When “depression” was simply a state persons could find themselves suffering, ‘depression’ was a useful word. Like any word, it nestled within a semantic network of many other words. We might say someone was “depressed” when we might also say he or she was discouraged, despondent, dismayed, disconsolate, demoralized, despairing, disheartened, dispirited, defeated, downtrodden, heartsick, unhinged, bereft, enervated—and so on.
Each of those words carries a different connotation, each points toward a bit different way in which life can be difficult, each evokes a bit different way we can find ourselves “down and blue.” ‘Depression’ was a generic term for many different ways of being down. And in and of itself, ‘depression’ said nothing about the severity of one’s distress or whether one needed professional help, much less whether suffered from an illness or disorder.
“Clinical depression”—more felicitously called “melancholia”—was a different beast. And beastly it was (as it remains). But melancholia was not an idea, not a theoretical construct: it was a phenomenon, observable and describable. No one needed to be “diagnosed with melancholia.” If you’d fallen prey to it, it was absolutely obvious—all-encompassing.
Today, ‘depression’ is not a useful colloquial term, but the name of a mysterious underlying condition alleged to cause all sorts of terrible things—symptoms—we want to be rid of. Today, Depression (big ‘D’ to make the point that it’s now a name, not just a noun) is an idea, and a bad one.
Why, exactly, is it a bad idea?
From a scientific perspective, it’s a bad idea for at least two reasons.
First, it fails to meet the basic epistemic conditions for positing an unseen entity, process, or force in any science (or other intellectual endeavor): to unite disparate phenomena in a conceptually clear and coherent manner, such that we can make predictions we otherwise would not have been able to make. The idea of big-D Depression simply does not do that.
Second, and related, conglomerating into one abstract idea the many different ways of being depressed—in the colloquial, “small-d” sense—makes for a confused idea. We mush too many things together whose only connection is a vague similarity of affect.
Similarity of affect is no indicator that disparate things have much in common. All sorts of different things can share an affective outcome without being at all the same. Successfully completing a difficult and challenging project, schadenfreude, the first-flush of new love, resisting a dangerous temptation that would violate one’s principles, the first beautiful day of Spring, and a good meal all have similar affects, but they are hardly the same thing.
It’s likely that one reason scientific research on Depression makes no progress is that this incoherent mélange actually has little to unify it. Big-D Depression is an artifact, a committee-created concept born of political and economic considerations by the creators of DSM-III, propagated by mental health professionals and pharmaceutical companies who profit from having us accept it. It probably doesn’t exist as a phenomenon in the world. Attempts to study it scientifically may well be doomed to the inconclusive, contradictory results we do, in fact, find in the research literature.
From the perspective of clinical practice, assessing the idea of Depression is a bit more complicated.
Whether you think Depression is a good idea clinically will depend partly on whether you think having insurance pay for help with depression is a good thing. One of the main reasons Depression came into existence was to insure that third party payers would cover treatment for little-d depression, as Edward Shorter details in Before Prozac: The Troubled History of Mood Disorders in Psychiatry.
Insurance companies will pay for therapy for Depression much more readily than they will pay for sorting out “lesser” problems. Presumably no one in his or her right mind would object to third party payers covering melancholia, since it is, in fact, a debilitating and dangerous condition. Big-D Depression embodies the pretense that little-d depression and melancholia are of a piece, simply different in severity—and that little-d depression, left untreated, is apt to become melancholia. Once patients, care providers, and insurers buy the idea that little-d, untreated, leads to melancholia, paying to treat non-melancholic depression becomes a no-brainer.
But there is absolutely no evidence that the idea is true, and plenty of common-sense and clinical evidence against it. For instance, little-d depression is common, while melancholia is rare. And anyone who practiced prior to the rise of the current ideology knows that even intense negative affect very rarely indicates impending melancholia. The many experiences lumped together by the generic, colloquial term ‘depression’ no more lead to melancholia than the common cold leads to pneumonia. But the mental health industries—talk therapists no less than biological psychiatrists—make a lot of money off the pretense. And patients can afford otherwise-overpriced therapy because insurers have to pay for it. Maybe that’s a good thing, maybe not. But it’s clinical reality.
Generally, I think that Depression is a very bad idea clinically for two related reasons: it makes for ham-handed, misdirected care, and it alters the patient’s self-image, and social status, in ways that are likely to impede, rather than fruitfully guide, the process of sorting out the sources of suffering.
I’ll discuss this at length in my next posting. For now, suffice it to say that understanding one’s suffering requires attention to two things: the exact form of one’s suffering, rather than its generic affective qualities, and the concrete particulars of one’s situation. Directing attention to the abstract notion of Depression, and attending mainly to the generic affect, precludes both.
One can become “red faced” because of embarrassment, sun burn, excess alcohol consumption, exercise, or any number of other things. The fact that these completely-different activities have one common feature is trivial in understanding any of them. If we invented a disease concept, “rosafascia,” we could accurately say that all of the different activities, processes, or conditions that make one red faced are due to rosafascia—and we would, by so doing, learn about as much as we learn from Depression.
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.