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:

“My thesis in this book is that the disease-centred model of drug action has been adopted, and recently widely publicised, not because evidence for it is compelling, but because it helped promote the interests of certain powerful social groups, namely the psychiatric profession, the pharmaceutical industry, and the modern state. Therefore, I offer the following study as an example of the way in which vested interests and the political environment can distort knowledge, in this case successfully deluding most of society for over half a century.” (p 13)

And later in the same volume:

“The data surveyed in this book suggest that psychiatric drug treatment is currently administered on the basis of a huge collective myth; the myth that psychiatric drugs act by correcting the biological basis of psychiatric symptoms or diseases. We have seen that for the three main classes of drugs used in psychiatry there is no evidence to substantiate this view. Instead, the evidence suggests that these drugs induce characteristic abnormal states that can account for their so-called therapeutic effects. This book has been about how and why this myth of psychiatric drugs as ‘chemical cures’ was constructed and sustained.” (p. 237)

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!

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:

“Overall there is little evidence to suggest that there is a characteristic abnormality in either of these systems [serotonin and noradrenalin levels] that is associated with depression.” (The Myth of the Chemical Cure, 2009, p.156)

Here’s what Elliot Valenstein – Professor Emeritus of Psychology and Neuroscience – has to say:

“Although it is often stated with great confidence that depressed people have a serotonin or norepinephrine deficiency, the actual evidence contradicts these claims.” (Blaming the Brain, p. 100)

and in the same book:

“The evidence is clear that none of the proposed biogenic amine theories of depression can possibly be correct.” (p. 102)

and

“…it has not been possible to demonstrate that any biochemical abnormality is associated with any of the subgroups of depression.” (p. 102)

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.

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.

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.

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.

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.

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.