Depression and the Disease-Pill Model of Mental Health
We should reject the idea that all depressive conditions are diseases.
Posted March 4, 2014
As I have been documenting in my past three blogs, there is a “crisis” emerging regarding the mental health of college students, and probably in society at large. Although there are likely many contributing factors for the emerging epidemic of neurosis, I partly blame psychiatry and psychology for the problems, albeit for very different reasons. I blame psychology because it is weak, fragmented, conceptually confused, and disorganized, and has failed in its obligation to provide society with a clear framework for understanding human thoughts, feelings, and actions, or providing clear pathways to improve human well-being.
While I am frustrated with how limp psychology is, I blame psychiatry far more for the current mental health crisis. Although psychology is guilty for being passive and weak, psychiatry much more guilty because it probably is actively contributing to the problems. Indeed, if I had to say what is likely the biggest single contributor to the growing levels of neurotic problems (i.e., levels of depression/anxiety/stress) in our culture, I would point to the Disease-Pill Model (D-PM) of mental health, which is financed by the psychopharmacology industry and is too often peddled by psychiatrists, even though they generally know better. (Or at least they should know better—when I talk to psychiatrists individually they seem to know better, but at least from where I sit, as a group they are not pushing back nearly enough against the tragic status quo).
To see clearly the nature of the D-PM of mental health, google “What is depression?” One of the first links is the National Institutes of Mental Health Information page. It quickly differentiates depression from occasional sadness, noting that depression lasts longer and interferes with functioning. It then, in no uncertain terms, says depression is a serious illness. It then lists kinds of depression that can be diagnosed, including minor depression. It then explains, in no uncertain terms: “Depressive illnesses are disorders of the brain”.
Before we dive into how problematic the D-PM is, let’s first understand the logic and what this framework justifies for ‘patients’, physicians, and the psychopharm industry. First—and this is important—there are a small percent of individuals with subtypes of depression that are usefully considered “diseases” (more on this below), thus there is a grain of truth to the model. Second, depressed individuals do have problems functioning. Third, when depressed individuals seek help from professionals, it does, generally speaking, improve their functioning. Fourth, mental health problems come with stigma, and many depressive people tend to be very self-critical. Thus, the attribution that depression is a disorder of the brain translates into the conclusion that it is not the person’s fault they are depressed—thus the D-PM solves the problem of blame. Fifth, it places the medical professional in the role of healer; with pills, now the doctor can correct the brain disorder/chemical imbalance. And, of course, there is the ultimate economic engine supporting all this—the psychopharmacology industry. (In 1987 about half a billion dollars were spent on psychiatric medications—and now the figure is over 40 billion). In sum, the circle is closed because everyone in it—the patient, physician and industry—benefit. Indeed, to the extent that the pills for the depression are financed by the patient’s insurance or the government, the economic costs are extracted from somewhere else. Thus, everyone benefits with few costs!
The problem is that the D-PM model applied to depression is fundamentally confused. And there is mounting evidence that it is failing us completely at the level of society. Whitaker in particular makes a compelling case that the D-PM of mental health, advocated by psychiatry and the psychopharm industry, is directly tied to the dramatic rise in neurotic conditions in this country since the late 1980s.
For the record, I am a health service professional (licensed psychologist) and certainly am not defined against modern medicine in general (note that there is much more to health than medicine--but that is a separate blog). And I do believe the D-PM is a great model for some medical problems. Consider polio, for example. It is well-characterized as a disease (i.e., suffering that stems from biological malfunctions), and vaccines in the form of injections and pills have been fabulously successful in reducing its incidence and prevalence. Unfortunately, though, depression is a different kind of entity than polio. To disentangle why the D-PM is wrong for depression, we need first a working conception of what depression actually is.
Depression, Defined and Explained
Properly considered, “depression” is a state of psychological shutdown. That is, at the level of thoughts, feelings and actions, a depressed individual is one who is dramatically decreasing their investments in acquiring new resources (which could be anything from skills, relationships, finances, etc.) and is instead directing psychological energy toward loss, at either past losses (i.e., rumination) or the avoidance of future loss. In this light, depression is (or should be) defined as a state of psychological/behavioral shutdown.
A brief primer on the psychology of moods and emotions will hopefully make this clear. Our mood and emotional system organizes and directs our actions. It provides us with psychological energy, orients us toward intuitive goals, and gives us feedback on the extent to which our actions meet our goals/needs. Broadly speaking, there are two systems of mood and emotion. One is the positive emotion/mood system that fosters the “behavioral approach” of desirable benefits, goals and resources (e.g., money, sex, status, connection with others). The other is the negative emotion/mood system, and it fosters the “behavioral avoidance” of costly investments, risks, dangers, and losses. Together these two systems work as nature’s behavioral guidance system, which, broadly speaking, attempts to invest action (and thoughts preparing for action) in a way designed to acquire benefits and avoid costs.
Money is a symbol of human potential energy, so thinking about how people spend money is a good way to think about how the nervous system is designed to spend behaviors. Now, think about an investor who loses her investments repeatedly; that is, despite her best efforts, she continues to fail to get a good return on her purchases. Eventually, she will get discouraged, give up and shutdown. This has clear parallels with the human experience of ‘depression’, and it is not an accident that economists call the societal state of economic shutdown a depression, as in The Great Depression of the 1930s.
From this perspective, then, depression represents a shift in the relative activation of the positive and negative mood systems, with a heightening of negative mood and a diminishing of positive mood. Thus, we can clarify our definition of depression as a state of behavioral shutdown associated with a noticeable shift in mood (heightened negative, diminished positive). This is what the generic term ‘depression’ should mean. Notice how far this is away from “Depression is a brain disorder”. Indeed, in many ways, it is the exact opposite. Instead of being some malfunction, now we see that depression is an inherent feature of the emotion-mood-behavioral guidance system. If the behavioral guidance system fails to effectively guide an individual toward resources/goals/needs etc., then eventually investment shutdown (i.e., a shift toward negative mood, and withdrawal of active investment) will often follow.
Three ‘Kinds’ of Depression
So we have our definition: Depression is properly conceived of as a state of psychological shutdown largely mediated by a shift in the emotional/motivational/cognitive mood system (i.e., a diminished positive and/or increased negative mood shift). Notice that with this definition there is no implication of cause. Indeed, now we can ask, in a psychologically commonsensical way, what might cause such a behavioral shutdown/mood shift? This basic question gives rise to a rather straightforward breakdown of depressive conditions that is completely missing from how lay people are taught to think of depression (although many do intuitively think of it this way, and it is present in clinical psychology/psychiatry if you know where/how to look for it).
The first answer to the question of where might such a behavioral shutdown/mood shift come from is that it might be “environmental”. That is, it follows logically from the above formulation that if an individual is in environmental contexts where they are chronically humiliated, trapped, abused, are constantly stressed or threatened and can’t get their basic needs met, or if they have experienced dramatic losses, then the state of depression simply would represent a logical extension of the circumstances. For example, I worked with a woman who, for $5, would perform fellatio on men under a bridge (which is where she lived!) so that she could get her next fix of heroin. I ask: Does it make any sense to consider this woman as suffering from a brain disorder if she regularly experiences a depressed mood?
Now, consider another scenario. What if an individual experiences some significant problems and then starts to get negative and withdraws, but this in turn creates more problems? I see this all the time working with college students in therapy (see here). The adjustment to college is hard. They get stressed, defensive and exhausted. As such, they are reactive, fearful, submissive, irritable, socially anxious, and often fail to perform effectively, socially and/or academically. So they feel even worse. And because society does not educate them well about emotions, they feel confused and bad about feeling bad. A spiral ensues and the end result is behavioaral shutdown/mood shift. The cause of the depressive shutdown here is a vicious, maladaptive behavioral cycle. If the level of distress and dysfunction is "clinically significant", then I would agree this is an example of a “mental health” issue, broadly defined (i.e., "clinical depression" does require intervention). However, it is decidedly NOT a brain disorder. (This is the case even if this person’s brain is different after the episode than before)! Instead, it should be thought of as a psycho-neurotic illness (see here for how to think of psychoneurotic illnesses).
Finally, since the time of Hippocrates, physicians have indeed noted that some people experience profound shifts in mood resulting in an almost complete psychological paralysis that is very difficult to explain. In Greek times these individuals were said to suffer from melancholia, and it seemed that the cause was located within the individual because the symptoms were pervasive and not obviously tied to the individual’s character or environment. As I alluded to above, there is indeed a small subset of depressive illnesses that look “disease-like” (for a great description of one such case, see here). Psychiatrists know this profile as “melancholic” depression. I do not have a problem with a general disease model of melancholic depression. It can be considered a “disease” because the nature of the symptoms are such that a reasonable inference is that they are caused by biological malfunctions. The problem is that, because of the pressures of Big Pharma pushing the D-PM in general, the system has grossly overgeneralized depression as a disease. Only a relatively small percent (say, perhaps 10%) of depressive conditions/illnesses are “melancholic” in nature.
To summarize, by recognizing depression as a state of behavioral shutdown mediated by shift in mood, we can separate the state from possible causes. When we consider causes, we can easily imagine three broad classes of causes: 1) depressive states could emerging largely as a consequence of environmental conditions; 2) they might emerge as a function of maladaptive psychological patterns; or 3) they could theoretically be the result of a biological malfunctions/disease processes (e.g., melancholic depression).
Confusing the Public and Increasing Neurosis
It is obvious that these three different kinds or circumstances of depression have radically different meanings and implications. Despite the obviousness of this simple formulation of depression and its associated implications, it is completely missing in how we educate the public about this condition. Instead, because it butters the bread of those in power, we have only the D-PM of depression represented at the NIMH.
It would almost be comical if the consequences were not so tragic. Unfortunately, however, the D-PM feeds itself. It rewards the physicians, for they now have the key solution to the problem. It rewards the patients because now the depressive symptoms are the result of a problem (chemical imbalance) that has nothing to do with their environment or their character; thus they can be told they are not to blame and rather than examine their lives they can just take two pills and feel better in the morning. And, of course, it bloats Big Pharma with billions of dollars so that they can market the next disease that we need to be cured from. (Can someone say anxiety? Currently, the NIMH implies rather than claims anxiety disorders as being brain diseases).
You might think that we psychologists would have something to say about all of this, but unfortunately we are so confused about our subject matter we can’t even agree on what it is. Nor can we agree on the identity of professional psychologists or how they are or should be positioned in health care. So, although we do occasionally see psychology rise up, as when the DSM-V was planning on removing the bereavement clause exempting a diagnosis of depression, it generally remains the weak sister discipline to psychiatry’s power monopoly mental health. Unfortunately, though, psychiatry is essentially now a drug peddling industry, and while it is certainly doing some good in some places, it offers such a misguided view of psychology that it very probably is driving our populace crazy. Of course, from their perspective, maybe this isn’t such a bad thing—after all they have just the drugs that are needed to fix the problems!