Taking Depression(s) Seriously
Because they have gotten out of control
Depressions (which must now be pluralized because there are over ten) are certifiable mental disorders. Their certifiable status means that they can only be diagnosed by licensed mental health professionals. You cannot diagnose yourself with a depression any more than you could diagnose yourself with strep throat. It is in this manner that the mental health industry has attempted to take seriously the growing pockets of human turmoil that have multiplied over the last several decades. But, however dignifiably-scientific they seem, the depression-related problems will never get sorted out this way. This hasn’t worked.
Depressive disorders and strep throat both require official diagnoses before any treatment can commence, and only credentialed personnel can supply them. You might think you have strep because the food you swallow feels like its tearing holes in your esophageal walls. But until the ear, nose, and throat specialist gets the special tongue-depressor culture-readings back from the lab, all that you are suffering from is a sore throat and cough. To illustrate this, if you were to complain of a torn esophagus to your physician, and she was to treat you for strep throat or pneumonia without doing the tests to confirm the diagnosis, then she would lose her medical license.
The same is mostly true of depressive disorders. You might think you have Persistent Depressive Disorder, for example, because your job and marriage seem meaningless. But until a mental health specialist diagnoses you with it (or one of the other depressions), you are simply bummed out about your job and marriage. But the depression diagnoses are different from the strep throat diagnosis. With the latter, the throat culture is examined for confirmation. If the incubated cultures reveal an infection, then a diagnosis is made. You cannot do this yourself. What if you were to make a mistake?
With its diagnosis, strep is confirmed. It was already present in your throat, but now its presence has been medically confirmed so that treatment can commence.
With depressions, there are no blood samples given or epithelial cultures taken. You are asked a series of questions about your job, your marriage, and how satisfied you are with your life, generally. You hopefully answer these questions as honestly as possible, but you might see where it could be helpful to embellish your unhappiness a little bit here and there, so as to make your case. The mental health specialist will choose to either trust your answers or decide that you’re malingering (ie, faking). If she trusts your answers, then she might also choose to diagnose you with Premenstrual Dysphoric Disorder (or one of the other depressions).
With its diagnosis, depressions are conferred — even accused. You are not depressed until you’ve been accused of it by a certified mental health practitioner. Only then may treatment commence.
The procedure for diagnosing Disruptive Mood Dysregulation (or one of the other depressions) follows the same protocols as those for medical diagnoses. As the ENT is trained to prepare and incubate throat cultures, the mental health practitioner is trained to judge the truthfulness of the responses given by the patient to the depression inventory. Once diagnosed, you may be treated for your depression.
Treatments vary, but over the last few decades, the National Institute of Mental Health (NIMH) and the American Psychiatric Association (APA) have been endorsing what they call “evidence-based practices” for treatment of depressions. These are the interventions that have allegedly been backed by science — that is, those that are understood to be the most effective, and those around which the most evidence has accumulated like darts on a dart-board, but more sciency. The principal treatment for depressions is pharmacotherapy with an emphasis on pharmacy. This is therapy-by-way-of-oral-drugs. The drugs are understood to target the tiny chemicals secreted by neurons.
It doesn’t matter that the relationship between depression and any imbalance of neurotransmitters is still at the educated guess part of the scientific method. It also doesn’t matter that there are as many as 1,000 competing hypotheses for what causes depressions that are still being engineered by neuroscientists, chemists, psychiatrists, analysts, and therapists. What matters is that there are NIMH- and APA-backed protocols for treatment. That makes the intervention strategies more confidence-inducing than describing them by way of their effectiveness (because their effectiveness is extremely poor).
The most common evidence-based, science-backed treatment is an oral drug called a selective-serotonin reuptake inhibitor (SSRI), which, as you might have surmised, selectively inhibits serotonin from being reuptaken. These are based on what’s called the monoamine hypothesis: that depressions are caused by a lack of serotonin in the neural synapses, and serotonin is what makes working conditions more tolerable. SSRI’s work by making it difficult for serotonin-secreting neurons to suck the serotonin back up into their terminal buttons after its release. When effective, SSRIs tend to take several weeks before there is any improvement in symptoms, or about the amount of time for a condition to resolve on its own without treatment. It would be more impressive if the depression symptoms lifted a few minutes after swallowing the SSRIs, like the warm buzz that follows a sip of whiskey. But they don’t.
To muddy the hard-nosed, rule-based scientific waters further, the effect of the treatment is only partially explained by the chemical properties of the SSRI drug itself. American psychologists Irving Kirsch and Guy Sapirstein (1998) have estimated that a whopping 75% of the treatment effect can be explained by placebo response. This is a combination of placebo effect and any improvement that would have happened normally and without any intervention. Moreover, the improvement that is found isn’t anything to write your senior thesis on. These patients’ marriages do not magically improve nor do their lives dramatically turn around. The editors of the journal were so nervous about this article being published on the pages of their journal that they printed it with its own version of a “THIS MATERIAL MAY NOT SUITABLE FOR ALL READERS” warning label.
The story is not much better for psychotherapy, either. This is where a depressed person sits opposite an expert in non-depressed living. In 2018, American Psychologist Jonathan Shedler published this in his article titled “Where is the Evidence for ‘Evidence-Based’ Therapy?” He reports that the experts who have received their evidence-based seal of approval get to boast a 5% rate of effectiveness for their psychotherapeutic treatment of Substance-Induced Depressive Disorder or one of the others. To establish such expertise, and by extension, receive a rubber-stamped NIMH- and APA-backed scientific credential for your wall, you must learn to follow a very specific sequence of techniques that have all been determined and defined in advance: step one, step two, step three, and so on, as if you are defusing a bomb. When compared to patients who received no therapy at all, these manualized approaches don’t seem to be any more effective at minimizing symptoms in the short or long term.
From the perspective of modern medicine, the phrase “taking depressions seriously” tends to mean that depressions are being considered as legitimate medical conditions. They’re treated this way when their diagnostic procedures mimic medical diagnostic procedures, when their practitioners and specialists wear lab-coats and require medical licensures and certifications, and when their leading hypotheses target human biology and neurotransmitters — the fundamental elements of modern biomedicine.
After reviewing the evidence-based evidence, the only thing clear is that the most essential qualities of depressions have yet to be taken seriously. Nowhere in the entire depressions-are-a-legitimate-medical-conditions approach does one find that which ails an alleged quarter of the adult population (and a mind-boggling percentage of children). Where might we look for this instead?
Backing up to the diagnosis itself, depression inventories are limited to questions that focus on subjective symptoms — the what it feels likedimension of Depressive Disorder Due to Another Medical Condition or one of the others. This is the dimension which lab-coat-wearing scientists find unimpressively crude. This would be like diagnosing strep throat as exactlyhow bad a patient’s throat hurts. Since strep is diagnosed by a throat culture, the infection is where antibiotic treatment is directed. Depressions, on the other hand, are diagnosed using inventories with questions such as “do you feel like a complete failure?” or “do you feel like you are being punished?” (taken from Beck’s Depression Inventory). These are personal questions. They are directed at a person’s way of being in the world, or what Aristotle had meant when he used the word psyche all those thousands of years ago.However, the leading interventions are directed at something entirely different: the release of or failure to release neurotransmitters from neurons.
In order to take depressions seriously, we would need to begin by seriously considering what the diagnostic questions themselves mean. To ask, for example, what it means to feel like a complete failure? The Boston Marathon is a competitive 26.2-mile foot race. It takes me over three hours to run. 10,000 other competitors will finish before I’m done, but I am still proud to finish when I do. On the other hand, the first-place female could finish 50 minutes before me, winning more money than I make in a year. She might still feel like a failure because she missed the women’s course record by 30 seconds. Is there maybe something that could be said about the meaning of her experience and mine? Or must we view the personal interpretation of life experience as evidence of neurons that haven’t learned to share their chemical goods?
In order to understand one experience of success and the other experience of failure, we wouldn’t begin with the serotonin levels in each person. In the case of a marathon, it seems like success and failure have a complicated combination of goals, aspirations, historical precedents, as well as the experience of fulfillment or lack thereof. In order to understand a person’s perspective of his or her own success or failure, we have to examine the significance it has in his or her life. This will involve understanding how success is defined and what the best-case scenario would look like for each. Part of this might be rooted in how a given person has learned to understand success, as well as what its potential benefits are. It could be rooted in a fear of letting others down, or in the presumed need to be viewed by others as a winner, hard worker, or disciplined person.
In short, what taking depressions seriously calls for, and this is going to send a cold bead of sweat right down the spine of our lab-coat wearing, bespectacled scientists, is an existential approach. Not the meditation-on-the-implications-of-human-finitude kind of existentialism, but a view that takes into consideration the entire life of the depressed person. As English philosopher of medicine Matthew Ratcliffe (2015) has summarised it [sic], “At a very general level, the majority of depression experiences are characterised by some kind of ‘existential change’, the variants of which all involve an experienced impoverishment of self and world.”
Until psychologists, therapists, analysts, and the whole lot of mental health practitioners start wading through this sense of impoverishment, I move that we stop saying that we’re taking depressions seriously.
References
Kirsch, I., & Sapirstein, G. (1998). Listening to Prozac but hearing placebo: A meta-analysis of antidepressant medication. Prevention and Treatment, 1 (2a).
Ratcliffe, M. (2015). Experiences of depression: A study in phenomenology. New York: Oxford University Press.
Shedler, J. (2018). Where is the evidence for ‘evidence-based’ therapy? Psychiatric Clinics of North America, 41, 319–329.
