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How we misunderstand depression

Psychological condition or biological disease? Three new books examine the causes and cures of an endemic mental health problem.

 

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The 63-year-old Brazilian fisherman had not seen the sea in years when he enrolled in a trial investigating whether the hallucinogenic ayahuasca could treat depression. He had barely left his home in a decade. His stomach felt “as rigid as wood”. The night after he drank the bitter drink, he experienced a dream that helped him understand his situation more clearly. Perhaps what he needed to do to lift this depression that nothing could budge was visit the ocean. As soon as he left the lab at the Brain Institute in Natal, in the north-east of Brazil, he headed for the coast. A week later, at a meeting with a psychiatrist, he lifted up his shirt, delighted to reveal that his belly, once so hard, had softened.

The fisherman had not been given ayahuasca. He was in the control group. His life-changing revelation had been brought on by a mixture of water, yeast, citric acid, food colouring and zinc sulphate, added to mimic the digestive upset caused by the hallucinogen. During the trial, the first to measure the antidepressant effects of ayahuasca, around 20 per cent of the participants in the placebo group showed significant improvements in their depressive symptoms after a week. (The success rate was twice this among those who took the traditional psychedelic.)

The placebo effect is often substantial in trials for antidepressants. It is rarely as high as in the ayahuasca trial, but then the participants were very poor, and the institute had provided them with food and shelter. Perhaps it’s no wonder they felt better. Usually, the placebo effect is confounding for researchers, but Draulio Barros de Araujo, the neuroscientist who headed the trial, was unfazed and upbeat. He thought it “one of the most beautiful things he’d ever seen”. Some of the trial participants had suffered for decades, their lists of medications ran over two pages, they had endured several rounds of electroconvulsive therapy (ECT), and now they had responded beautifully to little more than lemon juice.

This story stayed with me, although it occupies only a few paragraphs of A Cure for Darkness, the science journalist Alex Riley’s forthcoming exploration of depression and how we treat it. Expansive and thoughtful, it illuminates the complexity and elusiveness of his subject. Depression is a “product of upbringing, trauma, financial uncertainty, loneliness, diet, behaviour, sedentary lifestyles, neurotransmitters, and genetics that cannot be encapsulated in a word”, Riley writes. The debates surrounding depression – about whether it’s a biological illness or a psychic disturbance, a disease of hardship and trauma or a form of “affluenza”, an ailment invented by the global rich to medicalise away difficult feelings – can become excessively binary because we insist on oversimplification.

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Our modern understanding of depression is shaped by two ostensibly divergent traditions. On the one hand there is the psychological approach, pioneered by Sigmund Freud, which sees mental disorders as the product of psychic conflict. On the other there is the biomedical perspective, which developed from the efforts of the German psychiatrist Emil Kraeperlin to classify and codify mental illness and often shares his insistence that “so-called psychic causes – unhappy love, business failure, overwork – are the product rather than the cause of the disease”. And yet, Riley observes, from the outset these two traditions have overlapped. Freud, for example, was interested in drug treatments as well as talking cures, and championed the therapeutic benefits of cocaine.

The debates about the nature of depression will likely intensify in the coming months as we grapple with the psychological and emotional aftermath of the coronavirus pandemic and Britain’s catastrophic death toll. How should we think about the emotional shadow-pandemic this country is facing? Has the experience of mass grief, isolation, fear and uncertainty triggered a surge in mental illness, forms of depression, anxiety and obsessive compulsive disorder that are biomedical in nature and require a medical response? Or is it nonsensical to describe in medical terms the sadness and anxiety we feel as a natural and proportionate response to the loss of loved ones, of livelihoods, of companionship, of the future we had imagined for ourselves?

Perhaps we overstate the degree of conflict between these two perspectives, when often they complement one another. Many people find that a mixture of medication and psychotherapy works best for treating depression. This combination helped Riley, who interweaves his scientific history with an account of the years he suffered from a depression so profound he came close to suicide.

[see also: Can robots make good therapists?]

The title of Riley’s book is aspirational. He has not found “a cure for darkness”, and doesn’t believe there will be a single cure, though he has learned what helps him overcome the worst of his depressions. Instead his book offers a survey of the latest research, including the role chronic inflammation may play in depression, new experiments investigating the use of psychedelics and ketamine, and the revival of certain controversial techniques such as ECT.

Some of the most interesting interventions he explores are the most low-tech. He describes how a psychiatrist in Zimbabwe helped train elderly women to support people through emotional crises. These women set up “friendship benches” where troubled people could drop by any time and discuss their concerns with a sympathetic elder. Subsequent research showed that their presence had a marked effect on reducing depression within their communities.

For all the scientific investigation into new cures, one of the biggest challenges society faces is making sure people have access to existing treatments. The conversation about mental health in the UK often centres on whether people are being over-diagnosed with disorders such as depression, but the bigger problem is that worldwide so many people suffer alone and without help. This is partly a reflection of health inequality – in low-income countries there is on average just one psychiatrist per million people (even in the UK, mental health waiting lists can be months long).

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Mental health services in Britain and elsewhere are expecting demand to surge because of the Covid-19 crisis. Yet reading Mending the Mind, the Times journalist Oliver Kamm’s vivid account of suffering – and recovering – from clinical depression, I was also struck by the psychic barriers that prevent people from accessing outside help. One needs first to be able to recognise that one has a mental health problem, and then to be able to navigate the healthcare system.

Kamm experienced depression not as persistent sadness or anhedonia but as a radically altered mental state. He realised he had a problem when he forgot his home address. He usually had a superb memory for facts – he’d once been a contestant’s friend in the “phone a friend” part of Who Wants to Be a Millionaire – but he found himself stuck, sitting by the side of the road, trying to think how to get home when he couldn’t remember where it was.

Kamm describes depression as all-encompassing, unrelenting agony. He was consumed by self-hatred and existential guilt; he became delusional. “You wish only for oblivion,” he writes. “It’s pervasive, seeping into your being, and it’s hermetically encompassing, so you can’t recall how things used to be or imagine how they could ever be otherwise.” He initially saw his crushing depression not as a mental illness but a personal failing, and one worries what might have happened had he not had a network of supportive and well-connected friends. He eventually got medical help after he confided in a former colleague, who put him in touch with the mental health campaigner Dennis Stevenson, the first person to explain to him that he had clinical depression.

Unlike Riley, Kamm insists that depression is as organic as cancer or heart disease and a “disorder of a physical organ” – the brain. Kamm’s attraction to a biomedical perspective on depression is understandable, especially as he found the severity and strangeness of his symptoms so disproportionate to the “pedestrian” events that triggered them: the loss of his father, divorce, single-parenthood, the feeling that his professional success was meaningless. Yet one feels that ultimately Kamm is committed to the idea that depression is a physical illness to fend off any suggestion that it is instead a personal failing. In the latter view, the afflicted person simply needs to pull themselves together; depression is a “fashionable label” for old-fashioned misery.

[see also: Why do we struggle to admit we’re sad?]

“You cannot wish yourself healthy in mind, any more than you can mend a broken limb by the power of prayer,” he writes. That is true, and talking won’t cure you of cancer, but talking therapies can be remarkably effective at treating depression, which demonstrates at minimum that if depression is a biological disease it is unlike any other. Yet compassion or understanding needn’t be contingent on the conviction that one day we’ll uncover the physiological mechanisms behind depression. It is clear that sufferers cannot “snap out of it”.

Previously, Kamm had seen a psychotherapist after calling a counselling hotline at work. Although he acknowledges the therapist was “good-hearted”, he believes it was a “destructive encounter”. He didn’t see the point of her attempts to delve into his past; she noted that he was “resistant” to opening up. He was looking for “wisdom and insight” but felt he was instead on the receiving end of a “fishing expedition”. The whole episode convinced him that the “generous impulse to help people with their problems” can end up making things worse.

He is rightly concerned that therapy in the UK is unregulated: although there are professional membership bodies and accredited training courses, participation in them is voluntary, which means that anyone can call themselves a therapist. There are few protocols, therefore, to prevent vulnerable people from having potentially harmful encounters with unqualified, self-styled therapists.

But some of his other suspicions of therapy are overblown. He is concerned that therapists have a vested interest in retaining clients and therefore in keeping people unwell, or at least dependent, but the same could be said of drugs: surely the most profitable antidepressants would ensure that people notice enough of an improvement that they keep taking them, but not make them feel well enough to wean themselves off the drugs.

Kamm clearly hated his first therapist but insists it wasn’t personal. It was rather that the psychodynamic approach she practised, which focuses on psychic conflict and the subconscious, is unscientific and at best can only help people who “are not really ill”. He found cognitive behavioural therapy worked much better, and he’s reassured by how evidence-based it is. The meta- analyses I’ve encountered have suggested that the difference in effectiveness between different types of psychotherapy is marginal. What does strike me as unscientific is upholding one’s own experience of depression as emblematic, as depression memoirists often do.

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And yet, as Jonathan Sadowsky, a professor of the history of medicine at Case Western Reserve University, observes in his fascinating, dense cultural history of the condition, The Empire of Depression, memoirs and first-person testimonies have contributed a great deal to our understanding of depression. The rise of Prozac in the Nineties and society’s surging faith in a “chemical cure” ushered in a new generation of depression memoirists, such as William Stryon and Elizabeth Wurtzel, who gave shape to our understanding of depression as an illness while also encouraging a broader perspective. During the boom years of the biological model, memoirists were often ahead of professionals in how they anticipated the limits and identified the adverse effects of viewing depression as primarily a chemical imbalance.

The biomedical model of depression is attractive because it affirms the realness of the illness, but it is not the whole picture. As memoirs often make clear, life events and psychological experiences matter. If depression needed nothing more than a chemical fix then taking Prozac should be no more emotionally fraught than taking insulin, but few people feel that way. Wurtzel describes Prozac as a “miracle” but she’s also ambivalent towards it, comparing her psychiatrist’s office to a crack den and worrying about whether in overcoming depression she was also losing a part of herself. “I was so scared to give up depression, fearing that somehow the worst part of me was actually all of me,” she wrote.

To make progress in treating depression psychiatrists and researchers must find ways to sift through, identify and categorise the many ways in which people can become overwhelmed by depressive symptoms: sadness, anhedonia, feelings of worthlessness, guilt, despair. But every depressed person is more than a collection of symptoms. They are more than a psychiatric label, and their sense of self is often also bound up with that label – depression cannot be cut out like a tumour, or contained in a cast like a fractured bone. This is why, Sadowsky argues, modern medicine is constrained in how well it can treat depression, and scientific experiments can never tell the full story.

Depression is complex, just as people are complex. We are biological organisms, psychological beings and social actors. “Treating a whole person takes time. The whole person is not captured in a randomised, double-blind, clinical trial. The complexity of depression is hard to manualise,” Sadowsky writes. And so we must continue trialling new and more targeted medical treatments, and keep refining psychotherapeutic interventions, and continue unravelling the socio-economic and environmental factors contributing to depression, while also understanding that sometimes answers will elude us. After all, on some rare occasions a decades-long depression might be relieved with the help of a ceremonial drink of water, yeast and citric acid. 

[see also: It’s not just you: Why the current lockdown is having an extreme effect on mental health]

A Cure for Darkness: The Story of Depression and How We Treat it
Alex Riley 
Ebury, 464pp, £18.99

Mending the Mind
Oliver Kamm 
Weidenfeld & Nicolson, 320pp, £16.99

The Empire of Depression: A New History
Jonathan Sadowsky
Polity, 224pp, £25

Sophie McBain is a special correspondent at the New Statesman. She was previously an assistant editor. 

This article appears in the 03 February 2021 issue of the New Statesman, Europe’s tragedy