The area of the brain involved in forming new memories, known as the hippocampus, seems to shrink in people with recurring depression, a new study shows. Read the News
A new study from Johns Hopkins School of Public Health suggests Americans are overdiagnosed and overtreated for depression. Read the Story
Most people think of depression as a mental disorder, that is, a biological illness of the brain. Here I argue that the concept of depression as a mental disorder has been unhelpfully overextended to include all manner of human suffering, and, more controversially, that ‘depression’ can even be good for us—an idea that I first visited in my book The Meaning of Madness.
Let us begin by thinking very broadly about the concept of depression. There are important geographical variations in the prevalence of depression, and these can in large part be accounted for by socio-cultural rather than biological factors. In traditional societies human distress is more likely to be seen as an indicator of the need to address important life problems rather than as a mental disorder requiring professional treatment, and for this reason the diagnosis of depression is correspondingly less common. Some linguistic communities do not have a word or even a concept to talk or think about ‘depression’, and many people from traditional societies with what may be construed as depression present instead with physical complaints such as fatigue, headache, or chest pain. Punjabi women who have recently immigrated to the UK and given birth find it baffling that a health visitor should pop round to ask them if they are depressed. Not only had they never considered the possibility that giving birth could be anything other than a joyous event, but they do not even have a word with which to translate the concept of ‘depression’ into Punjabi.
In modern societies such as the UK and the USA, people talk about depression more readily and more easily. As a result, they are more likely to interpret their distress in terms of depression, and also more likely to seek out a diagnosis of the illness. At the same time, groups with vested interests such as pharmaceutical companies and mental health experts promote the notion of saccharine happiness as a natural, default state, and of human distress as a mental disorder. The concept of depression as a mental disorder may be useful for the more severe and intractable cases treated by hospital psychiatrists, but probably not for the majority of cases, which, for the most part, are mild and short-lived and easily interpreted in terms of life circumstances, human nature, or the human condition.
Another (non-mutually exclusive) explanation for the important geographical variations in the prevalence of depression may lie in the nature of modern societies, which have become increasingly individualistic and divorced from traditional values. For many people living in our society, life can seem both suffocating and far removed, lonely even and especially among the multitudes, and not only meaningless but absurd. By encoding their distress in terms of a mental disorder, our society may be subtly implying that the problem lies not with itself but with them, fragile and failing individuals that they are. Of course, many people prefer to buy into this reductive, physicalist explanation than, presumably, to confront their existential angst. But thinking of unhappiness in terms of an illness or chemical imbalance can be counterproductive, as it can prevent us from identifying and addressing the important psychological or life problems that are at the root of our distress.
All this is not to say that the concept of depression as a mental disorder is bogus, but only that the diagnosis of depression has been over-extended to include far more than just depression the mental disorder. If, like the majority of medical conditions, depression could be defined and diagnosed according to its aetiology or pathology—that is, according to its physical cause or effect—such a state of affairs could not have arisen. Unfortunately, depression cannot as yet be defined according to its aetiology or pathology, but only according to its clinical manifestations and symptoms. Given this, a physician cannot base a diagnosis of depression on any objective criterion such as a blood test or a brain scan, but only on his subjective interpretation of the nature and severity of the patient’s symptoms; if some of these symptoms appear to tally with the diagnostic criteria for depression, then, bingo, the physician is able to justify a diagnosis of depression.
One important problem here is that the definition of ‘depression’ is circular: the concept of depression is defined according to the symptoms of depression, which are in turn defined according to the concept of depression. For this reason, it is impossible to be certain that the concept of depression maps onto any distinct disease entity, particularly since a diagnosis of depression can apply to anything from mild depression to depressive psychosis and depressive stupor, and overlap with several other categories of mental disorder including dysthymia, adjustment disorders, and anxiety disorders. One of the consequences of our ‘menu of symptoms‘ approach to diagnosing depression is that two people with absolutely no symptoms in common (not even depressed mood) can both end up with the same unitary diagnosis of depression. For this reason especially, the concept of depression as a mental disorder has been charged with being little more than a socially constructed dustbin for all manner of human suffering.
Let us grant, as the orthodoxy has it, that every person inherits a certain complement of genes that make him more or less vulnerable to entering a state that could be diagnosed as depression (and let us also refer to this state as ‘the depressive position’ to include the entire continuum of clinical depression and other states of depressed mood). A person enters the depressive position if the amount of stress that he or she comes under is greater than the amount of stress that he or she can tolerate, given the complement of genes that he or she has inherited. Genes for potentially debilitating disorders gradually pass out of a population over time because affected people have, on average, fewer children or fewer healthy children than non-affected people. The fact that this has not happened for clinical depression suggests that the genes responsible are being maintained despite their potentially debilitating effects on a significant proportion of the population, and thus that they are conferring an important adaptive advantage.
There are other instances of genes that both predispose to an illness and confer an important adaptive advantage. In sickle cell disease, for example, red blood cells assume a rigid sickle shape that restricts their passage through tiny blood vessels. This leads to a number of serious physical complications and, in traditional or historical societies, to a radically shortened life expectancy. At the same time, carrying just one allele of the sickle cell gene (‘sickle cell trait’) makes it impossible for malarial parasites to reproduce in red blood cells, and thereby confers immunity to malaria. The fact that the gene for sickle cell disease is particularly common in populations from malarial regions suggests that, at least in evolutionary terms, a debilitating illness in the few can be a price worth paying for an important adaptive advantage in the many.
What important adaptive advantage could the depressive position be conferring? Just as physical pain has evolved to signal injury and to prevent further injury, so the depressive position may have evolved to remove us from distressing, damaging, or futile situations. The time and space and solitude that the adoption of the depressive position affords prevents us from making rash decisions, enables us to see the bigger picture, and – in the context of being a social animal – to reassess our social relationships, think about those who are significant to us, and relate to them more meaningfully and with greater compassion. In other words, the depressive position may have evolved as a signal that something is seriously wrong and needs working through and changing or, at least, processing and understanding. Sometimes we can become so immersed in the humdrum of our everyday lives that we no longer have time to think and feel about ourselves, and so lose sight of our bigger picture. The adoption of the depressive position can force us to cast off the Polyannish optimism and rose-tinted spectacles that shield us from reality, stand back at a distance, re-evaluate and prioritise our needs, and formulate a modest but realistic plan for fulfilling them.
Although the adoption of the depressive position can serve such a mundane purpose, it can also enable us to develop a more refined perspective and deeper understanding of ourselves, of our lives, and of life in general. From an existential standpoint, the adoption of the depressive position obliges us to become aware of our mortality and freedom, and challenges us to exercise the latter within the framework of the former. By meeting this difficult challenge, we are able to break out of the mould that has been imposed upon us, discover who we truly are, and, in so doing, begin to give deep meaning to our lives. Many of the most creative and insightful people in society suffer or suffered from depression or a state that may have been diagnosed as depression. They include the politicians Winston Churchill and Abraham Lincoln; the poets Charles Baudelaire, Elizabeth Bishop, Hart Crane, Emily Dickinson, Sylvia Plath, and Rainer Maria Rilke; the thinkers Michel Foucault, William James, John Stuart Mill, Isaac Newton, Friedrich Nietzsche, and Arthur Schopenhauer; and the writers Charles Dickens, William Faulkner, Graham Greene, Leo Tolstoy, Evelyn Waugh, and Tennessee Williams, and many, many others. To quote Marcel Proust, who himself suffered from depression, ‘Happiness is good for the body, but it is grief which develops the strengths of the mind.’
You see, people in the depressive position are often stigmatised as ‘failures’ or ‘losers’. Of course, nothing could be further from the truth. If these people are in the depressive position, it is most probably because they have tried too hard or taken on too much, so hard and so much that they have made themselves ‘ill with depression’. In other words, if these people are in the depressive position, it is because their world was simply not good enough for them. They wanted more, they wanted better, and they wanted different, not just for themselves, but for all those around them. So if they are failures or losers, this is only because they set the bar far too high. They could have swept everything under the carpet and pretended, as many people do, that all is for the best in the best of possible worlds. But unlike many people, they had the honesty and the strength to admit that something was amiss, that something was not quite right. So rather than being failures or losers, they are just the opposite: they are ambitious, they are truthful, and they are courageous. And that is precisely why they got ‘ill’.
To make them believe that they are suffering from some chemical imbalance in the brain and that their recovery depends solely or even mostly on popping pills is to do them a great disfavour: it is to deny them the precious opportunity not only to identify and address important life problems, but also to develop a deeper and more refined appreciation of themselves and of the world around them—and therefore to deny them the opportunity to fulfil their highest potential as human beings.
Neel Burton, M.D.