Is Depression Always a Disease?

Like most mental health writers, I have compareddepression to illnesses like diabetes in the past, and stressed the biochemical aspect of mood disorders in my efforts to reduce stigma. Somehow talking about the gene G72/G30 located on chromosome 13q (that may predispose individuals to depression and bipolar disorder) makes it more legitimate, as if the gene proves we aren’t making it up.

However, the more I read about how abuse, trauma, and chronic stress —unresolved issues of all kinds — can cause and aggravate depression, the less I want to compare it to diabetes.

Taking insulin really isn’t the same thing as taking an antidepressant.

It’s not that simple.

As I wrote about in my recent blog about selective serotonin reuptake inhibitor (SSRIs), the theory that depressed people suffer from a lack of serotonin and other neurotransmitters, which are replenished by antidepressants, sounds good, but isn’t totally accurate. SSRIs aren’t like insulin in that they fill in a deficiency. In fact, we still don’t really know how they work, but they certainly do for many people.

In his chapter A Heroic Passage in the book Darkness Before Dawn, psychiatrist James Gordon, MD, writes, “Depression is not a disease, the end point of a pathological process. It is a sign that our lives are out of balance, that we’re stuck. It’s a wake-up call and the start of a journey that can help us become whole and happy, a hero’s journey that can change and transform our lives.”

Part of me cringes when I read that.

Forever stuck in my brain is renowned psychiatrist Peter Kramer’s quote: “Depression is not a perspective. It is a disease. To see the worst things a person can see is one experience; to suffer a mood disorder is another.”

And yet, I agree with Dr. Gordon on some kinds of depression.

For example, the symptoms of sadness, irritability, and interrupted sleep I experienced at the beginning of this year was a wake-up call that I was working too many hours and trying too hard to build a foundation for treatment-resistant depression overnight. Crying for five days straight led to an aha moment, when I realized that my health and my family should always come first. So I backed down my work hours and delegated more tasks to other administrators in my depression community, and the sadness and panic faded. I don’t think popping a Xanax or upping my Zoloftwould have done much good.

However, there are also times when I know the depression is nothing more than a biochemical response. When I tried the natural hormone progesterone, for example, and my thoughts went from “I wish I were dead” to “Let’s review some suicidal plans immediately.” Luckily I knew my mental state was due to the progesterone because my psychiatrist had warned me about taking it (I didn’t listen), and I knew a friend who wanted to jump off the Bay Bridge after rubbing progesterone cream on her chest. I have a similar reaction when I eat foods made with sugar and white flour. I start doing death math. I don’t believe those hours obsessing about ways to die served me in any way. In fact, that kind of depression is a life-threatening condition that has killed almost a million people around the globe, including comedic genius Robin Williams.

In a New York Times piece titled It’s Not Always Depression, psychotherapist Hilary Jacobs Hendel describes her sessions with a patient, Brian, who came to her after years of treatment-resistant depression. He had already tried cognitive behavioral therapy, psychoanalytic psychotherapy, supportive therapy, and dialectical behavioral therapy. He had been prescribed several medication combinations, and had been hospitalized. Next on the list was electroshock therapy, which he didn’t want to do.

During her first few sessions with Brian, he was totally comatose. She writes, “He could barely bring himself to speak, and his voice, when I managed to get anything out of him, was meek. His body was rigid, his facial expression blank. He couldn’t look me in the eye. Yes, he seemed extremely depressed. But knowing he had been treated for depression for years without good results, I wondered about the diagnosis.”

She eventually diagnosed him as a survivor of childhood neglect, a kind of trauma, and proceeded with experiential dynamic psychotherapy, which focuses on “fostering awareness of the emotional life of the patient as it unfolds in real time in front of the therapist.” They worked together twice a week for four years, and he eventually let go of his shame, learned how to express his feelings, and engaged in meaningful work.

I’ve heard other stories like this that make me think that sometimes depression isn’t so much a physical disease as a spiritual and psychological condition — a kind of constipated state of mind, where your thoughts and spirit are stuck in a toxic quicksand that is swallowing you up minute by minute. In these situations, my guess is that drugs are probably less effective than a kind of psychotherapy or meditation technique or spiritual healing that confronts the source of the pain. But keep in mind I studied theology in college, not medicine.

A friend of mine who also had a traumatic childhood asked me the other day: “Do you think that the reason many of us have depression is because this is a warning signal from our minds and bodies that there is something wrong in our lives? That we are not ‘sick’ in the traditional sense, as in a diagnosis of diabetes, but we are being alerted that we have not yet reached the root psychological cause that is creating the anguish? In other words, you simply cannot put out the psychological fire until it is resolved within and that it may be so subconscious that we may not yet be aware of it?”

Six years ago I would have told her depression is always a physical condition that needs to be treated with the traditional psychiatric approach. In the years of 2005 and 2006, I spent too much time trying to locate the source of my unresolved issues, and frankly, it almost cost me my life. After all the yoga, meditation, and psychotherapy, I still had a bag of about 30 prescriptions ready to flatten my pulse. Not until I landed at Johns Hopkins Mood Disorder Clinic did I get my life back. However, during the last few years, I have seen and experienced the limitations of psychiatry and the biomedical model. I have witnessed people stay stuck, despite many sessions of ECT and medications and psychotherapy, which is why I felt strongly enough to start my foundation for intractable depression.

I would very much like to say that depression is always a disease.

It’s simpler.

Just as a diabetic needs insulin, we need antidepressants — that’s clean.

But the truth is that I have been so humbled in the last 10 years that I don’t really know what depression is and what works anymore. I appreciate that each human being is so unique with different nerve cells and tissues that it can be dangerous to make bold claims in any camp. I agree with Gordon that we need a more integrative approach to depression — one that includesnutrition, exercise, meditation, and other methods of healing like experiential dynamic psychotherapy. But I also think that we must always keep in mind that depression can be a life-threatening illness, a serious biochemical condition that we can’t think or pray ourselves out of.

We must always remember the people who did not survive this disease because they didn’t think it was a disease.

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