Years ago, the thinking was that heart attacks occurred when cholesterol-laden plaques formed on coronary artery walls and, over time, grew large enough to block blood flow in the artery. Today it's known that heart attacks occur only when a crack develops in the artery lining that covers the slow-growing plaque. Then platelets are suddenly drawn to the site, where they adhere to the exposed artery wall and rope in even more platelets. Clotting occurs within minutes, choking off blood flow to the heart.
Bones of Contention
The somatic changes of psychological depression go bone deep. Literally. The hormonal abnormalities that mark the disorder, particularly elevated body levels of cortisol, also rob the skeleton of calcium. The result: osteoporosis on a speeded schedule.
Researchers at the National Institutes of Health have found that depressed premenopausal women develop bones as porous as those of postmenopausal women. And the leeching of bone mineral persists, despite treatment with antidepressants. Led by David Michaelson, the team reported that bone mineral density was, on average, 6 percent lower in the spine among 24 depressed women than among 24 controls. And in the hip, it was 10 percent to 14 percent lower among the depressed—decrements that set women up for hip fractures.
"Once lost," Michaelson observes, "bone density is difficult to regain." It takes years, plus a modicum of physical activity and a calcium-rich diet. But it probably never returns to normal in depression, since the disorder tends to recur—and depressed people tend to be physically inactive and eat poorly.
It's not that chronic depression doesn't create a huge psychological burden. But it's becoming increasingly clear, says Columbia's Glassman, that "depression is an illness with very real and dangerous physical concomitants."
Sick, Not Sad?
The new corporeality of "mental" illness is perhaps most daringly embodied in the work of Bruce Charlton, a research psychiatrist in the department of psychology at the University of Newcastle in England. Depression, Charlton provocatively contends, doesn't just have physical concomitants; it is wholly a physical disorder, one that is misinterpreted by the brain. Sickness is read as sadness.
The low mood is a secondary response, a product of physical malaise, the same malaise—the lack of energy, slowed movement, lack of pleasurable appetites (including sex), inability to concentrate—one gets when, say, the flu strikes. "The trouble with malaise is that you don't necessarily know you've got it, and you blame yourself for your condition of low performance," he says. But it is the body's way of withdrawing (think of a wounded animal) to conserve energy and minimize risk, an "evolved pattern of behavior" mediated by the immune system. "Major depressive disorder," he says, "is sickness behavior inappropriately activated and sustained."
Charlton subscribes to the model of emotions put forth by the University of Iowa's Antonio Damasio, that feelings are the brain's representation of what's going on in the body. But, he says, sadness and happiness are "catchall names given to aversive and gratifying states, end products of more primary emotions."
Still, the prevailing body state, the malaise, colors all incoming perceptions and stamps them "aversive" as they are encoded in memory. Recall, then, summons up malaise, as does thinking about the future. To the extent the malaise continues, patients are stuck, unable to even imagine anything that makes them feel motivated and energetic. Bleakness! Despair! Depression!
In this view, antidepressants, notably the tricyclics, possibly Prozac, work to the degree that they are analgesics! "Antidepressants do not make people happy," Charlton insists. They treat the state of unpleasantness. "Their effect on mood is no more remarkable than the fact that it is easier to be happy without a headache."
Charlton joins a rising chorus in disputing the way antidepressants are said to work. British psychiatrist David Healy, a card-carrying psychopharmacologist, contends in his book The Antidepressant Era that these agents are falsely presented as specific to depression. And the idea that depression is a single specific disorder was created largely by drug companies with a product—antidepressants—to sell. He argues that depression is even more than a disorder of the whole body; it's a disorder of the whole person, existential or social distress marked by unhappiness and hopelessness. It is cast into physical symptoms precisely because they have been made fashionable, sanctioned and publicized by today's medical-industrial complex.
Flexibility Regained
Whatever pathways depression takes through the brain and the body, it is still experienced by sufferers as a disorder of the whole person, which is why its pain has always been so hard to locate. As a result, how depression is seen by psychologists and psychiatrists, how they explain it to you and me, and how patients understand their own disorder—all influence what symptoms patients complain of. And what they are willing to do about them.
Fashions in thinking about depression make a difference to recovery. "We have looked at clients' theories of why they are depressed," reports psychologist Michael Addis, of Clark University, "Their theories are predictive of the outcome of treatment."
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