Not so very long ago—certainly when I was in training—mental health professionals generally considered most depression to be symptom or sign—not a disorder unto itself, except in rare cases of major depression. Depression was like fever or pain or swelling—an indicator, though not a very specific one. And like fever or pain or swelling, it could come and go. Of itself, it told us little, but it got our attention. Once we paid attention, we could look for the source of the distress.
Depression was a state of mind, just as inflammation is a state of tissue. In my training, we learned that generally depression would yield in three to six months, if we established a good therapeutic alliance and provided insightful support. Once that happened, we could get on with the real work of understanding the patient’s difficulties and changing his or her life. We weren’t “treating depression.” We were working out the patient’s difficulties.
That was a working hypothesis, not a discovery—a guiding principle of our work. The idea grew out of the psychoanalytic tradition and spread far beyond it, as different schools of thought gave different accounts of people’s suffering. But clinical experience showed that this approach, in all sorts of forms, “works.” Plenty of clinical research supported that claim.
However, as many critics (including me) pointed out, depression tends to be self-limiting, and it responds well to general support. So maybe all our talk about “issues” was mistaken. Maybe we just gave people the support they needed to get better, or to sustain themselves while the depression ran its natural course, and then kind of hoodwinked them into learning how to live the way our school of thought they should. People came to therapy, felt better, gave the therapy credit for their better mood, and became receptive to our ideas about what constitutes “health.”
Nowadays, “depression” has become a dread malady in its own right, a disorder, not a symptom. It’s apt to last forever, demanding that one learn to “manage” it through medication and various “skills.” Mental health care becomes less and less about understanding one’s self and one’s life, so that one can become better, and more and more about learning to manipulate one’s moods. Mental health professionals learn less and less about life, and more about mood manipulation.
Has this change come about because of scientific discovery? Well, no. It’s a shift in perspective—a different way of envisioning a vast swath of human suffering.
What we know is that depression, as an experience, is horrible. In a bout of full-blown depression, our emotional processes can come unraveled, losing their proper function of indicating the significance of circumstances and preparing us to deal with them appropriately. Our moods may go into free fall, throwing us into abject terror. The self seems to disintegrate, actively and inexorably, its pieces collapsing into fiery despair. As we experience it, nothing we do changes or slows or stops the agony, because the self itself, so to speak, loses purchase on its own functional integrity.
Depression in this sense is an experience, a state of mind, a complex phenomenon. It’s a stone fact about the world. We know it exists because we observe it, whether we understand it or not.
The current concept of depression as a mental disorder is different from the experience. Supposedly it explains the experience, but it does much more. It claims that an underlying disorder manifests itself in the experience, and in many other experiences—all the items on the DSM diagnostic checklist. Many of those don’t much resemble the experience of depression. “Depression” is the thing underneath. That’s why we have to be “diagnosed as” depressed.
Psychiatric researchers have decided to designate more and more states of mind, activities, or physical changes as signs of depression. They’ve made a list of mental, emotional, and physical events (low energy, pessimism, thoughts of suicide, sleep problems, etc.), given the list a name (depression), then told us that the things on the list are manifestations of the name.
Giving a list of items a name is perfectly fine—e.g., ‘grocery list,’ ‘fitness regimen,’ ‘travel itinerary.’ But the name is just a convenient way of referring to the list, not the cause of the things on the list. The name doesn’t explain anything.
Let me be very clear about what I’m saying. I’m not saying there’s no such thing as depression. Not at all. Having felt the horrid maw of major depression a couple of times myself, I would never say such a thing. But the concept of a disease entity named “depression,” a “depressive disorder” that underlies and accounts for the various items on the DSM checklist, is a different thing altogether. It’s an idea, not an experience.
Whether that idea will eventually bear fruit remains to be seen. So far, mostly it justifies whatever current theory researchers and clinicians want to pursue and indoctrinate patients to believe—the chemical imbalance theory, the serotonin dysregulation theory, the hippocampus-neuronal-death theory, the cognitive distortion theory, the failures of attachment theory, etc.
Someday, we may be able to identify, measure, and intervene in the postulated underlying disorder, if there actually is one. Some or all of the signs and symptoms on the DSM checklist may turn out to be manifestations of that underlying thing, and that thing may be changeable by direct intervention. We don’t know–but it’s worth noting that the track record for this effort isn’t very good.
The experience of depression is horrific, and when we’re in it, we want—need—it to stop. I am not convinced, though, that postulating a depressive disorder helps much with that. It serves the purposes of the mental health industry—it gives us an air of esoteric knowledge, a rationale for the claim that we can spot and explain this underlying disorder. It’s intellectually interesting, as we try to create new theories of just what this disorder comprises. But it’s not clear to me that it helps much with people’s suffering.
In fact, I would suggest that when we lump many different elements of experience into the general category “signs of depression,” and we see that “underlying depression” as the “real problem,” we tend to become ham-handed and obtuse in how we analyze experience, how we listen to clients, and how we respond to distress. I suspect it leads us to see disparate sorts of suffering, with disparate causes and avenues to relief, as “signs” of something other than themselves. And I suspect that leads us to overlook important distinctions, and important ways of helping.
I’ll explain that suspicion in future blog posts.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.