Last winter, a particular client of mine complained, “I think I’m depressed. I think I need meds.”
No doubt he was miserable. He’d graduated law school the previous Spring, passed the bar on his first try—and gotten no job offers. An acquaintance was letting him work out of the supply closet in his office, trying to generate income by taking on nuisance suits—personal injury suits from opportunistic people trying to turn a buck. He was rather ashamed of the suits he was pursuing, and since few of them had merit, he was making very little money.
His long-time girlfriend had dumped him because she’d discovered that, yet again, he’d cheated on her. He lived in his parents’ house, apparently an emotionally barren place where the main activities were watching Fox News and reality TV and cursing Barack Obama. He tended to stay up too late, distracting himself with video games, porn, and alcohol. He couldn’t get himself into his “office” before late morning. He tended to go in wearing jeans and casual shirts, often rather lackadaisically groomed.
He certainly would not have been considered “clinically depressed” before DSM-III. His misery would have been seen as indicative, a sign of his difficulties. In fact, he was disappointed with the state of his life, ashamed of himself at many levels, bereft of love, discouraged, and emotionally starved. Positing some underlying illness, Depression, to account for his negative affect, seems to me un-illuminating.
Another friend from law school contacted him, to ask whether he’d like to work out of the offices of the small law firm the friend’s dad ran. My client was skeptical, and he wasn’t inclined to muster the energy. But we decided he should give it a try. Immediately, he had an office befitting a professional person, and within weeks, he was doing work he didn’t mind. He enjoyed being around his friend and his friend’s dad—and the office staff. He got up on time, dressed well, began going to lawyers’ professional events. Etc.
He was surely no longer “depressed.” He still had pragmatic changes to make—getting out of his parents’ house, for instance—and a lot of issues to work out—like his compulsive, self-defeating and other-harming sexual behavior. But his affect was infinitely better.
In my last two postings, I argued that our current concept of Depression is an artifact, conflating what once was called melancholia—which is an horrific, dangerous state of mind in which we’ve lost agency and control over the pain that assails us—with a great variety of painful negative affects that, in common language, we would call “depression.”
Scientifically, this makes little sense, since the concept of “major depression” does not meet standard conditions for positing an unseen entity, process, or force. Clinically, this new concept leads to ham-handed, often misdirected care.
In ordinary language, as I’ve pointed out before, ‘depression’ as a word sits within a complex semantic web. We can say someone is depressed when he or she is discouraged, despondent, dismayed, disconsolate, demoralized, despairing, disappointed, disheartened, dispirited, defeated, downtrodden, heartsick, unhinged, bereft, enervated—and so on. The ways these various states of mind resemble each other allow us usefully to see them as having something in common.
But each has its unique qualities, too—and those often matter, if we’re paying enough attention to notice. Finer-grain distinctions between affects help us toward more detailed knowledge of what’s going on in our lives and the lives of our patients. The DSM concept of Depression takes us in exactly the wrong direction—teaching us to make cruder, rather than more precise, analyses.
Treating all “down” states as manifestations of an underlying Depressive disorder mistakes family resemblance for identity, which can be highly problematic. Kissing one sibling has some things in common with kissing another, but they’re not at all the same thing. Two sisters may look a lot alike, but you’d better know which one you’re dating before you pucker up.
And each affect may have different causes, and different solutions. A loss of courage is different from a loss of meaning, and each is different from the effects of being overwhelmed by dire circumstance. Enervation is different from loss of faith in the dependability of important others. Absence of resources, social or financial or personal, is different from absence of opportunity. And so on. Each of these may be brought about by different events, different circumstances. And each patient will have different proclivities and capacities to institute particular changes in response.
Besides encouraging cruder analysis, the DSM concept of Depression often misdirects our attention in another way: in reality, the negative affect may be the least important aspect of a person’s situation, or even an important dimension to preserve—as an indicator and motivator—for as long as the status quo remains in place. We evolved our affective systems for reasons. We need to pay attention to affects—they serve important purposes.
One of the most distressing aspects of the rising emphasis on “affective disorders” is that care becomes preoccupied with mood manipulation. We cannot learn anything from affects, or use them as guides in changing our lives, if we manipulate them away.
Under the influence of the idea of Depression, therapists become very good at mood manipulation, and at teaching mood manipulation skills, but less and less informed about, and less helpful with, understanding life. Teaching patients to manipulate their moods replaces understanding and sorting out people’s lives.
We return, then, to the contention that conflating melancholia and the many ways we can be depressed (in the ordinary sense of the word) is just wrong. With melancholia, which rightly deserves to be seen as a disorder, one’s affects bear little or no relation to reality, and their intensity is dangerous enough that relief is critical. Suicide is likely in melancholia not so much because one thinks one doesn’t deserve to live, or because one cannot see a good future, but because the pain is too great to bear. Pain relief must be the first order of business. Furthermore, precisely because one’s moods have become unhinged, one’s beliefs about what has caused them are unlikely to be accurate. Melancholia needs to be relieved, not analyzed—and extreme caution about making changes in one’s life should be exercised in a state of melancholia.
Treating all negative affects as if they were part and parcel of melancholia—or dangerous and undesirable precursors that need to nipped in the bud—precludes our making proper use of them to change what needs changing in our lives. And that, to me, seems like bad care.
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.