The Idea of Depression, Part Two

Bob Fancher, PhD
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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.

12 COMMENTS

  1. It’s true, now people often say they’re “depressed” when they feel sad, or disappointed, or experience existential angst.

    We’ve become a society afraid of any but the most sunny, energetic feelings. This is not merely rhetoric. I’m not exaggerating, people have no tools anymore to deal with a slump.

    Mickey Nardo at 1boringoldman.com has been digging into the history of the confound around melancholia and depression in this and many other posts http://1boringoldman.com/index.php/2012/05/30/something-very-wrong/ (as well as other important topics in the downfall of psychiatry; Edward Shorter is a commenter).

  2. I really appreciate how deep and important is the entirety of this blog. You said so many valuable things, I will limit myself to comment on just one: “I think that Depression is a very bad idea […] 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.”

    Do you see the “do not harm” principle as applying to words, and more generally to theories?

    Philosophically, how do you handle the fact that theories about the mind have an enormous impact on the working of the mind itself? That dynamic loopback effect leads to many questions:

    Should theories of the mind be considered obsolete once they are extremely popular?

    If a theory/therapy relieves suffering, by creating a mindset that is associated with less suffering (and the benefits can be reliably measured), assuming the theory is not scientific in nature, does this theory/therapy belongs to official medicine?

    • Stanley H. said “Should theories of the mind be considered obsolete once they are extremely popular?”

      What an interesting idea! Once such a theory becomes popular, it is changing how minds work!

      A meme as epigenetic agent….

      A theory of mind has to become increasingly meta, taking into account the prior memes.

  3. devastate
    vb (tr)
    1. to lay waste or make desolate; ravage; destroy
    2. to confound or overwhelm, as with grief or shock

    vast
    adj. vast·er, vast·est
    1. Very great in size, number, amount, or quantity.
    2. Very great in area or extent; immense.
    3. Very great in degree or intensity. See Synonyms at enormous.

    shrink

    Slang A psychotherapist.

    v. shrank (shrngk) or shrunk (shrngk), shrunk or shrunk·en (shrngkn), shrink·ing, shrinks
    v.intr.
    1. To become constricted from heat, moisture, or cold.
    2. To become reduced in amount or value; dwindle: His savings quickly shrank.
    3. To draw back instinctively, as from something alarming; recoil.
    4. To show reluctance; hesitate: shrink from making such a sacrifice.
    v.tr.
    To cause to shrink.
    n.
    1.
    a. The act of shrinking.
    b. The degree to which something shrinks; shrinkage.

    Is it possible to shrink (reduce) a vast (enormous) devastation (depression, grief)?

    Words = Powerful. Creative. Destructive. Informative. Vital.

    ~ Peace

  4. Depression:
    “For myself, the pain is closely connected to drowning or suffocation-but even these images are of the mark. The pain persisted during my museum tour and reached a crescendo in the next few hours when, back at the hotel, I feel onto the bed and lay gazing at the ceiling, nearly immobilized and in a trance of supreme discomfort. Rational thought was usually absent from my mind at such times, hence trance.” _W Syrton, “Darkness Visible.”

    I search through the dozens of PDF docs on this laptop, looking for a good example of the latest science research on human development, which seems to hint at a natural reason for our experience of depression;
    “Humans have three principal defense strategies—fight, flight, and freeze. The Polyvagal Theory describes three developmental stages of a mammal’s autonomic nervous system: Immobilization, mobilization, and social communication or social engagement. Faulty neuroception might lie at the root of several psychiatric disorders, including autism, schizophrenia, anxiety disorders, depression, and Reactive Attachment Disorder. We are familiar with fight and flight behaviors, but know less about the defense strategy of immobilization, or freezing. This strategy, shared with early vertebrates, is often expressed in mammals as “death feigning.” (Porges, 2004).

    “In humans, we observe a behavioral shutdown, frequently accompanied by very weak muscle tone. We also observe physiological changes: Heart rate and breathing slow, and blood pressure drops. Immobilization, or freezing, is one of our species’ most ancient mechanisms of defense. Inhibiting movement slows our metabolism (reducing our need for food) and raises our pain threshold. But in addition to freezing defensively, mammals immobilize themselves for essential prosocial activities, including conception, childbirth, nursing, and the establishment of social bonds. However, immobilization with fear elicits profound, potentially lethal, physiological changes.” (Porges, 2004).

    Consider Styron’s description of depression again;
    “I feel onto the bed and lay gazing at the ceiling, nearly immobilized and in a trance of supreme discomfort.” (Styron, 1990). When viewed along side Steven Porges recent discoveries concerning our unconscious autonomic nervous system, the stimulus for depression’s fearful immobilization seems to be yielding to our conscious awareness, yet such knowledge is still so new it finds little awareness even amongst the profession most charged with depression’s alleviation. Perhaps only our common system of rank and status is preventing the nervous system’s role in mental illness being fully acknowledged by the medical profession. Healing disciplines that have traditionally focused on the body, have certainly embraced this new awareness though, and it seems a paradigm shift in the understanding of mental anguish is underway.

    The price we pay for our “I think therefore I am,” experience awareness?

    Consider a further description by Styron;
    “Rational thought was usually absent from my mind at such times, hence trance.” (Styron, 1990). Perhaps these words of personal experience are beginning to be understood by some therapists as this example shows;
    “Excessive parasympathetic branch activity leads to increased energy-conserving processes, manifested as decreases in heart rate and respiration and as a sense of ‘numbness’ and ‘shutting down’ within the mind (Siegel, 1999, p.254). Such hypo-arousal can manifest as numbing, a dulling of inner body sensation, slowing of muscular/skeletal response and diminished muscular tone, especially in the face. Here “cognitive and emotional” processing are also disrupted.” (Hartman and Zimberoff, 2006).

    References:
    Styron, W, 1990, “Darkness Visible a memoir of Madness,” Vintage Books, USA.

    Porges, S, W, 2004, “NEUROCEPTION: A Subconscious System for Detecting Threats and Safety,” University of Illinois at Chicago.

    Hartman, D and Zimberoff, D, 2006, “Healing the Body-Mind in Heart-Centered Therapies,” Journal of Heart-Centered Therapies, 2006, Vol. 9

  5. The hospital I work at recently had a “depression screening” day. If you need a screening to figure out that you are depressed, I think that you can’t be that depressed. Or perhaps you just want some external validation for your internal suffering, a label. The screaming inside isn’t enough these days to count for anything if you don’t have a diagnosis. You have to check off enough things on the checklist. If you just can’t get out of bed and want to die, that doesn’t mean anything until you have gone through the checklist.

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