Depression as a physical illness

One of the articles in the recent Nature issue on depression compared research on cancer with research on depression. The former has  made big advances over the last 50 years or so and is well supported financially, the latter not so much. The article cites several reasons, for example, the newness of the tools used for brain studies and genetic studies, problems with diagnosing and defining depression, the stigma associated with depression, and the relative lack of large groups lobbying for research funding.

I would love it if the stigma around depression disappeared. The “it’s all in your head” approach to mental illness of any kind, and the assumption that you have complete control over what’s in your head, is overdue for retirement. Robert Sapolsky, in a lecture on depression, compares depression to diabetes; you wouldn’t expect someone to be able, by force of will, to make the pancreas produce insulin, and it’s equally unreasonable to expect a depressed person to directly control the brain processes causing the depression. I think this is a good comparison because both diseases can be managed, and you can often make changes in your life that affect their course (although this process is limited, and is often indirect, imprecise, and mysterious in the case of depression), but you can’t will the underlying biochemistry into something different.

I’d like to see more funding for depression research, and in particular for genetic studies and large-scale studies that might help clarify its different types and manifestations and their causes. However, recognizing depression as a physical illness doesn’t mean that we should treat it only through medical means, even if you expand “medical” to include talk therapies like cognitive-behavioral therapy. I say this for two reasons.

Medical solutions are not the only solutions

First, even for conditions that are viewed as purely physical, medical solutions are not the only solutions. Medical treatments for cancer, cardiovascular disease, and diabetes are much better than they were 50 years ago, and that’s great, life-saving news. However, reducing the incidence of these diseases (especially CVD and adult-onset diabetes) and helping people live better with them also require environmental and economic solutions, and even better city planning. Consider the health dangers of coal-burning power plants, for example, or the cost and availability of healthier versus less healthy food choices; think about how walkable and bikeable your neighborhood is, and how easy it is to make exercise a part of everyday life.

I think depression is the same way: medical treatments are important, and in some cases they may be the only thing that will help. However, a person’s environment is also crucial, even (or perhaps especially) for people with a genetic tendency toward depression. Maybe a better social safety net, especially for children, would also help. People with richer social networks may be less likely to be depressed; this should inform the way we design housing and neighborhoods. I recently read a book urging writers to consider self-publishing because the traditional publishing establishment is disempowering, and disempowerment is the last thing writers need. That got me thinking about our control over our lives as a whole and how empowered the average person feels in terms of job security, hope for the future, the opportunity to learn and grow. A sense of powerlessness is an essential part of depression for many people, and I don’t think I’d describe the U.S. as a particularly empowering place overall.

These larger questions are much harder to address, but if we truly placed a high priority on health, they would have to inform all kinds of policy decisions. I think it comes down to a question of the proper balance between focusing on the individual and focusing on the system in which the individual lives. Purely medical solutions, especially interventions after a disease has emerged, lean too much toward the former.

My depression is not my enemy

The second reason has to do with the medical model of treating diseases as enemies to be fought. (I’m writing here on the basis of my own experience with depression, which has been long and varied. I can’t possibly speak for every depressed person, or even most of them, but I also think it would be foolish to assume that I’m unique.) There have certainly been times when I wished I could just push a button or take a pill and not only eliminate whatever depressive symptoms I was having at the moment but also wipe the tendency toward depression completely out of my life. It’s easy to see depression, like a tumor, as an invader to be repelled. Ultimately, though, it’s not an invader. It’s woven into my history and the history of my family; the tendency toward it is probably part of my DNA, and it’s almost certainly associated with other traits and behaviors that I would miss if they were gone. I wouldn’t be me if they were gone.

Once I realized that it’s a part of me, I became much more interested in making peace with it to the extent that I could. It makes more sense to me to think of managing symptoms rather than destroying an enemy. Maybe this is a result of how my particular depression has gone. Depression has often involved strong feelings of unworthiness and inherent badness, and treating any part of myself as an enemy just makes them worse. Fighting a part of yourself, whether it’s your depression or a physical condition, doesn’t seem to me like a good way to live with yourself.