Treating Depression

Somehow or other I missed Johann Hari’s book, Lost Connections when it was published last year. Given that it’s never too late to examine a thoughtful approach to treating depression, I will devote this post to summarizing his observations and conclusions.

You see, Hari takes issue with the medicalization of depression, with the thesis that it’s all in the biochemistry. To some extent we are married to the the biomedical approach because psycho analysis had failed conspicuously to treat depression. Some might say that Freudian treatment was really in the business of producing it.

Be that as it may, the arrival of a new class of anti-depressants, Prozac and Co., elicited a flurry of articles and books claiming that we could now cure whatever was ailing everyone, mentally. Prozac did produce some benefits for some patients, but it was grossly oversold. One reason might have been that it was good for the psychiatry business. It made psychiatrists feel that patients who were consulting with them had come to the right place and that they could offer something of value. Plus, it took far less time to write a prescription than to engage with a patient.

It seems not to be a coincidence but Hari’s emphasis on lost social connections might have something to do with the fact that a psychiatrist prescribing Prozac does not really connect with his patient. Of course, to be fair most psycho analysts refused completely to connect with their patients.

I will note in passing that I have not read Hari’s book, so I do not know whether or not he makes mention of the work that cognitive therapists like Aaron Beck and Martin Seligman have done to treat depression. It ought not to be confused with psycho analysis or touchy feely treatments.

As for a recent evaluation of the different treatments, Hari offers this, which seems accurate and worthwhile:

The World Health Organization, the leading medical body in the world, explained in 2011: “Mental health is produced socially: The presence or absence of mental health is above all a social indicator and therefore requires social, as well as individual, solutions.” The United Nations’ special rapporteur on the right to health, Dr. Dainius Pūras — one of the leading experts in the world on mental health — explained last April that “the dominant biomedical narrative of depression” is based on “biased and selective use of research outcomes.”

“Regrettably, recent decades have been marked with excessive medicalization of mental health and the overuse of biomedical interventions, including in the treatment of depression and suicide prevention,” he said. While there is a role for medications, he added, we need to stop using them “to address issues which are closely related to social problems.”

The causes are: biological (like your genes), psychological (how you think about yourself), and social (the wider ways in which we live together). Very few people dispute this. But when it comes to communicating with the public, and offering help, psychological solutions have been increasingly neglected, and environmental solutions have been almost totally ignored.

Next, Hari discusses the effectiveness of SSRIs. As you know, the topic has provoked some very serious controversy, made more acute by the amount of money involved.

Instead, we focus on the biology. We offer, and are offered, drugs as the first, and often last, recourse. This approach is only having modest results. When I took chemical antidepressants, after a brief burst of relief, I remained depressed, and I thought there was something wrong with me.I learned in my research that many researchers have examined the data on antidepressants and come to very different conclusions about their effectiveness. But it’s hard not to conclude, looking at the evidence as a whole, that they are at best a partial solution.

What are the research findings?

The studies that most strongly support chemical antidepressants found that some 37 percent of people taking them experience a significant shift in their Hamilton scores amounting to a full remission in their symptoms. When therapy and other interventions were added in addition to or in place of these drugs — in treatment-resistant cases — remission rates went higher.

Yet other scholars, looking at the exact same data set, noticed that over the long term, fewer than 10 percent of the patients in the study — who were, incidentally, receiving more support than the average depressed American would receive from their doctor — experienced complete remission that lasted as long as a year. When I read this, I noticed to my surprise that it fit very closely with my own experience: I had a big initial boost, but eventually the depression came back. I thought I was weird for sinking back into depression despite taking these drugs, but it turns out I was quite normal.

He concludes:

The drugs give some relief, and therefore have real value, but for a big majority, they aren’t enough.

Although antidepressant prescriptions have increased 500 percent since the 1980s, there has been no discernible decrease in society-wide depression rates. There’s clearly something very significant missing from the picture we have been offered.

From there he moves on to social and psychological factors. In that context depression is trying to tell the person something. It is a signal that something is wrong and an impetus to do something about solving the problem. Thus, their focus points toward social solutions:

But the scientists who study the social and psychological causes of these problems tend to see them differently. Far from being a malfunction, they see depression as partly or even largely a function, a necessary signal that our needs are not being met.

And social needs seem to relate to psychological needs:

There is equally clear evidence that human beings have innate psychological needs: to belong, to have meaning and purpose in our lives, to feel we are valued, to feel we have a secure future. Our culture is getting less good at meeting those underlying needs for a large number of people — and this is one of the key drivers of the current epidemic of despair.

The examples he offers have mostly to do with your social being, your place in society, your ability to fulfill your responsibilities (especially financial) to others, your ability to function as an economic being.

Loneliness, being forced to work in a job you find meaningless, facing a future of financial insecurity — these are all circumstances where an underlying psychological need is not being met.

Psychiatrists diagnose depression by checking off a list of complaints. But then, they also notice that people who are grieving seem to fulfill all of the characteristics of depression. But, if a real life situation caused one form of depression, why should it not have caused some of the others?

Why, some doctors began to ask, should grief be the only situation in which deep despair is not a sign of a mental disorder that should be treated with drugs? What if you have lost your job? Your house? Your community? Once you entertain the idea that depression might be a reasonable response to some life circumstances — as Joanne Cacciatore, an associate professor in the school of social work at Arizona State University, told me — our theories about depression require “an entire system overhaul.”

When a friend or relative dies you experience a loss of connection. Thus, you need to restructure your activities, your expectations and your plans. But, grief is not the only disconnection, that is, the only disruption in your daily or yearly routines:

Seven are forms of disconnection: from other people, from meaningful work, from meaningful values, from the natural world, from a safe and secure childhood, from status, and from a future that makes sense to you. Two are biological: your genes, and real brain changes.

What constitutes social connection? Hari offers a case study involving a woman who was prescribed group therapy. That meant, work with others in a garden. You will notice that this form of group activity did not involve feeling her feelings or expressing her emotions or sharing her deepest secrets. It involved working in a garden:

A patient named Lisa Cunningham came to Everington’s surgery clinic one day. She’d been basically shut away in her home, crippled with depression and anxiety, for seven years. She was told by staffers at the clinic that they would continue prescribing drugs to her if she wanted, but they were also going to prescribe a group therapy session of sorts. There was a patch of land behind the clinic, backing onto a public park, that was just scrubland. Lisa joined a group of around 20 other depressed people, two times a week for a full afternoon, to turn it into something beautiful….

Still, for the first time in a long time, she had something to talk about that wasn’t how depressed and anxious she was.

It took time and effort, it took work, but eventually both the garden and Lisa began to bloom:

As Lisa put it to me: As the garden began to bloom, the people in it began to bloom too. Everington’s project has been widely influential in England but not rigorously analyzed by statisticians, who tend to focus on drug-centered treatment. But a study in Norway of a similar program found it was more than twice as effective as chemical antidepressants — part of a modest but growing body of research suggesting approaches like this can yield striking results.

Hari concludes:

This fits with a much wider body of evidence about depression: We know that social contact reduces depression, we know that distraction from rumination (to which depressives are highly prone) has a similar effect, and there is some evidence that exposure to the natural world, and anything that increases exposure to sunlight, also has antidepressant effects.

Everington calls this approach “social prescribing,” and he believes it works because it deals with some (but not all) of the deeper social and environmental causes of depression.

Social contact, engaging in purposeful activity. It does not necessarily need to be cultivating a garden. Recall that Harvard psychiatrist Dr. Richard Mollica once exclaimed that: “The best antidepressant is a job.” After all, working in a garden teaches useful social skills. But, unless it's your business, it's not a job.