help to their clients. These staff members are a very small minority and the vast majority of mental health workers embrace the DSM taxonomy wholeheartedly and believe unquestioningly in the ontological validity of the diagnostic categories.
Next Post: Bipolar Disorder
#1 by aqua - August 9th, 2009 at 13:56
I am actually flabbergasted by this post. Not sure if it is satire (I hope so) or for real. I hope you post my response so others like me do not feel blamed for not rlieving and avoiding their MDD. In case you don’t I am going to post it on my website.
I struggle with MDD. I have had numerous clearly defined episodes throughout my life.
Until this current episode I was the epitome of what you suggest makes a person happy, yet I still fell into severe and often lengthy depressive episodes:
good nutrition
- fresh air I routinely biked, skied, swam outdoors and indoors, hiked, camped, canoed, gardened, walked everywhere was outside much of the time
- sunshine..see above
- physical activity…ditto
- purposeful activity…worked(loved it), went to schoo(really, really loved it)l, danced, played music, created art, wrote, helped others
- good relationships, beautiful friendships, very open, nothing we could, and did not talk about.
For me severe depression really did just pop out of nowhere. There was nothing wrong with my life during these episodes…I had a great life. It was the depression that stopped me in my tracks, not the other way around.
When you wrote, “When things are going well in our lives, we feel good”…I understood immediately that you misunderstand MDD. The sad thing about MDD is that even if things are going well this illness destroys a person’s ability toi feel good.
I find it difficult to understand how you treat people with depression when you place so much distance and dogma between yourself and your patients. When you say,
“Many of these individuals lived on a diet of soda pop [I can count on my hands the numer of sodas I have drank in the last 5 years], cigarettes[don't smoke], and salami sandwiches[I think the last salami sandwich I ate was in high school...I'm 44]. Others drank enormous quantities of alcohol [I used to drink periodically...like many other happy people I know...until I got as severely depressed as I am now. In which case it drove me to drink more to try to help my symptoms]. Few ate vegetables regularly[ was vegetarian.so did well here]. Many stayed indoors almost all the time [see my above list of favourite and common activities]. Physical activity was almost always minimal [ditto]. Purposeful activity – i.e. activity directed towards some kind of goal – was seldom present [university? , and good honest, open relationships almost non-existent...[great frienships?]…
…Chronically depressed people, however,are individuals who have been neglecting these areas for years. They spend the vast majority of their lives indoors, watching television and eating snack food. They are often over-weight, have no goals other than the next TV show, and although they may have many acquaintances, they do not share their concerns and worries in an open and honest manner”
…it struck me that you believe very strongly that “we”are so very different from you. We just don’t try hard enough to be happy. If only “we” would try harder, “we” could be as happy as “you”.
Have you ever really worked with someone with clinical depression? Contrary to your statement that we are indoorsy, crappy food eating, inactive, solitary, lazy, unfocused, fat, slobs.. [actually slob is my word…it’s how i sense we seem to you) people with MDD are a wide range of people…some of us even active, outdoorsy, friendly and friend supporting, anti-t.v., fit and interested and interesting people.
It becomes clear you have never understood what it is to be depressed when you state, “Depression or despondency is not as acute a sensation as pain”. In the past I broke both my elbows at the same time, had a severe case of CMV related hepatitis that required hospitalization, have broken my leg, my ankle, my wrist, had three concussions, was injured in a car accident, had a doctor drill into my leg bone for bone marrow, basically have suffered a lot of physical pain.
NOTHING is as painful as severe and chronic MDD. When I broke my elbows I had just come out of the hospital after having ECT. For the first time in years I felt mentally well. I REFUSED any pain medication for my physical pain, for fear that my psychic pain would recur. NOTHING hurts like mental pain…NOTHING.
#2 by Shahnawaz - August 11th, 2009 at 10:25
I have to agree with Aqua that you have a gross misconception of MDD. I have also suffered from this for several years and I can honestly say that I am living the life I desire. I am a nursing student and hence I know about the holistic nature of what makes people happy and hence I follow a healthy diet, exercise, etc. No one will argue with you that environmental factors are important in someone’s happiness but that does not mean that there isn’t a biological nature to the illness. There is a reason that it runs in families.
Depression IS an illness. I’m not talking about just feeling down; I am of course referring to depression in terms of the DSM criteria. I am disappointed that being a PhD, you would make such misinformed claims. You can’t determine the validity of an illness from a portion of psychiatrists who misdiagnose people. As you may know, there are specific criteria that you must have to be diagnosed with depression (specific symptoms for a specific amount of time). Also, there are several different types of depression (dysthymia, SAD etc.), MDD being the most severe of them. MDD is an Axis I diagnosis for a reason, the disorders in this criteria have a physiological basis. It is not a personality disorder and it is not merely feeling down.
I’m not sure what selective evidence you are looking at that determines depression to not be a biological condition. From my knowledge, it is well known that depression leads to chemical changes in the brain’s levels of serotonin and other neurotransmitters. There is also significant evidence that indicates that antidepressants lead to the correction of these chemical changes in the brain. Your premise for believing that depression is not an illness lies in the fact that there is no evidence for physiological changes. However, I think you are misrepresenting the consensus which is that we don’t know how they carry out their actions. A lack of clarity in the mechanism of action of antidepressants is very different from having no evidence.
The brain is complex and we don’t know much about it at this point. It is an organ, just like the heart and the liver. And like the heart and liver, it can get sick. The aspects of peoples’ lives like diet and exercise can exacerbate these chemical changes but that doesn’t necessarily mean they have caused it (correlation does not mean causation). Have you ever considered that because of feelings of worthlessness, anhedonia and lethargy, depressed people are not able to participate in these activities? I know that when I was in that state I did not have the energy or the desire to participate in any activities, let alone an appetite to eat anything. Hence, I lost over 60 pounds in under a year. These changes in my lifestyle were a result of my illness, not a cause of it. Why? because I wasn’t like that before. Just like Aqua stated.
For such an educated man, I would have hoped that your claims weren’t so paranoid as to imply that the pharmaceutical industry is out to get us. The antidepressants that I am taking are life savers, I could not function without them. Which is probably the most important criteria in diagnosing depression, that the feelings become so overwhelming you can not function. This is usually when people seek help and I know that was the case with me. If you had felt the psychological pain that comes with depression, you would have no doubt in your mind that it is an illness.
I invite you to visit my blog (http://theband-aid.blogspot.com/) and see some of the testimonials of people who are expressing suicidal ideation. Maybe that will give you a better idea of what goes through people’s minds at the height of their illness. An illness, which at it’s worst provokes individuals to go against all of their survival instincts and take their own life. This isn’t normal. It’s far from it.
#3 by Louise - August 11th, 2009 at 16:17
I think it’s difficult for anyone who is currently taking medication for depression to look objectively at an article like this one. But I think it’s important to try. The problem with anti-depressants is how easily they can be obtained. Instead of being a last resort, they are often the first thing offered to a patient who exhibits signs of depression. And they work, which means that people will continue taking them, often without making any other changes in their lives that might help with the depression.
If a shy person drinks a couple glasses of wine at a party, he will likely feel much less shy during the party. That is a direct result of the alcohol, but it doesn’t mean that his body was deficient in alcohol, or chemically imbalanced without the alcohol.
People medicate themselves in all sorts of ways. Marijuana, alcohol, nicotine, and doctor-prescribed pharmaceuticals are all options. The doctor-prescribed options just tend to be easier to get, and are often paid for by health insurance.
I have to wonder if we’ll look back on this in 30 years and wonder if the ubiquitous use of psychiatric medications had unintended side effects and consequences. 40 years ago, expectant mothers were routinely x-rayed. Just because something is the latest and greatest in the medical world doesn’t necessarily mean it’s good for humans in the long run.
#4 by CP - August 11th, 2009 at 20:45
Found this through Grand Rounds. Thought-provoking article–thank you.
I’m wondering what your thoughts are on the use of antidepressants as a stop-gap measure to help clients function while initiating psych therapy and/or lifestyle changes. Based on your experience, do you think this helps clients “get on their feet” or hinders their progress?
#5 by Phil - August 12th, 2009 at 09:33
Aquamarine: Thank you for your very detailed comments. I am sorry that my post seemed elitist or denigrating, neither of which was intended, and I will edit future posts carefully for material that might be interpreted in this way. I realize, of course, that a great many people in our society believe that depression is a brain illness and needs to be treated with drugs. My position is that this has never been proven, and that it is much more logical and reasonable to conceptualize depression along the lines set out in my post (i.e. that depression is an adaptive mechanism that encourages us to make changes).
It’s important to be clear that we are not disagreeing on the facts. The fact is that people sometimes get depressed. What we disagree on is how best to conceptualize these facts. The American Psychiatric Association, and mental health practitioners generally, conceptualize depression as an illness. I conceptualize depression as set out in my post.
If you ask a mental health professional why you are depressed, he will probably reply “Because you have a mental illness,” or words to that effect. If you ask further, “How do you know I have a mental illness?” the only possible answer is “Because you are depressed.” As an explanation of depression, the mental illness hypothesis is entirely circular and sheds no real explanatory light on the matter. The brain disease hypothesis, if valid, would of course break the circularity, but no one has succeeded in demonstrating this link. Valenstein’s’ book Blaming the Brain gives an excellent account of this area. Besides, if depression is a brain disease, why don’t we diagnose it through lab tests, or at least a neurological examination? Come to that, why isn’t it treated by neurologists?
You express the belief that I don’t understand “what it is to be depressed.” In 2001, after decades of excellent health, I contracted a rare disease called Wegener’s Granulomatosis. I consulted several doctors, all of whom told me there was nothing wrong with me – “perhaps the flu” – etc. Finally I went back to the first doctor and asked him to look harder. By then, my kidneys were destroyed, and I have been on dialysis ever since. For the first few years I was very sick from the illnesses and from the drugs I had to take. In 2004 the Wegener’s attacked my intestines, and I spent almost five months of that year in hospital. I, also, have known suffering and despondency. It is not my history of suffering, however, that validates my position any more than your suffering validates yours. Validity comes through logic and research. Although I have searched extensively, I have never found a piece of research that proves that all depressed people have a brain illness.
It is clear that you accept the mental illness explanation of your bouts of depression and that you are comfortable taking antidepressants. It is not my purpose to try to persuade you otherwise on either count. There’s room on the planet for all of us with our different lifestyles and different opinions. It is obvious that you have a good working relationship with your psychiatrist, and I encourage you to maintain this and to discuss these matters with him/her. I very much appreciate your taking the time to comment. Although we don’t agree, I believe dialog is always helpful. Once again, I apologize for the fact that you found my comments disparaging and elitist. This is absolutely not my stance towards anyone, and indeed it is because I care passionately about people that I feel the need to speak out in my blog against what I consider blatant and dishonest exploitation by psychiatrists and pharmaceutical companies. The fact that my position attracts a measure of odium and vituperation is unfortunate, but probably inevitable.
#6 by Phil - August 12th, 2009 at 11:09
Shahnawaz: There is a strong temptation, when we are confronted with opinions which differ from our own, to conclude that the other party doesn’t understand the issues. This theme – that I have simply missed the point – is very evident in your comment.
Please let me assure you, I am very familiar with the illness model currently being promoted by psychiatrists and pharmaceutical companies. I have studied this model extensively for the past forty years, and have watched it burgeon at the expense of society generally and individuals in particular. I am very familiar with DSM and the criteria for the various so-called diagnoses. I have worked in prisons, mental health centers, addiction units, and private practice. I have worked compassionately, and, I believe, very helpfully, with people from all walks of life and presenting all manner of problems.
The essential point of the illness model is that problems that people encounter in their lives are caused by mental disorders. In DSM the APA defines a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g. a painful symptom) or disability (i.e. impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” Now if you analyze this definition, what it actually amounts to is: “any behavioral or psychological problem.” In other words, when the APA say that people’s troubles are caused by mental disorders, the substance of this statement is that people’s troubles are caused by their troubles. It is not a valid explanation. A true understanding of people’s problems requires more than a label.
Over the years I have watched the American Psychiatric Association’s mental disorders “morph” into brain illnesses. The APA has never officially endorsed this development, but their members in the field promote this notion whole-heartedly. Incidentally, one of the APA’s criteria for a Major Depressive Episode is that “the symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).” In other words, if the depression is caused by a brain illness, it is not, according to the APA, a major depression. This contradiction is seldom discussed or even acknowledged.
Anyway, it is clear you are a thinking person. It is also clear that you are comfortable taking antidepressants and that you have a good working relationship with your practitioner. We each must find our own way in this world, and if your methods work for you, who am I to argue.
Thank you for your very detailed and thought-provoking comments.
#7 by Phil - August 12th, 2009 at 11:11
Louise: Thanks for your comments. I agree.
#8 by Phil - August 12th, 2009 at 15:05
CP: Thanks for your comment and your interesting question. It’s a particularly thorny question because “conventional wisdom” in mental health circles dictates that this should be done, especially if there has been any talk of suicide. It’s a brave practitioner who will go against the “conventional wisdom,” or standards of care as they are sometimes called. Economics makes cowards of us all.
That being said, it is my experience that “stop-gap” has a way of becoming permanent or semi-permanent. Additionally, if the antidepressants are successful in inducing “happy” feelings (sometimes they do, sometimes they don’t) then the incentive to change is often dulled, and motivation wanes. Conventional wisdom, of course, maintains the opposite, i.e. that the antidepressants give the individual the power to make lasting life-style changes.
I think the best way to conceptualize this whole thing is that many people like the effect of mood-altering drugs and will go to considerable lengths to obtain them. Some clients come to mental health centers to obtain a mood-altering prescription – and that’s what they get. Others come for counseling – often just someone who will listen to them and validate their concerns. I don’t think it’s for me to say, “you shouldn’t be taking antidepressants” any more than I would tell another person not to eat lettuce. Ultimately each person must choose what he or she eats. In this context, however, I think the comments by Louise on this post are pertinent.
The drugging (“medicating”) of children is a particularly thorny issue, but here again, the ultimate decision rests with the parents. (See my earlier blog on ADHD.)
Back to your question. I feel that this issue is particularly pertinent in cases of bereavement. The best (perhaps only) way to cope with bereavement is to put one foot in front of the other (in other words, stick to your routines) and talk frequently and at length to friends and family about the loss and its effects, etc.. So often today, however, there is a great rush to “medicate” (i.e. drug) the bereaved person. This is all done with the best of intentions – but the result is often that the bereavement process just doesn’t take place.
With regards to the suicide question, there are some who contend that antidepressants can make people more suicidal. I really don’t know. I would love to see a graph of suicide incidence (as a percentage of population) each year for the past 50 years. And plotted on the same page a graph of antidepressant usage (again as a percentage of population) year by year for the same period. I know that the second curve will show a steady rise, but will the first curve show a steady fall? Possible research project for someone?
Once again, thanks for the question.
#9 by CP - August 12th, 2009 at 15:44
Phil, thanks for your reply. And thanks for sharing some critical, independent thinking in an area that’s so dominated by convention. I agree that stop-gap measures often become permanent, and have definitely noticed that “counseling” often consists of validating the individual’s feelings without taking the next steps of providing tools for change. It seems these are easy traps to fall into, perhaps because they’re emotionally easier for both the care provider and the client. I believe that antidepressants can be useful for some people, but as a provider I would want to ask myself , ‘Am I recommending drug therapy because it’s the right choice in this case, or am I doing it because it’s easy and/or I don’t think I can offer anything better?’
#10 by Paul Hutton - August 15th, 2009 at 01:12
I’m not sure the question “is depression an illness?” is a particularly useful one to ask. I’m also not sure that the statement “depression is not an illness” makes a lot of sense. I suppose the main problem I have with your post is that I’m not really sure I know what you mean by the terms ‘illness’ or ‘disease’.
Quite clearly there is a recognisable pattern of thinking, feeling and acting which we label ‘depression’ and which can cause, or is associated with, an enormous amount of suffering, pain, disability and – for many people – an impaired capacity to make important decisions about their lives. The burden to the individual and society of this ‘condition’ or ‘state’ is large and far exceeds that associated with many physical conditions. In not using the term ‘illness’ and instead using terms such as ‘adaptiveness’ there is a clear risk that such negative consequences are undermined.
Certainly your remedies for reducing depression seem useful and sensible and are all supported by evidence. However, the danger with refusing to use the word ‘illness’ in relation to depression is demonstrated by the reaction to your post from people who have had this experience. That is, it seems to invalidate people’s suffering – albeit unintentionally.
A useful discussion of the issues involved in using the term ‘mental illness’ is provided here:
http://plato.stanford.edu/entries/mental-illness/
Finally, there is also a bit of dualism in your post when you insist depression is not a ‘brain’ disease. It seems a trivial matter of fact to point out that all mental events are caused or maintained by a complex set of social, psychological and biological processes working in concert (unless you believe in a soul, that is). You yourself point out that depression can, amongst other things, be a response to poor diet or excessive alcohol intake – both of which probably exert a substantial influence on cortical functioning. Whether the role of events at the social and psychological level have been neglected in our approach to understanding the efficient causes of this ‘condition’ is a separate issue, of course (for the record, I think they have).
#11 by Phil - August 17th, 2009 at 16:05
Paul Hutton: Thank you for your thought-provoking comments.
Definition of illness/disease: You are, of course, correct. Please see my response to CBT. The APA (in their introduction to DSM) define a mental disorder essentially as any serious, or potentially serious, behavior or psychological problem. So within the context of that definition, an almost limitless range of human problems can become mental disorders. Not surprisingly that is what has happened. DSM refers to mental disorders rather than mental illnesses, but the terms are used interchangeably in practice both by psychiatrists and by mental health workers generally.
My central objection to the mental illness model is that the so-called diagnoses are constantly presented as if they were genuine explanations of human problems (“you’re depressed because you have dysthymia, etc.”). In fact they have no explanatory value. All that they provide is a label for the behaviors in question. Now labeling behaviors in itself is a relatively harmless activity. Presenting these labels as if they were explanations of the behavior in question is very harmful, in that it creates an environment in which genuine understanding is not even pursued. If you “know” that a child is inattentive and disruptive because he “has” ADHD, then there is no incentive to explore the matter for genuine explanations. My position is that all human activity is ultimately understandable and that real help for human problems can only come through understanding, combined, of course, with compassion and concern.
In my view a genuine diagnosis constitutes a real explanation of the symptoms in question. If I ask a physician, for instance, why I am coughing up awful-looking phlegm and why I am tired all the time, he might, after an examination, tell me I have pneumonia. He might explain that a germ has infected my lungs and that my immune system is fighting them and this creates the phlegm, etc., etc.. The pneumonia is a genuine diagnosis and it provides a genuine explanation. The so-called mental illnesses are spurious diagnoses and provide nothing more than a label for the problem. The fallacy is the more insidious because it occurs constantly in everyday speech. For instance, consider the case of a small child who has been kicked or beaten by a bigger child. The victim runs home to his mother and tells her that Jacko down the street has beaten him. The mother provides comfort and soothing words. The child says, “Why does he do this?” The mother replies, “Because he’s a jerk. Don’t mind him.” Now I’m not castigating mothers for making logical fallacies, but if the child were to press the matter and ask how she knows that Jacko is a jerk, the only possible answer is “Because he hits people.” Similar examples occur very frequently in human discourse, and in my view this has conditioned us to accept the DSM’s spurious explanations as genuine.
You express the belief that my statement “depression is not an illness” doesn’t make a lot of sense. We live in a society, however, where the notion that depression is an illness is widely promoted by a variety of monied interests. The popular perception of these promotions is the blatantly false notion that depression is a brain disease. All I can respond is that for me “depression is not an illness” not only makes a lot of sense but needs to be shouted from the rooftops.
In your second paragraph you make the point that depression is a significant problem and that by refusing to embrace it within the concept of illness I am running the risk that it will not receive adequate attention. By this logic, however, a wide range of human problems should be called illnesses simply because they are serious or entail serious consequences. Crime is probably the best example. It involves negative consequences both for the perpetrators and for the victims. The consequences are often very serious. So by your logic we should be calling crime a disease/illness. I realize, of course, that according to DSM, crime is already a mental disorder (illness?), in fact several mental disorders, e.g. conduct disorder, exhibitionism, pedophilia, anti-social personality disorder, etc.. But the notion has not gained popular support as yet.
My point is simply that depression is not something going wrong with an organism (which is essentially my definition of illness), but rather something going right. It is an adaptive response alerting us of the need to make changes. (By adaptive I simply mean that it is useful.)
With regards to the reaction to my post from people who have experienced depression, my primary response is to point out that the popularity of a concept is often independent of its validity. The phlogiston theory of fire is a good example. This theory, which held sway among men of science during the 1600’s and most of the 1700’s, maintained that combustible objects contain an element called phlogiston which was released when the object was burned. Non-flammable objects simply didn’t have this substance. Towards the end of the 1700’s evidence was gradually amassed to debunk the theory in favor of the oxygen-combination ideas of today. Many scientists, however, including Joseph Priestley (the discoverer of oxygen!), tried to cling to the older theory.
Similarly, in former years, sickness and crop failures were often attributed to witchcraft. Here again, we have a spurious theory, i.e. that sickness and crop failures are caused by the actions of these so-called witches. Such thinking – back in the days – was very widespread, and witch-burnings were popular events. But the concept was nonsense, and today, thanks to science, we have a better understanding of the causes of illnesses and crop failures. Popularity is a very unreliable barometer for conceptual validity.
You also mention that my rejection of the illness model seems to invalidate people’s suffering. Well I guess we would just have to disagree. Personally, I think that DSM’s neat “packaging and labeling” of human problems is degrading and stigmatizing.
Dualism? I don’t know how you find this in my post. In fact, I think the opposite is the case. The “official doctrine,” in my view, entails a dualistic framework: there is a mind and there is a body; physical illness is illness of the body; mental illness is illness of the mind. I reject this kind of thinking completely. My position is: there is an organism which functions according to certain principles. This organism can be studied (and understood) from various perspectives (social, behavioral, biological, microbiological, molecular, etc.). But it is the same event being studied from different perspective. The behavioral event and the biological event are one and the same – it is only the perspective that differs. Of course I realize that there are neural correlates to depression (just as there are neural correlates to joy, listening to music, walking in the mountains, etc.). But this does not establish the principle that depression is a brain illness. Besides, if it’s a brain illness, it needs to be diagnosed by a neural exam and /or lab tests. Hypothesizing a brain illness on the basis of behavior is inherently unsafe. There are always multiple paths to the same behavior. For me the concept of mind is a category error as defined by Gilbert Ryle (1949). And by the same logic, mental illnesses are also category errors.
Anyway, there it is. I am most grateful for your comments, and for the opportunity to explore these important concepts. My rejection of the mental illness model is, I suppose, essentially a philosophical/logical issue although, as we have seen, it spills over into other areas.
#12 by martin - August 26th, 2009 at 14:58
Teach people ‘how to cope’ not how to take a pill for every ill feeling!
To use diet and exercise first and techniques to overcome those ill feelings.
We have raised a generation of chemically dependent individuals and will pay dearly in the years to come with chaos throughout society.
#13 by Phil - August 30th, 2009 at 20:01
Martin: Thanks for your comment. The past 50 years has seen a major shift in our society. What formerly were considered the normal problems and vicissitudes of living have become “illnesses” for which we must take “medication.” Of course, the drugs don’t solve the problems. They just mask them. I think your emphasis on coping is very valid. Coping successfully with life’s difficulties is one of the most important skills we can teach our children.
#14 by Werner - September 9th, 2009 at 10:12
Sometimes people make mistakes in their lives that in the final analysis they simply can not live with. We all have to die at some point so why is it wrong to die by your own hand as opposed to being struck by a horrible disease, or hit by a truck or whatever.
#15 by Phil - September 13th, 2009 at 10:27
Werner: Thank you for your interesting comment. There is a measure of logic to what you say: we’re going to die anyway, so why not choose the time, place, and method? The vast majority of people, however, want very much to go on living, and will go to great lengths to prolong life. In my post on depression I listed the six “natural” antidepressants: fresh air, sunshine, good nutrition, physical activity, purposeful activity, and at least one relationship in which one can be entirely open and honest. In my experience, if these factors are present, the individual will experience life positively, and questions of suicide don’t arise.
Your comment raises the question of guilt. The fact is that life is a complicated and difficult business. We all do things from time to time which, in retrospect, we might wish we had done differently. My personal formula for these situations is: face it; fix it; and don’t do it again. In other words: acknowledge my error, make reparations/amends where possible; and try to take corrective action to avoid repetition. Guilt feelings, in moderation, are helpful in that they encourage us to avoid these errors in the future. When guilt feelings become overwhelming, however, they can be very destructive and devastating. About the only good thing one can say about them is that they usually ease with time.
I strongly encourage you to share these concerns with someone you trust. If the matter is too sensitive to share with a family member or close friend, then talk to a counselor or, if you have a religious affiliation, a clergy person. My earlier post on posttraumatic stress disorder might be helpful.
Thanks again for the comment. I hope you can rediscover the joy of life and find reason to go on living.
#16 by technicolorsheep - October 24th, 2009 at 20:06
I know I am terribly late to this thread, but I cannot refrain from commenting (and it’s going to be looong, so I apologise in advance – feel free not to read):
Everything that you say with regards to ‘curing’ depression rings quite true to me. However, and I think that is why so many suffering from depressive episodes are irked by this post, it sounds condescending and an awful lot like patients were entirely to blame for the situation they find themselves in. To some extent, hard as that may be to face, this is true. But I would still like to put my story out there and ask – do we really have the power to influence all these things?
I come from a family where talking honestly and openly was, well, not always advisable. I didn’t do well during my first years in school, perhaps because I had never learnt how to handle the bullies. But we all grew out of it; I had a relationship, did a lot of theatre, charity work, and went to university (where I did well and loved what I was doing). I am awarded a (meagre) scholarship to go abroad, and as soon as I get there, my father falls seriously ill. He dies within the next year. Meanwhile, my mother and my sister aren’t speaking, and I consequently juggle relaying messages, studying in a foreign country – which can be a lonely, lonely experience – and flying home to care for my father (to the best of my then 21-year-old abilities). Once all that is over, I find I have to handle two moves and a funeral at the same time and, of course, my friends’ lives have moved on as well. Not the best of times to find your feet.
I could go on, but you get the gist. Once the shit starts piling up, it’s easy to find yourself deteriorating, physically and mentally. And no matter where I turned for help, all I got was pats on the back and a prescription for antipsychotics because (in a desperate attempt not to top myself as originally intended) I had, somewhere along the way, discovered that physical pain can be quite a powerful tool for keeping the feelings at bay, to remain functioning (And what choice did I have? Not bury my father? Not helping my sister with the paperwork or her newborn baby?). So I was diagnosed with Borderline Personality Disorder (Apparently, self-harming behaviour is now the only constitutive indicator) and resigned to taking the antipsychotics.
They got me back on track. Started doing all the things I once enjoyed … except for the fact that it felt as if someone had sucked all the creativity out of my bones and left only a frail shell to walk about. After two years I had enough and quit the pills. What followed was a brief moment of clarity, then another two years spent first starving myself, then starving, bingeing and vomiting – until I nearly had to abandon my degree right before finishing my thesis. Getting through the day was hard enough, who needs to deal with academic work then?
And then I find someone who listened. Someone who found me a place in inpatient therapy. (And some pills, which do nothing for depression but at least I am no longer afraid of wasps – they rule, these pills do!) Now? I am doing much better, and I’ve learnt some valuable coping skills. Still, my life is a drag and some days the only way to climb out of this hole seems to be to keep digging till I see light on the other side.
Thing is: Everything you say regarding the ‘cure’ I agree with, BUT: I’ve always eaten healthily. I’ve had purposeful activities galore. I moved around in fresh air. I lived in a wonderful city. I had friends, even good ones. But I had to give all that up and move to be able finish my studies and obtain treatment. So now I only have sports (which I’d never thought I’d enjoy), a yet-to-be-written thesis, and that’s it.
I cannot just order people to be my friends, there is no theatre here (let alone time to spend on it), the charity branch here is pretty understaffed and thus a bit of a pain. And the bloody sun refuses to shine no matter what I say or do – AND I AM EVEN FINISHING MY PLATE, FOR CHRIST’S SAKE!
So, hell yes to healthy living and actually changing your life. I do both, it works, and it sure is necessary. But hell no to blaming each and every one of us for somehow being shoved on that slippery slope and ending up in that hole. Not everyone starts out life healthy, well-adapted and surrounded by wonderful, wonderful people. Recovering, improving, changing takes time and effort – but once you’re unable to sleep or get out of bed, simple advice like ‘Take a bloody walk and eat your greens’ doesn’t do the job.
#17 by Phil - October 28th, 2009 at 22:50
technicolorsheep: Thank you for your comment. Essentially what I said in the depressions post was:
1. Depression is not an illness.
2. Depression is a “message” from one’s own body encouraging us to make changes.
3. The changes should be in the direction of
- better nutrition
- more fresh air
- more sunshine
- more physical activity
- more purposeful activity
and
- talking to a trusted person openly and honestly about the things that trouble us.
My position in this matter is in direct contrast to those practitioners (and they are the vast majority) who say that depression is an illness and that taking antidepressants is on a par with a diabetic taking insulin.
I am sorry if the blog sounded condescending. This was not my intention, nor is it my stance. I will edit future posts carefully for any material that might give this impression.
You make two other interesting points. Firstly, bad things sometimes just happen. This is certainly true and is an important fact of life. We can take precautions, of course, but even with the best of care, disasters great and small come our way. For me the key concept here is habit. If I have established functional habits, there is a good chance that these will carry me thorough the rough times. If I have not established habits of this kind, or worse still, have established dysfunctional habits, then I don’t stand a chance. I will be swept away by the crisis emotionally and perhaps physically. Unfortunately statements like this sound like blaming and guilt-tripping. But they’re not. They are simply statements of fact. Our entire western Judeo-Christian culture is founded on blaming and guilt-tripping (man is born bad and needs to be “redeemed” through various religious activities), and this way of looking at the world (and at ourselves) is deeply ingrained. I personally believe that this world view is responsible for a great deal of the misery and unhappiness in the world – but that’s a huge issue. Essentially the point I am making is the obvious one: that if my life is not going well, and I make no changes, then my life will continue to not go well. Cinderella is far more likely to find happiness through emancipation and assertiveness training than by marrying a prince.
The second point you make which I feel is very important is that we don’t all get the same start in life. I believe that a major parenting task is instilling functional habits in the child. This doesn’t always happen. The point here is not to bash parents, but to acknowledge that we are not always as successful as we might be in preparing our children for adult life.
Broadly speaking, there are two kinds of problems in this area: problems that are happening to me, and problems with my own behavior. An example of the former would be an earthquake. An example of the latter would be overeating or smoking, etc. With regards to the former – well we do the best we can. With regards to the latter, we always have a choice: keep the problem or fix it. Now I’m not saying that life’s problems are easy to fix. Often they are very difficult. But there’s no third option. If I don’t resolve the problem, I will carry it throughout my life. And that isn’t fun either.
It sounds like you have found a therapist you can work with and that things are coming together for you in positive ways. Once again, thanks for your thoughtful comment and best wishes in your various endeavors.
#18 by Gee - January 7th, 2010 at 12:23
I have a friend who is suffering from depression despite being on pharmaceuticals for a few years now. I found this blog by searching “depression is not an illness”. I searched as such because in my experience, as a health care enthusiast and parent of 3 children, I noticed that mostly anything that people around me were struck with was a direct result of an imbalance in the integral system of either the human biology or nature or both. Quickly on the nature aspect, I believe that most of the strife we witness in the world today is a denial or ignorance of humans place in the web and cycle of life (life meaning the evolutionary impulse or biological process of all things on earth and in the cosmos). Just because we don’t “grow” out of the ground like a blade of grass many of us think we are separate from the earth. If we were planted here by God, evolved from bacteria, or dropped here by an alien species it doesn’t’ matter; we “fit” in to puzzle in some way. When we separate ourselves we lose harmony and synergy and cause illness in the world and in ourselves.
On the human biology aspect I noticed in some posts that some were saying that they did all the things necessary to be “healthy”. They talked about they got enough sunshine and they ate well, etc. But I have learned that when a person believes they are eating well, and you ask them what they are eating, you will discover the opposite. For example even though the food guides of North America tell people to eat large amount of grains in their diet there is evidence both empirical and anecdotal that they can cause great harm (inflammation to gut, joints, BRAIN) to many. The same goes for shunning fat in our diet. We need fats, even a tiny bit of the so called bad ones. As far as exercise, there is an optimal range; too much or too little will cause imbalance. Sunshine – being out in the sun is good; but most of us have been trained to shun direct sunshine to our bodies by covering ourselves with clothes or lotions. WE NEED DIRECT SUNSHINE TO OUR BODIES; NOT JUST OUR FACE AND ARMS; THE WHOLE BODY! Most people need about 20-30 minutes a day to the whole body depending on skin type, etc. MOST PEOPLE ARE DEFICIENT IN VIT D because of this. When deficient it is shown now in medical literature that this will cause many diseases, depression, etc.
The point is that even if people think they are doing the healthy thing, sometimes they are not. Don’t rule out what Phil is saying about the 6 requirements even if you think you do all those things. To all of you who are suffering – don’t rely on one solution; keep an open mind; study the requirements of your body; look out for deficiencies and/or toxicities.
#19 by technicolorsheep - January 9th, 2010 at 02:30
Dear Gee,
Thank you for your take. However, I would be very pleased if you refrained from judging my lifestyle without knowing me and also if you stopped assuming that everyone is US-American. Thank you.
Also, I sense a certain amount of condescension toward those people who apparently are too stupid to ‘do the right thing’ according to your theory. Context matters, honey: Not all everyone lives under climatic and/or socio-economic conditions in which your advocated measures are as easily accomplished as they seem to be for you. If you want to convince people to “keep an open mind” and try out your approach, this might be something you may want to reconsider. Just saying.
For my part, therapy has helped (and still does help) a lot; I am getting better by the day, even though it’s winter (How did that happen?), even though there is no sunshine let alone the possibility of exposing your body to it, even though my diet is less healthy than it used to be (Thank fructose intolerance, lack of finances and my thesis).
So, does that make me a miracle, or might it be that the ‘traditional’ approaches of learning how to cope actually work? For my part, I don’t care what it is, it works and I am glad. Actually no, I am happy. Happy that for the first time in years I am able to concentrate, work, relate to my friends, go out, get organised, do all the stuff normal people do…
And I resent the fact that this talk about toxins and food being the be-all end-all of the issue may result in some people not receiving the understanding and help they need in order to get out of this and start making changes in to their lives. Basically, the ‘eat right, live right, do as I say’ approach is a sorry excuse for the old ‘Pull yourself up by the bootstraps’ advice. It is insensitive and it prejudges people. I, for one, much as I believe in taking care of my mind and body, am not convinced.
#20 by Louise - January 9th, 2010 at 11:51
Gee, I wanted to comment and say how much I agree with your position. I believe that diet and lifestyle impact our physical and mental wellbeing to a huge degree. I also believe that what most people consider a “healthy” diet isn’t really great – your point about the food pyramid is correct. We need a diet that is primarily based on vegetables, not grains. Ultimately, we’re each responsible for our own health, but I believe that the government (at least in the US) has played a role in creating a society where a majority of the individuals are overweight and “lifestyle” diseases are increasing in frequency.
Technicolorsheep pointed out that lack of finances is having a negative impact on her diet, and unfortunately, this is a problem faced by nearly everyone with a limited budget. It is much less expensive to buy a Big Mac combo meal than to get several ingredients for an organic salad. A lot of this has to do with the way the US government structures farm subsidies – billions of dollars are paid to farmers who grow corn (mostly used to feed livestock or process into things like high fructose corn syrup), cotton, rice, wheat, and soybeans. Not a penny in subsidies is given to farmers who grow vegetable produce like carrots, cabbages, and kale.
I like your reminder about sunshine too. We’re lucky to live in a climate that gets a lot of sunshine, although the winters are bitterly cold. Despite the cold, we’ve made a point to go outside every sunny day this winter, wearing summer clothing. It’s not comfortable, but we like knowing that we’re improving our health by increasing our vitamin D levels.
#21 by technicolorsheep - January 9th, 2010 at 13:38
Dear Louise,
Actually, here in Germany a Big Mac (or fast food in general) is not the least expensive food available. Not by a long shot. It’s more like bulk buying bread, apples and cheese, and choosing your produce wisely that will make your budget last, but that doesn’t make it any less imbalanced and lacking in variety. As I said: Not anywhere is the USA, so please don’t assume everyone is living the same lifestyle – not even those with depression or other mental health problems, no.
All I meant to say was that being in financial dire straits and having no perspective for the future will impact your resilience/ability to bounce back. It seems long-term unemployment and – what is that nice term economists use nowadays? – “elevated levels of food insecurity” are major stressors. Does that really surprise us?
What I am trying to say: A lot of the things suggested above may be fine for low/medium levels of depression and a middle-class background. Pack financial instability or a lack of education and social networks on top: Not so much. I’ve seen in my fellow patients how hard it was for poor, single mothers to cope and how little all the good advice did for them. Seems we’re all mighty privileged.
#22 by Phil - January 10th, 2010 at 19:19
Gee: Thanks for your interesting and thoughtful comment. You mention our “place in the web and cycle of life,” and I agree that this is an important notion. In a relatively short space of time (a few thousand years) we have gone from being hunter-gatherers in small groups to wielders of technology living in enormous cities. Even the farmers (the producers of food) spend most of their working day sitting in the cabs of tractors and combine harvesters. We call all of this progress, and of course in many ways it is. Nobody wants to go back to washing clothes in a cold river or watching their children die of diseases that are seldom even heard of today. There is a cost, however, to all of this. In my post on the so-called anxiety disorders I discussed some of these costs, and I think you care correct in identifying the severance from our biological roots as a fundamental issue.
You also make the point that there is often a wide discrepancy between what people actually eat and what they say they eat. This is certainly true. People whose diet is less than ideal often feel very guilty about these matters, and will present a picture of their dietary intake that is rosier than the reality. In many cases this is as much self-deception as a desire to deceive others. Many years ago I was talking to a client and he mentioned that he always ate a good breakfast before going out in the morning. I asked him what he actually ate, and he replied “two pop tarts and two cups of coffee.”
The central theme of my depression post was that depression is not an illness, but is rather a warning signal from our bodies, to the effect that something is wrong – something needs to be changed. Tragically the bio-psychiatric school has persuaded large numbers of people that depression is an illness (“just like diabetes”) and needs to be “treated” by taking drugs.
Once again, thanks for your comment.
#23 by Nostalgic - January 10th, 2010 at 21:53
Phil, I think what you’re saying can be a little dangerous. Looking at depression in an evolutionary manner, as you are doing, can be really helpful. But we have to keep in mind that although depression can be a signal for the self to change, in a tribal context, it is also a cry for help. It is a physiological and psychological adaptation to prove to the individual’s community that their suffering is genuine. By solely talking about the individual’s responsibility to change we tend to put too much blame on an already vulnerable person. If the depression becomes so severe as to provoke someone to take their life, it’s as much of a failure of the society as it is of the individual.
Even though this could be thought of as a normal evolutionary response, psychological pain like this, as with physical pain, can become dysregulated. Depression is “not an illness” if you are talking about the mild stuff. If it’s something that’s prolonged, intense, frequent and exists even in the absence of triggers, then it’s something that needs to be addressed with psychological and medical interventions. Many types of depression are quite clearly a biochemical malfunction. For example: in certain diseases, the immune system develops auto-immune pathologies, and makes antibodies to serotonin, which can then lead to depression. And in chronic infections, depression can also arise from raised interferon-alpha levels, which are known to affect the serotonin system.
All I ask of you is not to categorize all depressed people into the same group. As you can judge by some of the responses, every case is different and some quite prolonged and severe. As much as we’d like to simplify the treatment into six factors, for some, this approach would be insulting and discouraging. There are clearly some people who need the pharmacotherapy along with the psychotherapy; perhaps as an adjuvant or a catalyst for change. We speak of ‘quick fixes’ as bad things but we know that treatment for psychological illnesses tends to take a long time and anything that would speed up the process has the potential to save lives. The only thing lacking is competent practitioners who know when and how to appropriately use medication.
#24 by Phil - January 12th, 2010 at 17:14
Nostalgic: Thanks for your detailed comment. You make the point that suicide is as much “…a failure of the society as it is of the individual.” This is certainly an interesting perspective. In Western culture we tend to emphasize independence in our child-rearing practices. “Standing on one’s own two feet” is considered a great virtue, and there’s a measure of validity in this notion. However, we sometimes neglect the need for companionship and mutual support. Asking for help of any sort is, in various subtle ways, considered a weakness. Tragically many young people reach adulthood without any truly supportive relationships. They have no one with whom they can be truly honest; no one to whom they feel they can turn in times of emotional need. They are so driven to appear “cool” that they tell no one that they are hurting, even when the hurt is extreme. Your point seems to be that as a community we should be reaching out to these individuals in an active, solicitous way, and encouraging them to talk about their hurts and concerns. Perhaps you are right, though there is a danger of guilt-tripping the families and friends of people who have killed themselves, on the grounds that they didn’t do enough to reach the individual. The problem with this approach is that in my experience families and friends have usually made great efforts in this regard, but without success. So, like everything else in this field, this is complicated.
You express the view that mild depression is not an illness, but severe depression is. You also state that: “Many types of depression are quite clearly a biological malfunction.” My position is that there is insufficient evidence for either position. Of course depressive feelings are always accompanied by neural events. If I punch someone in the jaw, my action can be described from various perspectives. From a psychological point of view, it could be pointed out that the individual had insulted my favorite baseball team (say) and I retaliated physically. A sociologist might note that there were on average five physical altercations in the particular establishment each month, and that the combatants always came from different ethnic groups. An anatomist might describe how the human arm was uniquely suited to the purpose of striking blows to other objects. A physiologist might study the movement and interplay of muscles, tendons, etc. And a neurophysiologist might focus on specific mechanisms that link neural and hormonal correlates of anger with large muscle neurons, etc.. Now all of these perspectives are valid ways of examining the event in question. But no one would suggest that the act of throwing a punch should be regarded as an illness just because it has some neural correlates. Similarly, feeling good or feeling down can only occur if certain neural events happen in the brain. This does not establish the principle that depression is an illness. At the risk of stating the obvious, it is clear that a brain malfunction could cause depression. But the biopsychiatric adherents, despite their claims, have never established that this actually occurs. For a very detailed examination of the evidence in this matter, I recommend Elliot Valenstein’s book Blaming the Brain (1998).
Even if brain malfunctions were identified and were shown to cause depression, it seems unlikely that it would account for more than a tiny proportion of the depression we see in our society. The notion that human brains are “breaking” with such frequency is difficult to accept, especially when more parsimonious behavioral explanations are available.
You ask that I not categorize all depressed people into the same group. And in this, we are in full agreement. One of my major criticisms of DSM is that it does just that. It purports to collapse the enormous complexity of human life into the so-called diagnostic categories. My position is firstly, that every case of depression is different, and secondly, every depressed person is understandable if we are willing to take the time and trouble to listen and encourage communication. Within the DSM context, this almost never happens. The “diagnosis” is assigned and the pills are administered, and the “just like insulin” fiction is perpetrated.
With regards to pills, I don’t encourage people not to take them. In my experience some people take pills, others don’t. If you find them helpful, who am I to argue? My only position is that depression is not an illness, and anti-depressant drugs are not medication.
Anyway, despite our disagreements, I’m extremely grateful for your comments. I believe that dialog is the only way to move forward, and your thoughtful and detailed comment is greatly appreciated.
#25 by Salvora - April 30th, 2010 at 05:55
A healthy diet, exercise, sunshine, fresh air, purposeful activity, and relationships are all very important to feel well. I notice the effect they have in my mood. In particular, I notice the effect that sunshine and exercise have on my mood right away, and so they are a very good medicine against depression.
When one is depressed, one is very likely to be missing out on those six factors. Perhaps lacking those things is a cause of the depression, but most certainly that is also going to be the result of the depression. Because depressed people find it a lot harder to do the things they need to do to feel better. In other words, lacking those six things can be both cause and effect of depression.
Here is where I think that antidepressants can help. They can improve the mood of the person so that she can implement the changes that she needs to make in her life. Sometimes to make those changes requires a lot of effort and help. Sometimes professional guidance and support.
I am right now being treated with antidepressants, but I’m also having psycotherapy. I lack good relationships in my life, and there are difficulties that preclude me from having them. Some of those difficulties are emotional, others have to do with a lack of skills.
I have been treated with antidepressants before without any other treatment or help, and that only helped temporarily. My psychiatrist and I think that the reason why is that the things that make me depressed lie somewhere else.
#26 by Phil - May 3rd, 2010 at 15:44
Salvora: Thanks for your comment/question.
When people’s lives are lacking one or more of the six factors you mention, they become despondent. If corrective measures are not taken promptly, the despondency deepens, which in turn leads to a reduction in overall activity – including the very activities that would in fact mitigate the depression. It is clear from your comment that you recognize this dynamic very clearly.
The question you raise is: which causes which?
Well, my fundamental position is that the normal state of the organism is one of pleasure /happiness/joy/contentment. When things are going well for us, we feel good. This is not an accident – it is nature’s way of telling us to keep doing what we’re doing. This “message” from our bodies is not infallible. It apparently tells smokers, for instance, to keep smoking! But for the most part, the feelings of joy and depression are essentially “messages” from our bodies that nudge and coax us in directions compatible with the welfare of the organism, in the same way that hunger drives us to eat and the feeling of satiation encourages us to stop eating.
This perspective on the joy-depression mechanism is internally consistent and can be conceptualized as an adaptive mechanism that has evolved in a great many species besides man.
Now if we consider the alternative – that the inactivity was caused by the depression, the first question that arises is how did the depression arise in the first place. The bio-psychiatric position, of course, is that depression is an illness – that for unknown reasons, a “chemical imbalance” arose in the brain and this pathological condition can only be corrected by taking drugs.
The first thing that needs to be noted is that the bio-psychiatric position is making an extreme assertion, i.e. that a very large proportion of our population has incurred some kind of brain damage or brain illness. (My position, in contrast, asserts that what’s going on is in fact the normal life activity of evolutionarily advanced organisms). In science, the onus of proof lies with the individual or group making the assertion and the bio-psychiatric lobby has never made its case.
Here’s what Joanne Moncrieff – herself a psychiatrist – has to say:
Here’s what Elliot Valenstein – Professor Emeritus of Psychology and Neuroscience – has to say:
and in the same book:
and
So who do you believe? Now the APA and the pharmaceutical companies have a huge vested interest. Writers such as Moncrieff, Valenstein, and others do not. In the end of the day, each individual must choose for him/herself. What sort of an organism do you think you are? Are you “broken” and in need of pills? Or are you – as I believe to be the case – nature’s supreme moment: the apex of about 3 billion years of evolution. In my view, the bio-psychiatric position is not only false, but is a tawdry and venal insult to the human race, and is promoted by psychiatrists and pharmaceutical companies for financial reasons.
And so to the question of pills. Some people like to take drugs – others don’t. I never suggest that people take pills – nor do I ever suggest that people stop taking pills. In the end of the day this is a personal preference similar to eating meat or being a vegetarian. Some drug users get their product on the street – others from physicians and pharmacists. Do what seems right for you – but know the risks.
My primary objection in this area is to the practice of telling people that they have a brain illness which is corrected by the drugs in the same way that insulin corrects the blood chemistry of a diabetic. This is not only false, it is insulting, but it is a fiction that has to be maintained to preserve the bio-psychiatric sand castle. I strongly suggest that you read Mad in America (2002) by Robert Whitaker.
Anyway, there it is – complex issues arising, as always, from apparently simple straightforward questions.
You did mention in your comment that there are “difficulties” that preclude you from having good relationships. And I assume that this is a reference to something in your history. The key to traumatic history is to talk about it – over and over – until the bad memories become desensitized and lose the grip they hold on us. Psychotherapy in my view can be extremely helpful if it provides a context in which this kind of desensitization can occur. But it is also important to practice interpersonal skills in the “real world.” If this is difficult – and your letter suggests so – then start with “baby steps” and work up. Also try to figure out what it is that is making you sad. This is a question that almost never gets asked, but is often quite helpful and revealing when pursued with self-honesty and determination. Are you feeling sad because of some problem/deficiency in your life? Or because the days are passing and you feel you’re getting old? Do you feel overwhelmed? Do you wish for something you don’t have? Etc… Life is so busy for most of us nowadays that often we don’t take the time for this kind of introspection. But it is important, and can provide clues to why we are feeling down. I hope you are pursuing these kinds of questions in your therapy sessions.
Anyway, thanks for a very insightful and pertinent question. If you’re doing well with your therapist, then stay with that person and use the sessions to the full. I hope things continue to improve for you. Don’t hesitate to get back if there’s something you don’t agree with or would like clarified.
#27 by Tereza - May 24th, 2010 at 21:21
Dear Dr. Hickey, let me express my deep appreciation for your pure rational thinking untainted by dogmatism, which is very rare indeed. And for the poise with which you answer the comments! My heart sings with joy at reading your words! Alone the beautiful RATIONALITY exhibited by people like you is sometimes sufficient to alleviate depression, since it makes us aware of some kind of deep connection that we share. I have a strong feeling that the DSM philosophy might potentially be dangerous and it is only right to challenge it openly. What’s dangerous is dogmatism. Why is it so widespread? Perhaps an adaptive mechanism also? I’m sorry to hear about yout affliction! I wish you well! Sincerely, Tereza
#28 by Phil - June 1st, 2010 at 12:52
Tereza: Thank you for such kind words! I apologize for the delay in responding. Nancy, my wife of forty years, fell and broke her thigh bone Monday of last week. She was in hospital for about a week. She is home now but very incapacitated, so I haven’t had a chance to blog.
Your comments concerning dogmatism are extremely relevant and compelling. Dogmatism confronts us in almost all areas of life and can be very destructive. You suggest that it might be an adaptive mechanism. I could agree with that up to a point. I think that dogmatism provides a measure of comfort in a world that can be fraught with uncertainty. In that sense I believe it could be described as adaptive. But it would be more adaptive (in the sense of useful) to accept that there is always a degree of uncertainty and unpredictability to life, and to develop coping strategies and networks of mutually supportive relationships to enable us to deal with life’s vicissitudes (like broken legs!) as they arise.
In my view the notion of mental illness is spurious for reasons discussed elsewhere in the blog. But once this spurious step had been accepted, the APA was free to invent “mental illnesses” pretty much at will. And, of course, the drug companies were able to develop the “treatments.” I suppose this bio-psychiatric system provides a measure of comfort to some individuals, but comfort bought at the expense of truth is illusory and usually short-lived.
I can find within me a measure of sympathy for psychiatrists. After all, their livelihoods are at stake, and economics makes cowards of us all. Most of them avidly support the official dogma. Occasionally – very occasionally – one encounters a psychiatrist with a conscience. I recall many years ago talking to one such individual. He said: “Someday this whole sand-castle is going to crumble, and we’ll have to find honest work.” Well, of course, that day hasn’t arrived! But the sand-castle is under serious attack. Robert Whitaker’s book Mad in America is selling well and creating a stir, and other writers are raising serious questions about the validity of the DSM system.
Anyway, thanks for your nice words, which were greatly appreciated, and for your very interesting thoughts and observations.
#29 by Tony O’Farrell - July 16th, 2010 at 09:13
Dear Phil,
What you have to say is very interesting, and rather shocking. It appears that there is no scientific evidence of specific chemical imbalance in most people suffering from depression, and so no scientific basis for the treatment of depression by antidepressive drugs. You cite specific sources for this finding. I had no idea. In my job as Head of Maths I’ve encountered many depressed students in my time, almost all on medicine, and never dreamed of suggesting they come off the medicine. In fact, I assumed that if they did so, they would be at increased risk of suicide, which is, along with road traffic accidents, one of the two main causes of death among our students. And everything I’d heard before this, including comments by professionals, was to the effect that “the drugs work”, and in fact that “there has been no progress in psychiatry apart from the development of useful drugs.”
I still won’t advise people to stop taking the pills, but I won’t encourage them to continue, either. Not my job, or competence. Patients should be able to trust their doctors. But doctors have to follow current professional guidelines, or risk serious consequences, so the issue is with the guidelines of the professional psychiatric bodies. The book by Valenstein appeared 12 years ago. Has it been dismissed as the work of a crank, or is the profession seriously examining its guidelines?
#30 by Phil - July 19th, 2010 at 13:54
Tony: Thanks for your comment which raises several interesting issues. Yes, there is no scientific evidence to support the so-called chemical imbalance theory of depression. Valenstein’s credentials preclude the possibility of dismissing him as a crank. What the bio-psychiatric sector does with writers like Valenstein is simply ignore them. The pharmaceutical companies have hijacked medical research so that it supports their agenda, and they spend enormous sums of money in promoting their philosophy and practices. Valenstein becomes a voice in the wilderness. But lately there are other voices.
Joanna Moncrieff, herself a psychiatrist at University College London, has written a truly wonderful book: The Myth of the Chemical Cure (2009). She has this to say:
And later in the same volume:
Robert Whitaker has two books in print on these topics: Mad in America (2002) and Anatomy of an Epidemic (2010).
You mention the question of suicide, and of course this is the bio-psychiatric contingent’s trump card. Nobody wants to have a suicide on their conscience, and the bio-psychiatric lobby has established the myth that anti-depressant drugs are the best way to prevent this – indeed the only way. Robert Whitaker devotes a good deal of attention to this question in Anatomy of an Epidemic, and it is clear that the efficacy of anti-depressant drugs in this regard is not as straight-forward as the pharmaceutical companies would have us believe. In fact, there are indications that some anti-depressant drugs increase the risk of suicide.
As a general principle, I refer to pharmaceutical products that are designed to alter mood and behavior as drugs. Medicines, in contrast, are for treating illness. Encouraging the use of the term “medication” to refer to their psychotropic products is just one of the ways that the bio-psychiatric lobby has developed and promoted their spurious philosophy.
You refer to the myth that “there has been no progress in psychiatry apart from the development of useful drugs.” This is indeed widely believed and actively promoted. In reality there had been some great developments by psychiatrists prior to the drug era. Eric Berne’s Games People Play (1964) was, and is, a classic analysis of human interaction. Harry Stack Sullivan, a psychiatrist who wrote extensively and with insight on human relations, is dismissed by modern psychiatrists as irrelevant. And so on.
The problem for psychiatrists is that the problems they purport to treat are not illnesses. But for turf protection reasons they have to pretend that they are illnesses. The inevitable shoe-horning of ordinary human problems into a medical mold creates an untenable level of tension. I once heard a psychiatrist remark that some day the bio-psychiatric edifice will come tumbling down and “we’ll all have to find honest work.” Well, of course, vast resources are being expended to shore it up. So we’ll see. The fundamental question is: what does one mean by the term “illness.” My definition is: something going wrong with the organism either from internal malfunction or from external attack. But the bio-psychiatric lobby will argue for a much more inclusive definition. In a reply (#2) in the comment section under another post I have discussed the problem with the APA’s definition of a mental disorder. Their definition can be paraphrased as: any problem of living. So, of course, they can expand their turf endlessly.
You are correct in drawing attention to the guidelines of the professional psychiatric bodies, or standards of care. And at present the standards of care in this area enshrine the spurious bio-psychiatric position.
And so it goes. Life’s problems are complex and will never succumb to simplistic explanations or solutions. Once again, thanks for your comment. I believe you are correct in not encouraging or discouraging individuals with regards to anti-depressants. In my experience, some people like to use drugs (street or pharmaceutical); others don’t. Some feel they derive benefit from these products. But there are always costs!