How to Understand Depression
Dr. Sapolsky adopts the wrong frame for depression.
Posted Apr 15, 2017
Dr. Robert Sapolsky is a world-renowned expert on stress and how it impacts health. A professor at Stanford and author of the critically acclaimed and popular book, Why Zebras Don’t Get Ulcers, he is a brilliant man with impeccable academic credentials. I just finished taking his course on Stress and Your Body in my car, and it was entertaining and educational. He has a very straightforward, easy, humble manner of explaining things. There was, however, one section that I do not think he got right. His framework for understanding the nature of depression missed the mark. (See the endnote for definition of depression).
A Summary of Sapolsky’s Views
Before diving into the problems I see with Dr. Sapolsky’s understanding of depression, let me summarize what he does say in a fair amount of detail, so that I provide a full and accurate representation of his views. In Stress and Your Body, he offers one lecture on the biology of depression and a second lecture on its psychology. He repeatedly states that to understand major depression, we need to look at both, which is a claim I can get behind.
He opens the biology of depression lecture with the point that depression is a serious disease, one that is associated with much suffering and creates a huge burden on world health. He also very clearly differentiates depression as a disease from temporarily feeling down or disappointed. He then moves into the ways that bio-physiology has been implicated in depressive conditions. He starts with the evidence associated with the role that three major neurotransmitters —norepinephrine, dopamine, and serotonin—may play in the condition. He goes on to note that sometimes there are seasonal variations (i.e., some folks get depressed in the winter) and also points out that eating and sleeping patterns are frequently disturbed. And he makes the point that depressed individuals are, physiologically speaking, highly stressed. Since the whole structure of the course is centered on how long term, chronic stress is damaging at many levels, this is clearly not a good state to be in. His main point for understanding depression, stated over and over again, is that major depression is a disease that “screams biology”.
The lecture on the psychology of depression starts with a discussion of gender differences, beginning with the finding that women are about twice as likely to develop a depressive disorder as men. He considers a number of possible psychosocial reasons for this, but proceeds to place his bet on hormonal fluctuations, pointing out depression correlates with puberty, post-partum periods, and menopause in women. He then comments on the fact that a number of depressive disorders, perhaps as many as 15-20%, may be associated with thyroid problems.
By this stage in the game, I was getting a bit antsy. To spend the first half of the “psychology of depression” lecture on these pieces was frustrating for me as a psychological doctor. He then brings up Sigmund Freud apologetically and entertains the idea that depression may stem from aggression turned inward. This idea is intuitively appealing to him but he leaves it with a big question mark and proclaims that it cannot be studied scientifically. He then discusses learned helplessness as a scientifically legitimate perspective. He frames this in terms of a pathological cognitive distortion, whereby individuals with depression tend to perceive themselves as having much less control, less support, and are much less able to look for positives in the future than is actually warranted. He believes this may be a vulnerability that stems from past losses, especially experiencing the death of a parent as a child.
In prepping this blog, I discovered there was a transcript of a lecture by Dr. Sapolsky on depression that covered much of the same material that was in the course. Let me offer some direct quotes from this lecture, so you can see his argument in his own words.
I will make the argument throughout here that depression is as real of a biological disorder as is juvenile diabetes. And you don’t sit down a diabetic and say, oh, come on, what’s with this insulin stuff? Stop babying yourself. Pull it together. You will see this is just as much a biological disorder.
He summarizes his view of the condition is as follows:
If I had to define major depression in one sentence, I would say, it’s a lot biochemical disorder with a genetic component, and early experience influences, where somebody can’t appreciate sunsets. And that’s what this disease is about.
To bring his views alive, he offers the following vignette:
Let me give you an example. You have late middle aged guy, perfectly healthy, and suddenly out of nowhere he has a major heart attack. He is lying there in a hospital. And the reality is, he’s going to recover. He’s going to have to make some changes in his lifestyle. But he’s going to recover. He, instead, falls into a major depression. This has transformed his sense of who he is. Suddenly, he’s an old man. Suddenly there’s all these things he can’t do. He falls into a major depression. Yet, he’s recovering.
Every day, his family is in there, saying, look, you’re just depressed. You’re getting stronger. The doctors are saying you’re getting stronger. You’re just depressed. It happens the hospital is circular. It has a corridor that forms a circle in it. And one day, the family is in there saying, you’re getting stronger. Look, the nurses said yesterday you did one loop around the hospital. And today you did two loops. You’re getting better. You’re getting stronger. And the person says, no, no, you don’t understand. They’re doing some construction. Last night, they closed down the outer corridor. And they opened up a new little. So the two versions of this one, two loops there is shorter than the large one. I’m getting weaker. I’m getting weaker. I’m going to die. I’m hopeless.
This is like someone expecting to believe that last night there were beavers digging through the walls there making this new – this was the father of an acquaintance of mine, a structural engineer. This is what a structural engineer looks like when they’re delusional to the point of saying that this is a world in which everything is inevitably getting worse, depression is built around that.
In sum, according to Dr. Sapolsky, depression is a biological disease just like diabetes. It is a disease that involves a genetic predisposition to have problems with the pleasure system and to have negative cognitive distortions about what one can control and what one can do, and these vulnerabilities interact with stressors in life to create a disabling disease state.
The Key Missing Piece: Depression is, first and foremost, a state of psychological shutdown
Dr. Sapolsky fails to get the basics of the psychology of depression right. In some ways, this is more the fault of psychology than it is Dr. Sapolsky’s. The field of psychology is such a mess that it does not communicate well what its key findings are to outsiders. This is evident in Sapolsky’s treatment of Freud, which is then contrasted with the theory of learned helplessness. The fragmentation of these two ideas results from the fact that clinical psychology is fragmented between psychodynamic and cognitive/behavioral interpretations.
But psychology’s fragmentation is not the only thing that leads Dr. Sapolsky a bit astray. He is so keen to make the case that depression is a disease that he misses the fundamental psychological logic of depression. Although emphasizing the disease angle may be intuitively useful for a host of reasons (e.g., it absolves the individual from blame, may reduce stigma, and clearly makes the point that folks just cannot “snap out of it”, etc.), this does not mean it tells the whole story, or even offers the right frame for the condition.
My argument is that to understand depression we must, first and foremost, understand the psychological logic of depressive presentations. As I have written repeatedly in articulating the Behavioral Shutdown Model of depression, depressive conditions should, first and foremost, be considered states of behavioral or psychological shutdown. This frame is crucial because it allows us to understand the form and function of depressive conditions.
I don’t know how much psychotherapy Dr. Sapolsky has observed, but I can say as an expert in psychotherapy that his example of the heart attack patient seems very atypical. Most of the people who come into psychotherapy and are diagnosed with Major Depressive Disorder look and sound pretty normal in many ways. That is, their misery does not appear to be some weird, delusional misperception of their life and surroundings. More often than not, such individuals are lonely and do not feel known and valued. Or they are deeply disappointed with the way their life is going. Or they feel defeated and powerless, often because they lack resources, don’t trust individuals, or have been betrayed or abused. They are often irritable and/or highly self-critical. They feel trapped and guilty or shameful about the way things are. And they frequently can’t eat well or sleep well or freely engage in sexual activity.
In terms of psychological processes, there are a number of features that are notable. They tend to look at the negative in their lives, have trouble with frustration tolerance and problem solving, and often ruminate in unproductive ways. Crucially, many do not know how to process their negative feelings in a productive way. Instead, they attack themselves for their feelings or they try to avoid thinking about bad things or they try to buck up and put on a happy face. But despite their best efforts they continue to have an internal, emotional war going on inside their heads. All of this conflict and stress leads them to a state of behavioral shutdown (see here for a clinical example).
It is essential to emphasize here, though, that very rarely does their narrative seem to be framed through some bizarre, delusional negativity, as the individual described in Dr. Sapolsky’s example. Instead, more often than not their shutdown usually makes good sense given what they have experienced, how they are processing their feelings, and how they are thinking about themselves and their problems.
To understand why folks shutdown behaviorally, it is useful to keep in mind the basic function of the nervous system. The nervous system is the organ of behavior and it searches for productive avenues of investment. If an individual gets “dead ended” by life (i.e., they have experienced major losses or disappointments and can find no good avenues for getting their needs met and they tend to process emotions in a less than healthy way), their motivational-emotional system will start to shift. First, they will get anxious, upset, and frustrated as they seek but fail to find productive ways forward. But if nothing changes, then the system starts to move toward a state of “behavioral shutdown”. It achieves this shutdown by jacking up the negative affect and dampening positive affect and orients the cognitive system to focus on past losses and problems associated with taking action. It also saps energy and undercuts the initiation to engage in new activities. Unfortunately, this shutdown can create more problems than it solves, and thus a maladaptive vicious cycle of misery and shutdown ensues.
This basic psychological framework of depression as a state of behavioral shutdown is completely consistent with the various pieces of the puzzle that Dr. Sapolsky lays out. It is consistent with the fact that depressed individuals are stressed, ruminate, and have low pleasure responses. It is consistent with the idea that both genetics and early learning make some folks more vulnerable to depression. It is consistent with the idea that this is a deeply biological state (i.e., the formulation predicts we should see big biological differences between clinically depressed and nondepressed individuals).
However, there is a big difference in is how the condition is framed, treated, and explained to the public. In Dr. Sapolksy’s disease view, the core is about biological malfunction. And it follows that if we think about depression as primarily a disease state, then we want to teach people that these negative feelings are meaningless, that they are the result of a faulty pleasure system, a hypoactive thyroid, or an overactive cortex that convinces the rest of the brain that its imaginary fears or pessimistic ruminations are real. And it follows that we need medicine to correct a “chemical imbalance”.
The Behavioral Shutdown formulation is very different in emphasis. It emphasizes, first and foremost, a psychological functional view. People who are depressed are, descriptively, in a state of psychological shutdown. And rather than immediately interpreting such feelings as stemming from malfunctioning biology, the BSM encourages us to ask Does it make sense, psychologically, that this person would be shutting down? This is the question that I have in my mind when I listen to someone’s story in psychotherapy. And if there are clear themes of loneliness, broken dreams, unprocessed painful emotional losses and past traumas, chronic stressors, poor coping strategies, critical self-talk, insecure attachments, primitive defenses and so on, the answer I, as a psychological doctor, usually generate is yes, I can understand why behavioral shutdown is happening here.
It is very important to note that the BSM fills out a big empty space that resides between the dichotomy that Dr. Sapolsky uses to set the stage for his formulation (see here). Recall that Dr. Sapolsky sets his lecture up via a contrast between being mildly bummed out and being so delusionally depressed that one cannot get out of bed. The issue here is that the vast majority of people who would be diagnosed with depression do not really resemble either of these extremes. The BSM emphasizes the need for a framework that accounts for this massive group of individuals in the middle.
It is also the case that the BSM explains another central feature of depression conditions, and that is the high comorbidity with other illness conditions. Dr. Sapolsky never addresses the issue that depressive conditions overlap enormously with virtually all the other psychiatric diagnostic categories. It overlaps with the trauma disorders, the anxiety disorders, the psychotic disorders, the addictive disorders, the eating disorders, the personality disorders and on and on. If the condition was like diabetes in that it emerges from a discreet biological malfunction of the pleasure system, why would this be the case? Of course, if we view depression is a state of shutdown that emerges when there are no productive avenues for getting one’s psychological needs met, then the comorbidity issue becomes perfectly reasonable.
The BSM formulation means that instead of thinking about depression as being akin to diabetes, we should think about depression as being more akin to a state of hunger. There is a dramatic difference between being hungry enough to have a second slice of pie and being truly hungry. And, if someone goes hungry for a long time, the body begins to breakdown and demonstrates many disease-type vulnerabilities and malfunctions. It is a profoundly unhealthy state. Likewise, chronic major depression is a profoundly unhealthy state, associated with many vulnerabilities for physiological breakdown and dysfunction. Thus, both severe, chronic depression and severe malnutrition are profoundly biological.
We can go further. Consider that there are some rare forms of hunger that stem from physiological problems. Similarly, I believe there are some folks that cannot extract psychological nourishment from the environment because they have some sort of faulty brain-based mechanisms that keep them feeling shutdown. In other words, this model suggests there are indeed rare cases of pure depressive diseases (e.g., depressive shutdown stemming largely or fully from a malfunctioning pleasure system or cortex that is misfiring in a delusional negative loop). Thus, from my vantage point, Dr. Sapolsky’s model is the right frame for a small percentage of depressed individuals. However, as with most cases of hunger, this is the exception, not the rule. Just as hunger results primarily from a lack of sufficient food intake, depression results primarily from a lack of productive pathways for investment and stems from a failure to get “psychological nourishment” from the environment.
To conclude, the BSM argues when we see a depressive state we must, first and foremost, look to understand how the individual is adapting to the environment they are in given their past experiences, and how they are processing their feelings to understand why the shutdown might be happening. In short, depression “screams psychology” far louder than it screams biology.
*Depression is a tricky term to define because it has many different definitions. Here is a blog I did on how I think about the various definitions. There is the everyday use of the word, which means someone felt bummed or down for a while. Then there are the “clinical” definitions, which are usually referenced against the DSM or ICD diagnostic criteria. Basically, these require increasing levels of severity and functional impairment. The most basic definition of clinical/major depression is a Major Depressive Episode, defined here. It is crucial, though, to realize that there is HUGE dimensional variation contained within an MDE. MDE requires five of nine symptoms (i.e., depressed mood, loss of interest, low energy, negative thoughts) to be present most of the day for two weeks. It ranges from “Mild” to “Severe/Psychotic” in degrees. A stressed unhappy college student who everyone thinks is fine on the outside might be privately suffering from a Major Depressive Episode (probably of Mild Severity). Of course, in the extreme cases, there are some people who are so impaired they are essentially catatonic (meaning they bare even move), and must be hospitalized. This is why the analogy of “hunger” works. We can imagine folks with fleeting hunger that obviously is not clinical, and we can imagine mild to moderate malnutrition to severe malnutrition, bordering on death. As we move into more and more serious and chronic malnutrition, the structural bio-physiology becomes increasingly crucial and central. This is true of depressive conditions. But, as with hunger, the core of the condition is not primarily a disease state in the sense of being primarily characterized by a biological malfunction.