In a recent popular blog, I took the position that anxiety and depression should, first and foremost, be considered symptoms, not diseases. Not surprisingly, a number of commentators raised questions about this formulation. One stated they had had a “good life”, but nevertheless they were plagued with anxiety and depression since they were five years old. Given this, they wondered how I could claim it was not a disease. Another commentator was concerned that folks with depression will be disheartened reading the article because depression is not just an emotion and “research shows that patients with depression have different levels of neurotransmitters”. Another commentator pointed out that they were helped by medications, and wondered why I was against taking pills for the condition. These commentators are raising important points, and I take the opportunity here to address them.
Let me reiterate the most fundamental point about the blog and the one that our society needs to internalize. Depression and anxiety are negative emotional-mood states. Emotions send signals about our goals and they prepare us for action. Desire, joy and excitement are positive emotions that orient us and send signals that there are good things out there to be approached. In contrast, shame is the feeling we have when we are incompetent or inferior. Anger emerges when folks have violated our rights and interests. Fear and anxiety tell us that there are threats out there, and they prep us for defensive action. Depression is a state of shutdown that ensues when our course of action is not resulting in a productive return on our investment, and we are not getting our psychological needs met. Given this basic understanding we can call the "First Principle” about depression and anxiety is that they are negative emotions that serve as signals of threats or losses regarding core psychological needs in relationships (family, peers, partners, society and self) and/or competence and control and safety. As such, the fundamental point of the blog is that when someone is dealing with depression and anxiety, the first question we should be asking is: How are these feelings related to core human psychosocial needs for relationship, safety and purpose?
After we have this ‘First Principle’ understanding, then we can start to explore ways in which depression and anxiety can themselves become problems, and here we can start to address some of the concerns of the commentators. Specifically, after we acknowledge the First Principle, we can proceed with additional understanding that allows us to adopt a reasonable mental health position on these conditions. Namely, with such an understanding, we can further articulate that: 1) there are definitely genetic and neurobiological elements that influence individual differences in the levels of depression and anxiety they experience; 2) there are many cases when levels of anxiety and depression do indeed contribute to mental health problems and thus provide an appropriate context for us to think about “anxiety and depressive disorders”; 3) there are RARE cases where we might want to use the label “depressive diseases”—I think we should refer to these as cases of melancholia and they are not the normal picture of what depression looks like in the general population; and 4) there are circumstances in which medication might be very appropriate to take the edge off of depressive or anxious symptoms. Let me clarify each of these points in a bit more depth.
Clarification Point 1: Understanding Neurotic Temperaments
Personality research has demonstrated that individuals vary in what is called “neurotic temperament” or neurotic traits (see here and here). Trait neuroticism refers to level of sensitivity and reactivity of the negative emotion system. In short, people high on trait neuroticism are, relative to others: sensitive; easily upset; vulnerable to feeling stressed and tend to be reactive when stressed; likely to feel on edge and defensive; are more likely to worry and be self-conscious; and be irritable. There is much evidence that one’s trait neurotic temperament plays a key role in how vulnerable one is to developing problems with anxiety and depression.
Clarification Point #2: Symptoms can become problems; thus anxiety and depressive disorders are real conditions.
Depressive and anxious emotions can indeed become part of the problem and are often the focus of treatment. Near the end of the blog, I explained that there clearly are “negative affect syndromes”, which emerge when individuals experience stress (usually pertaining to core needs) and then respond with negative emotions that create more problems than they solve, especially if the individual does not have the right frame for dealing with and processing their emotions. Anxiety tends to result in avoidance patterns and depression results in the shutdown of psychological energy and exploration. Unfortunately, in our modern context, these tendencies can often result in greater isolation, frustration and difficulty, leading to more negative emotion and thus completing the cycle. In short, many people do not know how to process their negative emotions (see here) which leads to problems. Modern psychotherapies (e.g., CBT, EFT, Psychodynamic, Mindfulness) are designed to help people process their emotions and the thoughts associated with them in a more adaptive way, and doing so can reverse the vicious cycle.
Clarification Point #3: There are some RARE cases in which folks present with symptoms that warrant the label “Depressive Disease” (see here).
I have worked and supervised clinical work for many years in state hospitals. I ran a major trial for folks who had made suicide attempts. Thus, I am very familiar with the severe end of the depression spectrum. There are SOME, RARE cases in which depressive syndrome can be reasonably conceptualized as a disease state. That is, the depressive symptoms are so pervasive and nonresponsive to environmental changes, to appropriate community/relational contexts, and to effective emotional processing that it is reasonable to consider the condition a depressive disease. I prefer to call this melancholia or melancholic depression. What I am pushing against is the broad application of the disease model and pointing out the need for the First Principle.
Clarification Point #4: Meds sometimes make sense.
When I pulled a muscle in my chest, it hurt. The pain was a symptom of the damage I did. Nevertheless, I took meds to dull the pain. Thus, there is nothing about the first principle that says one should never take a pill. Indeed, given Clarification #2, that symptoms can become the problem, it logically makes sense to consider meds for the reduction of anxious and depressive symptoms, especially if they are contributing to the problems. In so doing, the following should be considered: 1) For mild to moderate cases, the effectiveness of meds have been oversold by Big Pharma; 2) The disease-pill model of attribution should be rejected (the pills are not fixing some “chemical imbalance” that is causing the problem) and replaced with a drug-symptom reduction approach (i.e., the pills are reducing the symptoms and thus might help to improve the problem); and 3) Pills often help to avoid feelings that one needs to process; thus pills can work against the emotional work that needs to be done. As such they should be used in the context of other treatments, if possible.
The context for the blog is that, at the level of mental health, our society is getting sicker. There are lots of reasons for this, including: problematic changes in how we are rearing our kids; lifestyles that are constantly stressed and pressured; the loss of grand narratives for making sense of our lives; the fact that we live in a complex, politically fractured society with rapidly changing technologies; the fact that it is harder and harder for some folks in society (less educated, under skilled) to maintain their lifestyles and so forth.
For all the above mentioned reasons, we must get smart about mental health. And, unfortunately, there are many dominant narratives pertaining to mental health that are way off in how they are presenting the issues. The key to mental health is NOT found in brain function or chemical imbalances per se, but IS found in relational connection (i.e., being known and valued by important others) and inner harmony between the head and the heart. And we must understand that anxiety and depression, first and foremost, are not disease states but rather are symptoms that core relational needs are threatened or going unmet. With this understanding in place, we can then achieve a more sophisticated and nuanced understanding of how to approach situations in which folks are experiencing these feelings and when and how they might be signaling issues or creating additional problems.