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Depression
Why Do We Misunderstand Depression?
Depression is a complex and serious illness — not a matter of willpower alone.
Posted December 28, 2017
As a psychiatrist who has grappled with it both professionally and personally, I know depression can be a multilayered beast, interlaced with one’s personality, vulnerabilities, and upbringing, all intermingling with the dark shades of misfiring brain chemistry. This complexity leads to ongoing confusion and debate over how much mental illness relies on personal resolve vs. personal biology.
Too often, people are quick to stigmatize depression and other mental illnesses as forms of moral weakness or a lack of willpower, especially in the individualistic American culture. People are quick to judge therapy or medication as a crutch in a perceived simple game of mind over matter: Such treatments are seen as either an easy tool for wimps who can’t solve their own problems, or a toxic mind-control method created by conspiratorial forces.
But after the suicide of beloved star Robin Williams several years ago, something seemed to shift. People started to recognize that depression must relate to biology, because who would give up such an outwardly gifted life? Williams was always busy making the rest of us happy, and we adored him for it. For such a source of outward joy to crumble so violently — what happened?
Depression’s biology skews one's vision and distorts reality. It sprays a fog that makes the afflicted person feel that nothing is ever good enough, that people hate them, and that they will never feel secure in the world, no matter what. Sometimes it is accompanied by anxiety, which brings crippling panic, feelings of danger, racing thoughts of doom, and an obsession with misery, plaguing you in the dark of night or jerking you awake at the crack of dawn. You feel a horrible, self-punishing sense of isolation and loneliness. And yet you can appear outwardly perfect, seeming to have it all together. You frenetically play-act while you feel your soul dying.
To varying degrees, the foundations of your background can help or harm you: If you have supportive parents, financial stability, good friends, or a job you love, you might do well despite some negative biology. Others have resilience, overcoming negative socioeconomic or situational circumstances and ending up with a positive outlook, as long as they are not saddled with certain genetic vulnerabilities.
Confounding matters is the influence of external stressors and trauma on a person’s neurobiology, particularly in childhood. Several studies have shown that abuse and trauma can affect one’s hypothalamic-pituitary-adrenal (HPA) axis, which triggers one’s fight-or-flight response. The HPA axis is a circuit between your brain, your hormone glands, and the rest of your body. The different parts are constantly signaling each other.
For example, you see and hear someone yelling at you. Your brain recognizes it and signals the parts of the brain — the hypothalamus and pituitary — that release hormones to signal your adrenal glands, which in turn release chemicals that raise your heart rate and blood pressure. You go into hyper-alert mode, until the threat passes, and other hormones shut down your signaling loop. However, prolonged stress exposure can actually modify your HPA axis’ thresholds over time so that your system does not turn off easily, or is hyper-reactive to minor, even nonexistent threats. Your brain chemistry changes to one that is more easily prone to anxiety and depression, since the same chemicals and signals are involved in this fear response.
The brain is even more sensitive during childhood, which renders that population especially vulnerable to future mental illness. Early intervention, in these cases, may lead to better long-term outcomes. But even in adulthood, the HPA axis can be malleable. Both medications and therapy — and often a combination of the two — have been shown to help restore its balance, which I have witnessed in research and clinical practice.
Another factor is epigenetics, a burgeoning field where scientists are realizing that the genome can partially change its code in response to outside stressors or influences. So some people who might have a genetic tendency toward depression, anxiety, or schizophrenia may not develop those conditions if they grow up in a safe, nurturing environment. But if they are exposed to even minor trauma, parts of their genome involved in the HPA axis or other neurochemical circuits in the brain might get activated — like a railroad switch, leading one down a more perilous track.
However, there are some genes that switch on from the beginning with a severe and intractable course, and no amount of love and support can overcome them. Virginia State Senator Creigh Deeds’s late son was a classic example of someone who, despite having a solid and well-off family, developed a serious mental illness. He became acutely delusional and committed suicide after attacking his father. Williams also likely battled his condition valiantly for many years, but may have taken a turn for the worse after the additional biological stressors of open-heart surgery and Parkinson’s disease, both of which are known to exacerbate and/or cause depression. (His family later revealed that he had Lewy Body Dementia, a progressive disorder related to Parkinson's.) These treatment-resistant cases indicate the ongoing need for more cutting-edge medical and genetic research into what causes devastating conditions, like schizophrenia, severe bipolar, and psychotic depression, as well as how to develop better treatments.
We have only scratched the surface of how the brain functions, although we have made amazing advances in the last few decades thanks to new strides in DNA and genetic research and neuroimaging. Medications and psychotherapy and treatments like electroconvulsive therapy (ECT) are important and can be helpful, but our complement of tools remains relatively limited, and crude, in light of the brain’s immense complexity, and the complicating factors of life itself — how people interact with their world, how they talk to others, and their aspirations, goals, heartbreaks, tragedies, and flaws. The brain and the universe are in constant flux, playing with and against each other, with the mind struggling to make sense of how to survive out there, and the world pushing back against the brain’s physical limitations.
For the unfortunately common perception that getting over depression and anxiety are just a matter of snapping out of it, pushing ahead, or just being happy and grateful, we need to step back and recognize the immensity of what we are dealing with. Even without understanding advanced neurobiology, you can recognize that the brain is, really, everything to us. We see what happens with even small strokes or traumatic brain injuries — how your ability to talk, think, speak, and move all quickly get affected, and how limited our ability to treat even small damages is. Our behavior and moods are no different; they are also part of the central package.
These tragedies should be a clarion call for Americans and others around the world to recognize that mental illness is real and nobody’s “fault" — and that there is no shame in getting help. Mental illness is physical and medical, but it is more intricate than that; mental illness ties into our very existence, our interaction with everyone and everything. Each person's prognosis runs on a spectrum relative to their genetic loading and their environment.
Mental health professionals can intervene and help some people hang on, improve, come back against biology, and soothe against environment. For those that we can save, the rest of us must stand watch and bring them to light, instead of losing them to falsehoods and misplaced moral codes about independence. After all, is it stronger and more effective to till a large field alone, or with a team of fellow human beings alongside you?
A version of this article was originally published in The Daily Beast.
