Depression(s)

Mine. Yours. Ours.

Photo by author

---

For every complex problem there is an answer that is clear, simple, and wrong. — H. L. Mencken

The “medical model” is a paradigm for delivering health care to patients. It is built on the following process:

1. observation (assessment/exam)

2. + findings (symptoms)

3. diagnosis (syndromes)

4. intervention (treatment)

It’s a pretty good system for providing care, except for a few serious flaws:

• Standard exams usually miss important data

• Syndromes are often not “real” things (reification)

• A diagnostic label compresses many different things into one thing (reductionism)

• People with the same diagnosis will respond differently, or not at all, to the same treatment (variability)

“Cancer”

Over the long and terrifying history of cancer (dysregulated cellular growth) and its treatment, physicians applied whatever treatment was in vogue at the time (see Siddhartha Mukherjee’s brilliant book “The emperor of all maladies”). When scientists started to evaluate treatment safety and efficacy (clinical trials), the results were … unimpressive. When an effective evidence-based treatment is finally discovered, it takes an average of 14+ years to be widely adopted by medical practitioners, by which time the initial positive results have often faded somewhat. Two steps forward etc.

The current state of cancer research and its clinical application suggests that

• Most of the screening (“early detection”) processes for cancer are riddled with false positives (saying cancer exists when it does not) and false negatives (saying cancer doesn’t exist when it does), both of which cause harm

• The organ in which cancer is discovered is not the optimal focus for differential diagnosis/treatment

• The nature of a specific cancer is defined by its genetic and cellular features which will determine its clinical course and response to treatment

The emerging paradigm for cancer treatment is a personalized approach that treats not “cancer” or breast/lung etc. cancer, but YOUR cancer by identifying specific biological targets for intervention.

“Depression”

Depression is a classic case of reification and reductionism. A cluster of mental and physical symptoms are organized as a syndrome, given a name, and viewed as a unitary disease for which treatments are prescribed (the DSM5 and ICD10 are the reference manuals for these diagnostic entities). If you tell a mental health professional that you have low energy (anergia) and life satisfaction (anhedonia), negative thoughts about yourself and the future, and feelings of helplessness/hopelessness, it is a near certainty that you will be diagnosed with “Depression” and prescribed anti-depressant medication and/or cognitive-behavior therapy (CBT). Those interventions will help some people some of the time, but not everyone.

The treatment paradigm above is an example of applying a relatively simple solution to a complex problem (which is the root cause of many human failures). Simple solutions can handle simple and sometimes complicated problems, but not complex ones. A car engine is complicated. It has X parts working together. If your car won’t start, there are a finite number of reasons for that problem. Fixing the car involves making a checklist-informed assessment of the relevant component parts (battery, ignition, fuel etc.) until a cause/fault is found and addressed. This process works very well in every kind of car.

Human behavior is like the weather: everybody talks (and complains!) about it, but it’s hard to predict or control. Unlike a complicated car engine, the human body is made up of multiple systems (sensory, motor, metabolic, immunological, cardiopulmonary etc.) that are self-regulating and interact simultaneously with each other through a set of multidirectional feedback mechanisms.

What we call depression turns out to be a complex problem.

Renewable Energy

When a person tells me they have a problem and asks for my professional advice, I like to use a paradigm called the bio-psycho-socio-environmental model. This means that people and their lives can be impacted by four powerful systems and their interactions:

• Their organic body/brain (hardware)

• Their mind (software)

• Other people

• The non-human environment (organic and inorganic)

A good process for understanding and intervening with a complex phenomenon like depression (as well as problems with school/work performance, relationships, sex, etc.) involves exploring each of these sectors for possible contributors. If ten people are depressed, they may have similar symptoms with very different causes (etiology). Prescribing the just right intervention for each person will require first understanding the cause(s) of THEIR depression, just like with the personalized approach to cancer treatment mentioned above.

Depression can be thought of as a downstream end-state (LOW ENERGY) resulting from action in one or more of the four sectors of the biopsychosocioenvironmental paradigm. To illustrate the complexity of a systems paradigm for depression, here are 25 (!) pathways to a chronic low-energy state. Each will require an aligned intervention to effect a ‘cure’ or improvement or, at a minimum, better management/coping.

⬇️⬇️⬇️⬇️

---

BIOLOGICAL causes of “depression”

• Genes: + family history for major (endogenous) depression

• Illness: hypothyroidism, anemia, autoimmune disorders (MS, rheumatoid arthritis, lupus, Guillain-Barr syndrome), chronic fatigue/post-encephalitic syndrome (e.g. lyme disease), sleep disorders (e.g. apnea, narcolepsy), fibromyalgia, chronic pain, cognitive decline/dementia

• Rx medication (side)effects: beta blockers, ACE inhibitors, corticosteroids

• Substance abuse (barbiturates, opioids, THC, alcohol)

• Lack of cardio-pulmonary fitness

• Biological lifecycles: puberty, menopause/andropause, later adulthood/frailty

PSYCHOLOGICAL causes of “depression”

• Pessimism/fatalism (mindset/belief that our actions have little effect on events or our future)

• Perfectionism (pursuit of an unattainable ego-ideal)

• Chronic uncontrolled stress/anxiety

• Failure to achieve a vitally important goal or moral standard

• Loss of a role that was a source of status and esteem (to self and others)

• A diagnosis of a life-threatening illness

SOCIAL causes of “depression”

• Helplessness/powerlessness re other people

• Rejection/neglect/abandonment by an important attachment figure

• Violence/trauma

• Enforced low status/opportunity (caste)

• Ostracizing/expulsion from a reference group (tribe)

• Loneliness

• Grief (loss of a beloved figure)

ENVIRONMENTAL causes of “depression”

• Work strain/burnout

• Unemployment

• Poverty, malnutrition, homelessness

• Low sunlight (vitamin D)

• Lack of an open horizon/vistas

• Lack of exposure to non-human ecosystems (“nature”)

---

Thought Experiment: Select ONE of the 25 pathways to a chronic low energy state that you believe will NOT respond well to either medications or CBT. Then imagine an intervention program that you think would help for that specific cause of suffering.

---

---

Conclusion

The purpose of this essay is to broaden our paradigm for understanding the common cold of psychology/psychiatry. Rather than viewing depression as a unitary disease/illness with a couple of causes (brain chemistry, negative thinking) and related treatments (medication, CBT), better to think of it as a downstream end-state (chronic low energy) with multiple possible vectors and etiologies (biological, psychological, social, environmental).

Some depressions will respond well to standard psychological and biological treatments. Many others will benefit more from extra-clinical interventions (protection/safety, financial resources, social supports, employment assistance etc.) that used to be the purview of the Social Work profession before it converted largely to a psychotherapeutic practice in the late 20th century.

A society can and should be judged by the degree to which it cares for its citizens and all the factors that can rob them of the vital energy needed to live a good and full life (pursuit of happiness). Depression statistics are like a thermometer of societal health, and current trends in the US and elsewhere are not heading in a good direction.

When it comes to health care, earlier intervention is best. Prevention is even better.

---

Here are some pathways to MORE energy ⬇️

Energize. Regenerate. Rejuvenate.