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Why is the concept of depression so elusive?
As a practicing neurologist, I
see plenty of depression masquerading as physical complaints, the patients either unable or unwilling to acknowledge that the mind can create all kinds of physical symptoms (constant headaches, neck and low back pain, non-specific dizziness, and so on). These are patients who best benefit from
treatment of depression. The problem is in getting them to recognize it.
I see a second group of people — the chronically disgruntled, with the
lifelong hangdog expression — who insist they are depressed when the problem is probably not depression. Rather, they have a variety of personality disorders ranging from standard passive-aggressive behavior (“What can you do for me?”) to a constitutionally based inability to experience joy.
Whoa. What right do I have to say what others are feeling? That’s the very
attitude that has put doctors on the top of everyone’s least-loved list. But this is the question: How does anyone know if someone else is depressed?
Is the person’s word good enough? Take a look at late-night TV. Is the teenage girl who laughingly says of her boyfriend, “he makes me so depressed,” talking about the same thing as someone who can’t get out of bed and who seriously considers suicide? Is this merely a matter of degree, or are we talking about different
emotions, different underlying neurochemistry?
Isn’t there something more rigorous about the diagnosis of depression than
The National Library of Medicine Health Services defines clinical depression
as “a mood disorder as opposed to a normal reaction to life’s difficulties. Not only is the mood affected, but there are often cognitive, behavioral, and [physical] symptoms.” So far, so good. But here comes the problem. “The mood disturbance may include apathy, anxiety, or irritability in addition to or instead of sadness.”
May include? Maybe? Using this standard psychiatric definition of
depression, one could argue that irritability may be the sole manifestation of depression. But irritability can simply be self-indulgent behavior without any emotional implication. Certainly there is a difference between petulance and grief.
Contrast hopelessness, discouragement, despondency with bitterness,
resentment, frustration, disappointment. They do not feel the same. Why not say “I am suffering from frustration,” rather than using depression as a blanket all-inclusive diagnosis?
If we are to understand depression, each of us needs to be the
self-analytical equivalent of a novelist. We need to understand nuances of feelings, shadings, subtle distinctions in mood. We need to be self-aware and able to describe our feelings with some precision. We would not think
of lumping all forms of growths together. You don’t need chemotherapy to treat a wart, though a wart is as much a growth as any cancer. And you don’t need Zoloft to treat resentment.
Unfortunately, we are swimming upstream against a psychobabble epidemic, in which all negative feelings tend to be lumped under depression. I suspect that, in part, this is because depression is increasingly viewed as neurochemical and beyond our control. If we are depressed, it is our
chemicals mistreating us. If we are resentful, there is a hint of a
character defect, and, God forbid we should have any personality flaws.
Frustration, resentment, bitterness imply an inability to take life’s lumps;
they imply some personal weakness. So why admit to frustration when you can blame your serotonin receptors?
Check out Webster’s unabridged dictionary; its definition of depression includes a
sense of humiliation. Humiliation is a feeling, but it also is attached to an idea of self. It is not of the same category as depression or elation; it comes from a different area of our psyche. Embarrassment is not the same as despondency.
I haven’t had the privilege of hearing Woody Allen on the couch, but the
public manifestations of his depressive persona are tinged with humor, irony and a variety of intellectual posturings. In fact his protestations of depression are a bit wearisome, precisely because they do not evoke true empathy. They are attention-getting devices. Allen’s self-aggrandizing self-mockery is not the same as the sinking sensation of true
despair. (Another definition of depression is a hollowing out of the landscape.)
We can watch a Beckett figure and sense alienation, but as we watch, we are
uplifted, filled with a sense of wonder at the very life we are mocking. Sit in the audience of “Waiting for Godot” and hear the laughter generated by the recognition of the humor of our pitiful existences. People leave the theater exhilarated. Again, we have the trappings of depression — moping, shuffling, mumbling static figures — but we do not have the mood of depression.
Recently, in the New York Times, there was a photo of a young woman from
Brooklyn in shorts and T-shirt walking three frisky dogs through Prospect Park. The woman said she suffered from lifelong depression and that she had failed all forms of treatment. Perhaps, but the picture didn’t ring true. My mind, cynical as it is, wondered about disability checks. She probably has a loving spouse back home doing the dishes, sweeping out the yard, carrying out the garbage for her, because she’s too “depressed” to handle life’s mundane details.
So what is this disorder than can be anxiety, irritability, humiliation or
lack of self-esteem; that may create sadness, or may not? Is this a single psychiatric disease? When is it biological and when, if ever, is it within our control? Can we tell? Or is this all seat-
Yes and no.
A good psychiatrist might answer the same way a Supreme Court justice once defined pornography: I may not know how to define it, but I know it when I see it.
We have all had some degree of true depression, some more than others.
Imagine a time when nothing is going right. After a few horrible sleepless nights you awaken with a sensation of — pick your own word — doom, dread, hopelessness. But it is a sensation, a sick feeling that rattles you to your bones.
Depression is not about ideas and postures. It isn’t about laziness and a languorous desire to spend the day in bed. It is a feeling of sickness. It is brain chemistry gone awry. In someone who is clinically depressed, functional MRI scans would show areas of altered brain metabolism. The spinal fluid might show decreased levels of vital neurotransmitters; there would be alterations in hormonal levels.
But, having said that, we still haven’t solved the chicken-and-egg dilemma.
Did some psychological malfunction trigger bad feelings that, in turn, triggered the biological response, or was the chemical aberration primary?
If you believe the biochemistry came first, then you opt for
anti-depressants. If you think that some psychological malfunction triggered the chemical response, you opt for therapy. Already you can sense the problem of treatment. The patient immediately is subject to his own bias for/against the psychological. Ditto the doctor.
One possible answer is to look for biological markers — like a strongly positive
family history, or a pattern that suggests one of the classical mood disorders, such as a history of manic behavior pointing to a true bipolar (manic-depressive) disorder. Soon there will be more precise genetic markers, maybe even nice neat lab tests that indicate predisposition.
But even if there were such lab tests, would we really understand the
triggering mechanisms beyond saying that someone was predisposed? If you knew you had a tendency toward depression, could you control it with therapy, exercise, meditation, mind control, willpower? Or would you opt for the latest serotonin modulator?
There is no easy answer. Not to recognize depression is to misdiagnose a
wide variety of chronic complaints (headaches, back pain). To diagnose depression when the problem is based in character is to create a drug-dependent nation. Pretty soon Prozac will be added to public drinking water. To not acknowledge the complex interplay between psyche and chemistry is to abandon any sense of personal responsibility, and create a generation of victims.
At the same time, we must recognize that depression may be beyond a person’s control, can be a serious medical problem.
At bottom we are struggling with the very notion of how to define our sense of self. We see our chemicals as not being a part of us; only our psyche counts, is responsible. But this line of reasoning reduces each of us to a machine with a superimposed little man or woman sitting at the top, wearing the driver’s hat but not really having a grip on the wheel. It’s not a very healthy self-image. It’s even a bit depressing.
Robert Burton, M.D., is the former chief of neurology at Mount Zion-UCSF Hospital and the author of "On Being Certain: Believing You Are Right Even When You're Not." His column, "Mind Reader," appears regularly in Salon.More Robert Burton.
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