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When Depression is Treated as a Disease

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Memoirs of depression like Daphne Merkin's in The Sunday Times (May 10, 2009), and for that matter like William Styron's Darkness Visible, make me sad. Of course I feel sadness for the writers' dense and burdened suffering, set off so strikingly against their lucid, often spritely prose. But more importantly and far more troubling, I feel sad for the inadequacy of the therapeutic approaches they use, for the lack of understanding their suffering yields them and, especially, for the fact that inadequate approaches and limited understanding are offered to readers as "state of the art."

Daphne Merkin and her doctors seem to have concluded that depression is a disease characterized by inadequacies in brain chemistry that are best treated by drugs that raise the levels of neurotransmitters like serotonin and/or norepinephrine. In fact, the evidence that depression is a disease is mixed at best and the weight of the research evidence -- negative studies on antidepressant drugs have notoriously been unpublished -- suggests that antidepressants are little better, if at all, than simple placebos.

What is absent from Merkin's account and, most sadly, from her experience, is an effort to address the fundamental biological, psychological and social processes that may precipitate depression and contribute to its persistence: the severely impaired response to stress that may indeed be the consequence of the kind of prolonged early life deprivation and trauma Merkin describes; nutritional deficiencies (apparently untested in Merkin's case) that can cause or contribute even to the most severe depression; the need for the healing power of sustained and sustaining support and intimacy that may have been absent in early life.

Nor do her therapists suggest other powerful, non-pharmacological modalities that are proving effective in significantly improving mood. For example, exercise, which is at least as effective as antidepressant drugs (it appears among other benefits to stimulate neuron growth in areas of the brain where cells have been destroyed by chronic stress and depression) and meditation which enlarges our perspective on the role of suffering in our lives and shifts brain activity from cortical areas connected with pessimism and depression to those associated with happiness and optimism.

Finally, the saddest thing about Merkin's account is the passive role she assumed, one which it appears was acquiesced, if not encouraged, by her therapists. "Do what we say; take the pills we tell you to," they seemed to have said, "and all will be well." In fact, therapeutic interventions in which we actively participate are doubly powerful. They have the kinds of inherent benefits I suggested above. Equally important, acting on our own behalf, working in concert with physicians and therapists who value our efforts, we overcome the helplessness and hopelessness that are the hallmarks of depression. Moving forward, as Merkin finally and unexpectedly does, we discover the possibility of change, to see, perhaps for the first time, light in the darkness which had seemed to surround us.

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