Understanding Depression: A Pluralistic Approach

The controversy surrounding the report “Understanding Depression” by British Psychological Society has prompted much reflection on my part. In particular, it appears to me that it is no longer sufficient to criticize. What is needed is an alternative answer, one that can do some justice to the complexity of the issue at hand. What is also needed is not a medical answer, for that is already dominant and pervasive. Rather we need an answer that goes beyond the medical, and that provides a space for societal dialogue. In this blog post, I attempt the beginnings of such an answer. While I have confidence in the earnestness of my attempt, I have less confidence in its success.

 

Understanding Depression: A Pluralistic Approach

Depression is a common human experience characterized by feelings such as unhappiness, despondency, dejection, sadness, despair, or misery. However, the depression that is the subject of our discussion, the depression that comes to the attention of clinical professionals, and the depression that is characterized as a “mental disorder” is not entirely the same as this commonplace understanding of depression. This notion of depression as a clinical entity is continuous with the more ordinary understanding of depression, but also differs from it in important ways.

One of the ways in which depression as a clinical entity (“clinical depression”) differs from our commonplace understanding is that clinical depression is understood as a constellation of related problems. These problems include experiences such as inability to experience joy, changes in appetite, changes in sleep, low energy, slowed movements, guilt, difficulty thinking and concentrating, and thoughts of death or suicide. That clinical depression exists as a cluster of problems is an empirical observation, repeatedly made across time and space, although the exact configuration of the cluster varies. In clinical depression, these problems are understood to be pervasive (present most of the time and in most settings) and persistent (continuing on beyond fluctuations of mood in ordinary life). Furthermore, these problems are severe enough to cause distress or impairment in one's daily life such that these problems are recognized by the person or their family/friends as presenting a challenge to the person's well-being. That is, depression as a clinical entity is understood to be typically unmanageable or intolerable, such that the ordinary means of support in one's life have failed to offer relief.

Depression as a clinical entity is often described as “major depressive disorder”, but that is not necessarily the case. “Major depressive disorder” is the typical diagnosis given by healthcare professionals when individuals present with clinical depression, but what may look like depression to a person or their family may not be understood by a healthcare professional as “major depressive disorder”. It may very well be the case that what looks like depression is interpreted by the healthcare professional as belonging to a diagnostic category different than major depressive disorder, such as adjustment disorder, bipolar disorder, anxiety disorder, or dementia. This is because the experience of depression can exist in many different ways and can exist alongside many different problems. This matters a great deal in clinical contexts, but less so for the purposes of our discussion.

How to make sense of depression is a question that throws us into the complicated debates surrounding the relationship between mind and body, the nature of psychiatric diagnoses and explanations, and the colors and quirks of human subjectivity. These issues, like most philosophical problems, are open-ended, unsettled questions. We live in a society where narratives of depression as a medical condition have become dominant. These narratives take many forms. A common narrative widely promoted by pharmaceutical companies that has permeated our popular culture is the notion that depression is caused by a “chemical imbalance” in the brain. This narrative has encouraged a predominantly biological understanding of depression and has been used successfully to market antidepressant medications. However, our best scientific and philosophical understanding of depression is inconsistent with any simplistic explanation in terms of brain changes.

Understanding depression as a medical condition is not simply a matter of hypothesizing brain changes. Rather, from a practical standpoint, something becomes a medical condition when it is deemed appropriate to be assessed using the methods of medicine and to be treated with the tools of medicine (with the recognition that the methods and tools of medicine are themselves evolving and fluid). Individuals with depression have sought the care of physicians since the early days of medicine. Depression was recognized as a clinical entity by ancient physicians such as Hippocrates and by medieval physicians such as Avicenna. However, the depression that has been recognized as a clinical entity for much of history is, from today’s perspective, depression of a more severe variety, such that often its subjective experience feels qualitatively different from ordinary unhappiness; it is often profoundly disabling, and often complicated by unusual experiences such as delusions or hallucinations. Over the 20th century, the boundaries of what is considered clinical depression have steadily expanded to include milder forms of depression, such that a lot of what is considered clinical depression today is probably closer in its subjective experience to intense ordinary unhappiness than it is to melancholia of yore. Thus, clinical depression is a spectrum, ranging from mild to severe, from qualitatively familiar to qualitatively unfamiliar, and from distressing to disabling.

From a medical perspective, clinical depression is a syndrome that results from a complex interaction of biological factors (such as genetics, neurotransmitters, inflammation), psychological factors (such as personality styles, cognitive styles), and social factors (such as abuse, poverty, social adversity, social discrimination). There are, however, other perspectives available to us. From a psychodynamic perspective, for example, experiences such as clinical depression are woven into the fabric of our lives and rooted in enduring patterns of thinking, feeling, motivation, attachment, coping, defending, and relating to others1; from this perspective, clinical depression cannot be understood as an entity separate from the person experiencing it. Individuals with depression want relief from depression, but this may exist in the context of problems of living, such as inability to connect with others or feelings of shame, such that it may be meaningless to attempt to relieve depression without dealing with those problems of living.

From an interpersonal and relational perspective, the experience of depression may be related to the events and circumstances of a person’s life, both in the past and the present, together with the meaning those events have for them2. From a social perspective, the experience of depression may be related to social oppression, economic inequalities, and societal expectations of individual productivity. From a spiritual perspective, the experience of depression may be related to our disconnection with sources of meaning in our lives and opportunities for transcendence. From an environmental perspective, experience of depression may be related to our increasing isolation from nature. From an existential perspective, experience of depression may be related to our struggle as conscious beings in an apparently absurd universe facing inevitable death.

That multiple perspectives are available to us means that no single perspective can offer us all that we need to make sense of the multifaceted reality of depression. The perspectives available to us allow us to see depression as a problem inside or outside the individual, as a problem requiring a scientific explanation or a difficulty in need of an existential narrative, as a syndrome to be understood medically or an experience to be understood psychologically, as a disorder that requires medication or as a spiritual crisis that compels one to undertake an 1,100-mile hike on the Pacific Crest Trail.

To reduce this plurality of perspectives to a single dominant narrative, whether it is medical or inter-personal, is to impoverish our existence and to deprive us of the tools we need to make sense of our selves in relation to our worlds. It is inevitable that different professionals will utilize different perspectives as tools, and different individuals will find that their depression makes more sense from a particular perspective. The perspectives that we find valuable will depend on our specific questions and specific interests. A clinician asking “How can I offer relief to this individual in great distress sitting in front of me in my office?” requires adopting different perspectives than a politician asking, “What services should be funded and made available to reduce the burden of depression in my community?”. An anthropologist asking, “How do I make sense of the experiences of depression across different societies and cultures?” requires adopting different perspectives than a depressed individual asking, “What meaning does my depression hold for me?”

Our task, the arduousness of which cannot be over-estimated, is to do justice to the plurality of perspectives, and to the plurality of pluralities. This is a responsibility that cuts across our divisions of individual and social, secular and spiritual, and medical and psychological.


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Footnotes

1. Jonathan Shedler in interview with me: “This is a radically different way of thinking about depression. It is less about what we have and more about who we are. Our difficulties are woven into the fabric of our lives and rooted in enduring patterns of thinking, feeling, motivation, attachment, coping, defending, and relating to others—that’s what we mean by personality. From this perspective, depression is an effect, not a cause. It cannot be treated in a vacuum, separate from the person experiencing it.”

2. BPS. Understanding Depression. Executive Summary. “Often, the experience of depression is related to the events and circumstances of a person’s life, both in the past and the present, together with the meaning those events have for them.”