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Depression
Is Depression a Disease? ( Part 2): The Great Debate
Is Depression a Disease? (Part 2): The Great Debate
Posted September 15, 2008
As mentioned in my previous post, there are certain inherent problems with applying the medical or disease model to mental disorders in general--and to depression in particular. If you follow this link, it will lead you to a fascinating, spirited and intellectually stimulating transcript of a televised debate featuring PT blogger Dr. Peter Kramer, Dr. Thomas Szasz and others on the controversial question of whether or not depression is a disease.
One problem with thinking of depression and other serious mental disorders as biologically- based diseases is a philosophical one. If depression is understood to be a biological disease, like tuberculosis for example, does that not make one a victim of the disease, indirectly promoting an accompanying victim mentality? Is the person afflicted with depression like Job of the Old Testament, an innocent victim of Satan's sadism? Or do we play some part in the process of experiencing and perpetuating depression? And in becoming physically ill, for that matter. If not, there is little we can do about it. But if so, this also implies possessing the power to defeat or at least decrease depression (and, to some extent, other mental and physical symptoms) by active participation in the healing process.
This is especially pertinent in the treatment of depression. Depressed patients already tend to feel powerless, hopeless and helpless. Telling a patient (or them telling you) that he or she has the "disease" of depression places them in a completely dependent position: If depression is a biological disease, all the patient can do to help him or herself is dutifully take the medication prescribed by the doctor. Or remain depressed. But what effect does this passive role have on the patient's personal empowerment? How does it influence how he or she feels about being depressed, what it means, and what can be done about it? Yes, one way to help oneself through a major depressive episode is to take an antidepressant religiously as prescribed. That's a start. But it's only a beginning of what needs to be an arduous journey of self-discovery, moving through the darkness of depression and despair toward finding and fulfilling one's destiny.
This existential riddle of responsibility looms especially large in forensic psychology. The perennial philosophical problem of personal responsibility is brought into sharpest and most vivid focus in the criminal justice system. For example, underlying the insanity defense is the philosophical query regarding personal responsibility. However, psychiatry and psychology have permitted individual responsibility for behavior to be gradually eroded recently. As a society, we have come to view individuals as hapless victims of circumstance: bad genes, biochemical imbalance, dysfunctional families, physical or sexual abuse, domestic violence, alcoholism and other addictions, poverty, racism, and so on. As one Lutheran minister put it, " we seem to believe that if our behavior is biologically determined, then the genes we inherit--not we ourselves--can be held responsible for what we do. Confronted by moments of moral crisis, we are often quick to scapegoat our genes." The disease model of depression plays right into this tendency. On the other hand, should a defendant suffering from some demonstrably biologically-based medical illness or debilitating neurological condition be held fully responsible for his or her actions? For example, eight years ago a deranged man tried to force his way into the cockpit of a commercial airliner during flight. It was later reported he was suffering at the time from acute encephalitis, a viral inflammation of the brain. And what of the schizophrenic or manic or profoundly depressed person who commits evil deeds? If psychosis and depression are seen simply as biologically caused diseases like encephalitis, can such patients legitimately claim that the depression--like the devil--made them do it?
Depression can be physiologically or hormonally induced, as for example in hypothyroidism. Seasonal Affective Disorder (SAD) demonstrates the powerful influence of environmental factors such as insufficient sunlight exposure in biological mood regulation. Chronic sleep deprivation can also exacerbate and induce depression. But depression and its accompanying biology can also be triggered psychologically, by trauma, loss, despair, narcissistic injury, and the inability to imagine a meaningful future. In other cases, there has been a chronic repression of what I call the daimonic; a denial of "negative" or unacceptable emotions such as anger or rage, resentment, sorrow, or, for some, sexuality. The patient has clamped the lid down so tightly on these unconscious feelings for so long that he or she can't feel much of anything anymore. Depression results. Depression--and any underlying biology--is not the cause of this condition, but rather the consequence. Biology affects psychology, as psychology affects biology. The two are inextricably intertwined.
My point here is that depression usually has psychological, existential and spiritual significance. It is not merely the result of bad genes or biochemistry. Dismissing this possibility of meaning does a disservice to the person suffering from depression. It deprives the patient of the opportunity to find and fulfill his or her destiny. To defeat the Hydra. To slay the man-eating Minotaur and liberate themselves from the lightless labyrinth of depression. This heroic confrontation with depression is not a denial of depression's biological aspect. It is a mature, realistic acceptance and transcendence of biology. Biology, in the case of depression and other mental disorders, is not, as Freud said, destiny. Biology is our fate. Destiny is what we do with that fate. To be biogenetically and temperamentally prone to depression or bipolar disorder or schizoaffective disorder may be one's fate. But it need not totally dictate one's destiny. That remains the individual's responsibility. And one's existential freedom to transcend fate and participate in creating one's destiny.
This is by no means a romanticizing of depression. Depression is destructive. But it is a recognition that even the noxious demon of depression--as with suffering in general-- may possess certain redeeming qualities. For example, in some cases, depression can be a kind of forced introversion when the conscious personality has become overly extraverted. This is what Carl Jung called the compensatory quality of the unconscious. The ego is overcome, drowned, defeated by the depression. Hence, the ego, no longer master in its own house, becomes even more despondent over this loss of power, prestige, rationality and control. But psychologically, there is something important happening here. The depression demands a different attitude on the part of the ego, especially as it pertains to the relationship with the unconscious. Potentially, there is much to be learned here about the limitations of the narcissistic ego, the intellect, rationality, and the need for greater respect regarding the power of the unconscious.--that which is beyond the ego. It is a spiritual crisis. This may seem like romanticization of depression to hardcore scientific rationalists, who strive to reduce depression to its most basic biological structures and to demonize it as disease. But really it is basic depth psychology I‘m speaking of, a phenomenological description of a psychospiritual process to which countless patients have bravely submitted and found their salvation.
Nor is the long-noted correlation between symptoms of bipolar disorder (formerly manic-depressive illness) and creativity, as described, for instance, in psychologist Kay Redfield Jamison's study Touched With Fire, a naïve romanticizing of depression. It is a phenomenological fact. That there is a connection between creativity and madness or psychopathology has always been clear. This intimate interrelationship is also addressed in my book Anger, Madness, and the Daimonic: The Psychological Genesis of Violence, Evil, and Creativity. Artists of all types suffer greatly from serious emotional disorders like depression or bipolar disorder. Novelist Herman Melville, himself a depressive type, suggests in Moby-Dick that creative greatness "is but disease," and that such individuals "are made so through a certain morbidness." So Melville viewed creativity itself as the byproduct of depression, madness or mental disorder! This is why many artists avoid psychiatric treatment and psychotherapy, fearing (falsely, in my opinion), like the poet Rilke, that if their demons are dispatched their creativity too will be diminished.
Prior to Sigmund Freud's psychoanalytic revolution, all mental maladies were viewed and treated as biological diseases, usually stemming from so-called "hereditary taints." Whatever his failings, Freud forced the role of psychology to the forefront in the study and psychotherapeutic treatment of psychopathology. Jung further developed and demonstrated the influence of the unconscious in the formation, perpetuation and psychotherapy of psychiatric disorders of all kinds, including manic-depressive illness and psychosis. What is both fascinating and alarming is how we have come full circle today, how far the historical pendulum has swung back to pre-Freudian perceptions of mental illness. It is a reactionary, reductionistic and regressive trend with devastating consequences for patients, the consumers of mental health services. Indeed, I contend that this trend toward biological fundamentalism reflects an underlying denial and lack of sophistication regarding the role of psychology in the formation of mental disorders and in many physical diseases as well.
Today we are engaged in a pitched battle for the hearts and minds of the public as regards the relative roles of biology and psychology, nature and nurture, genes and traumatic stressors, in the development and treatment of mental disorders. Here, I am fighting for the depressed patient's need for more, not less, psychology. But if, for example, the general public and mental health professionals accept, as many already have, the literal materialist notion of depression as disease, or the self-proclaimed "scientific fundamentalism" of evolutionary psychologists like fellow blogger Satoshi Kanazawa--who shockingly claims that parenting (or lack thereof) exerts zero, nada, zip, no influence whatever on personality development and psychopathology--this fight will be lost. What side are you on? I invite you all to join the debate!
