Friday, October 16, 2020

Understanding depression

The new British Psychological Society (BPS) document on 'Understanding depression' has created controversy, at least on twitter. For example, @ProfRobHoward sent a tweet saying that it is "stigmatising and politically motivated", and @wendyburn in her tweet linked to what she called a "powerful and disturbing" blog post by Lucy Dimbylow (@lucywriter), who in turn had sent a tweet saying the report "trivialises depression, gaslights sufferers and suggests it's [depression's] not even an illness".

Actually the report says there can be advantages in thinking of depression as an illness and some people find medication helpful. Depression of course can be a normal experience and there can be benefits for some people of 'normalising' depression. The report also makes clear that depression can be debilitating and associated with psychosis at the other end of the spectrum. A strength of the report is that it provides personalistic explanations of depression, taking a holistic perspective rather than narrowly focusing on the brain.  I don't think the report is misleading or undermines depression as an illness. It is a helpful, balanced report written in everyday language.

The argument on twitter about whether depression is an illness deflects from taking on board a key message of the report that depression is not a brain abnormality. I wish these debates would become less polarised and focus on the fact that depression is not the result of a brain disease. The symptoms and signs of depressive illness, although enabled by the brain, are not merely epiphenomena of a causal brain process. Depression needs to be understood in interpersonal context. Maybe that's why some people feel so threatened by the BPS report, because they know that depression is not a brain abnormality but wish it was. 


Richard Gipps said...

I largely agree with you Duncan, certainly when it comes to the errors of the critics of the document you mention. But it strikes me that the document is in one sense unhelpfully 'political' - it simply reproduces, without in any way interrogating, the standard clinical psychology way of thinking about depression. This general model is only interested in answering 'why?' questions by citing environmental or endogenous causes (see part 2). Again and again the psychologists largely ignore the immanent or formal causes of depression because, in their wish to be scientific, they derive their thinking about what should count as causes from the kinds of relations treated by such disciplines (the natural sciences) as enjoy the prestige they seek. This we have endless examples of the "childhood trauma --> unhelpful beliefs about ourselves --> adult depression" sort, but nothing that really helps us look at our selves as self-creating systems with their own dynamics. (The only exception is a tiny section on 'schemas'.) Yet it is often by looking at such internal dynamics that we stand the best chance of helping the patient. Or so it seems to me (as a clinical psychologist who specialises in psychotherapy). My patient is depressed: she has a way of relating to herself, and set of expectations as to how she'll be treated by others, that stymie her self-becoming. She has unwittingly made shame her abode; so entrenched in it is she that she can no longer see it for what it is; it has become the water in which she swims. She relentlessly and quite unknowingly takes the wind out of her own sails before anyone else could do that too her. She has but a fragile 'good internal object' to help maintain her sense of herself as lovable and valuable. It strikes me as perverse that a discipline called 'psychology' should be so relentlessly on the run from the internal world. What was the cause of my patient's depression? Well, it largely caused itself, I imagine: a certain gentle groove was etched by this or that experience in the mind, but it then endlessly entrenches this groove more deeply within itself. Because we become who we are in and through our self-understandings, there's no possibility of separating out the causes and effects which the psychologists, wanting to follow the natural sciences, still seek. However to think as they do is not to gain true scientia (knowledge) of the mind, for it employs a form of cognition not apt to its object. Thus backfiring. .... Or so it seems to me!

DBDouble said...

I do agree, Richard, that we need to move on from these endless ‘merry-go-rounds’. Any suggestions about what BPS should be doing with its monies apart from producing these kind of documents, which I guess inevitably have errors and are open to misinterpretation?

WeCareAboutMH said...

"Depression of course can be a normal experience and there can be benefits for some people of 'normalising' depression."

I totally disagree with this usage of the word depression. The word used to be reserved for clinically debilitating states towards the extreme end of the spectrum.

By attempting to reduce stigma and normalize the experience, MH professionals have inadvertently increased the stigma routinely faced by people suffering from more severe and enduring forms of mental illness. And I'm happy to use the word illness in this context because severe clinical depression meets the criteria of an illness.

In your critique, you state that depression is not a brain abnormality and that it is not a biological disease. This is quite possible, but that has not been convincingly demonstrated. The best we can say based on the current science is that scientists have so far been unable to find an organic cause for depression, that the illness sometimes responds to antidepressant treatment, the newer SSRIs which target the serotonin system are more effective for some patients, there are also psychotherapies such as CBT which are effective treatments. It is quite possible that with advances in brain imaging, pharmaceutical treatment and other diagnostic techniques that an organic cause will be found, we just don't know.

The whole debate about whether depression is an illness, whether diagnostic constructs are useful is a huge distraction away from the search for effective treatments for depression. It is very clear that the best strategy we have at the moment for treating depression is to use everything we have in our tool kit and to combine drug treatment with psychotherapy, while taking into account social factors. Reports such as the latest BPS report, which deliberately downplay the importance of drug therapy and adopt a partisan stance on controversial issues, make it less likely that psychiatrists, psychologists and other MH professionals will come together in a search for more holistic approaches.

DBDouble said...

Thanks, WeCareAboutMH! I think you’re right that our modern concept of depressive illness is a broadening of traditional concepts like melancholia, which were serious illnesses. As I’ve tried to emphasise, I’ve no problem with the term ‘mental illness’ and want to reduce the stigma associated with both the label and the underlying illness. Where I think we differ is that you seem to believe that depression may be found to be an organic illness, whereas I do not. The point of the blog was to try and encourage more debate on this issue, so I’m glad we’ve reached that point. I don’t want to undermine your belief in medication and psychotherapy, but I seem to be more sceptical about the evidence than you and tend to focus on social factors in treatment. Like you, I agree it’s not helpful to be polarised on these issues and we need to work together, I would say towards a more relational psychiatry.

WeCareAboutMH said...

Thank you for your response. I believe there is quite a lot that we agree on. I am actually agnostic as to whether depression, understood as a debilitating clinical condition, will be found to be an organic illness. At the same time, I am in little doubt that organic causes will not be found for the milder forms of depression which are often (in my view wrongly) treated with antidepressant medication. I also believe it is very unhelpful to make categorical statements about underlying aetiology when the science neither supports nor refutes those statements. I also agree that it would be more helpful to focus on the many social factors and less on the highly polarised debate surrounding medication and diagnosis.