The Philosophy of Depression
Processing through a literature-based framework
The Struggle is Unclear
We all know the numbers — roughly 6 to 10% of American adults will experience depression in a given year. However, it’s clear that something is wrong with the current mentality surrounding the medical apparatus. More and more people are taking antidepressants and are generally “aware” that there is help available for depression, yet the number of cases keeps rising. Certainly the changing environment has something to do with it, but I have a different perspective on this. A large part of this has to do with the base unit of psychiatry/psychology being self-reporting and the heavy ethical restraints placed on a licensed professional who you open your mind to. In essence, they can only help you help yourself, which begets the question what exactly do we need help with?
First, it’s important to understand what depression isn’t. One of the most notoriously popular misconceptions is that depression is caused by a “chemical imbalance” in the brain. There is absolutely no evidence of this; in an umbrella review of decades of research on this theory, a recently published paper in Nature concluded
…there is no convincing evidence that depression is associated with, or caused by, lower serotonin concentrations or activity.
This review suggests that the huge research effort based on the serotonin hypothesis has not produced convincing evidence of a biochemical basis to depression. This is consistent with research on many other biological markers [21]. We suggest it is time to acknowledge that the serotonin theory of depression is not empirically substantiated.
This is nothing new — it has been known for a while professionally that depression is not such a linear problem as, say, treating an STD, where you take a pill to resolve the condition, follow the course of treatment, and are cured.
Northwestern University’s Dr. Christopher Lane highlighted in a commentary in Psychology Today a 2005 study that explored the disconnect between advertisements of SSRIs and the scientific evidence to support their use. Lane quotes Daniel Carlat, the editor of The Carlat Psychiatry Report, “I’ll often say something like the way Zoloft works, is, it increases the level of serotonin in your brain (or synapses, neurons) and, presumably, the reason you’re depressed or anxious is that you have some sort of a deficiency. And I say that [chuckles] not because I really believe it, because I know the evidence really isn’t there for us to understand the mechanism…
A familiar face rears its head as part of the coalition that seems to have never informed the public that chemical imbalance theory wasn’t professionally accepted at all — big pharma marketing.
The review authors highlighted a study (n = 893) that found that 88.1% of respondents believed a “chemical imbalance” to be a cause of depression. This idea, the authors point out, was heavily pushed by drug companies aiming to sell serotonin-selective reuptake inhibitor (SSRI) compounds. Eli Lilly, for example, promoted their compound Prozac in 2008 with the following: “Many scientists believe that an imbalance in serotonin, one of these neurotransmitters, may be an important factor in the development and severity of depression. PROZAC may help to correct this imbalance by increasing the brain's own supply of serotonin.”
But even if you didn’t follow that research, a simple glance at some charts would tell you that something is off about the “take pill” model for treating depression. Antidepressants show some efficacy as a short term treatment
Without antidepressants: About 20 to 40 out of 100 people who took a placebo noticed an improvement in their symptoms within six to eight weeks.
With antidepressants: About 40 to 60 out of 100 people who took an antidepressant noticed an improvement in their symptoms within six to eight weeks.
but drop off in efficacy as a longer-term treatment:
The study included people who took all types of antidepressants, including selective serotonin reuptake inhibitors like Prozac, serotonin-norepinephrine reuptake inhibitors like Effexor and older antidepressants such as clomipramine and phenelzine. Researchers assessed both mental and physical quality of life with a survey that asked questions about subjects’ physical health, energy levels, mood, pain and ability to perform daily activities, among other things.
The paper found no significant differences in the changes in quality of life reported by the two groups, which suggests that antidepressant drugs may not improve long-term quality of life. Both groups reported slight increases in the mental aspects of quality of life over time, and slight drops in their physical quality of life.
Note that this isn’t an indictment of antidepressants as a treatment for depression — clearly they can work! — but rather I highlight that there is a slight correlation between antidepressant usage and reduction of depression, but there’s simply no causality present whatsoever. A similar note can be made regarding the efficacy of therapy — it’s a very common complaint that therapy just “doesn’t work” for an individual. Certainly there are good therapists and bad therapists, but we simply don’t know what causes depression and we don’t exactly know how to treat it. Therapy’s efficacy necessarily depends on knowing what you are attempting to get out of it, or at least being able to express what depression means to you, and you helping yourself. As such, I can’t really comment on the potential biological and chemical causes of depression. But I suspect that it’s not exactly a “biological” problem — there’s a metacognitive element to the whole ordeal, and by using an intellectual characterization of depression one can help themselves manage and plot a treatment for this condition.
Notes from Underachiever
Now that we’ve identified what depression isn’t, let’s move on to how I define it. I generally bucket depression into two categories: for-cause depression and no-cause depression. Note that one is not more “justified” than the other; the separation is due to the variance in the questions that arise.
For-cause depression tends to be the more straightforward of the two, in that there’s a clear cause-and-effect relationship present that led to the depressive state — the catastrophic loss of a family member, sudden financial loss or hardship, the ending of a long relationship, and so forth. As a result, I suspect that the medical model works better in these cases — the patient goes into the psychiatrist’s office knowing what they want help dealing with, so antidepressants and therapy work as sort of a “crutch” while the patient tries to figure out their depression. Certainly not every situation can resolve favorably, but the questions that arise take a form closer to “why did this happen to me”, “how could the world be so unfair”, “what do I do to recover from this” — straightforward questions which, over time, can be processed and dealt with, even if the cause of the depression lingers on permanently as a thought in your own head. For-cause depression resolves with an acceptance of circumstances and the nature of variance itself — that it’s not worth being permanently debilitated over some depressing scenario.
No-cause depression, on the other hand, is a philosophical struggle, and I suspect that most long-term or recurring depression falls into this category. This is due to no clear causality being present — the “why did this happen to me” question cannot be grounded by contextualization. It is fairly common for otherwise successful, put-together people to feel clinically depressed, after all. Any attempt to reason that one shouldn’t be depressed due to the makeup of one’s life misses the mark as sort of a failure of self-actualization. Consequently, no-cause depression can be thought of as an existential affliction — that such a depression is purposeless, that it’s simply part of the nature of life itself. Being in this state is an existential torture of sorts — suicide makes no sense as an overly ham-fisted solution akin to “curing” yourself of cancer by terminating your life preemptively, yet the depression doesn’t seem to ever fully abate, but rather waxes and wanes based on how much time you actually have to sit and think. But one clearly cannot remain in this state. So how does one improve themselves from this place?
The misfiring of self-actualization here results in the equating of “pointlessness” and “meaninglessness” with the resulting notion that “life is not worth living.” This should look familiar to any literature enthusiast — this is the very basis of absurdist literature. Accordingly, we can turn to an absurdist framing of the conflict as presented by Camus — the notion that, if the urge to kill oneself is not so strong such that one actually does it, then life must be worth living, no matter what action is taken. Thus the only course of action is to continuously improve oneself while understanding that this is not directly treating the cause of depression because it’s an untreatable affliction through pure reasoned conduct. Therapy and medication can help maintain a sufficient mood to enable a state of activity, but it cannot resolve this ontological affliction by itself. I wholly believe that processing absurdist literature is a very good way to understand depression without diving into rabbit holes of pseudoscientific theorization. It’s not a solution in and of itself, but it is doing something.
The difficulty of explaining no-cause depression and how it resolves is well beyond the capacity of the normal person to express themselves (hence why I turned to, well, Camus.) But I would like to address a common statement (oft-criticized by sufferers of depression): that “to stop being depressed, you just stop being depressed.” This is certainly reductionist, but it does contain an element of truth: by consistently tinkering and doing positive things for yourself in life, you enable yourself to look at your life more positively, in a sense “snapping” out of depression because you’re no longer enveloped in a lack of positivity that led to the affliction in the first place. Similarly, you can “treat” depression through the medical model by allowing yourself to be treated — the mind is weird in that if you’re convinced you are recovering and working towards it, you are likelier to actually get there. The stubborn, rationalizing mind is the most crippled in recovering from depression: the unwillingness to absolve oneself of the perceived necessity to “interpret” depression hampers recovery.
As Arcade Fire put it, “my body is a cage… but my mind holds the key.”