This crayon drawing by a hospital in-patient with severe depression alludes to her temporary withdrawal from mainstream society. The months that she spent in hospital gave her the time and the solitude to think over her life, and the motivation to make difficult but necessary changes to it. She went on to make a full recovery.

Many a man curses the rain that falls upon his head, and knows not that it brings abundance to drive away the hunger. – St Basil the Great

Happiness is good for the body, but it is grief which develops the strengths of the mind. – Marcel Proust

Depression around the world

There are important geographical variations in the prevalence of depression, and these can in large part be accounted for by socio-cultural factors. In traditional societies, human distress is more likely to be seen as an indicator of the need to address important life problems, rather than as a mental disorder requiring professional treatment. For this reason, the diagnosis of depression is correspondingly less common. Some linguistic communities do not have a word or even a concept for ‘depression’, and many people from traditional societies with what may be construed as depression present with physical complaints such as headache or chest pain rather than with psychological complaints. Punjabi women who have recently immigrated to the UK and given birth find it baffling that a health visitor should pop round to ask them if they are depressed. Not only had they never considered the possibility that giving birth could be anything other than a joyous event, but they do not even have a word with which to translate the concept of ‘depression’ into Punjabi!

In modern societies such as the UK and the USA, people talk about depression more readily and more openly. As a result, they are more likely to interpret their distress in terms of depression, and less likely to fear being stigmatised if they seek out a diagnosis of the illness. At the same time, groups with vested interests such as pharmaceutical companies and mental health experts promote the notion of saccharine happiness as a natural, default state, and of human distress as a mental disorder. The concept of depression as a mental disorder may be useful for the more severe and intractable cases treated by hospital psychiatrists, but probably not for the majority of cases, which, for the most part, are mild and short-lived, and easily interpreted in terms of life circumstances, human nature, or the human condition.

Another (non-mutually exclusive) explanation for the important geographical variations in the prevalence of depression may lie in the nature of modern societies, which have become increasingly individualistic and divorced from traditional values. For many people living in our society, life can seem both suffocating and far removed, lonely even and especially amongst the multitudes, and not only meaningless but absurd. By encoding their distress in terms of mental disorder, our society may be subtly implying that the problem lies not with itself, but with them. However, thinking of the milder forms of depression in terms of an illness can be counterproductive, as it can prevent people from identifying and addressing the important life problems that are at the root of their distress.

Problems with diagnosis

All this is not to say that the concept of depression as a mental disorder is bogus, but only that the diagnosis of depression may have been over-extended to include far more than just depression the mental disorder. If, like the majority of medical conditions, depression could be defined and diagnosed according to its aetiology or pathology, such a state of affairs could not have arisen. Unfortunately, depression cannot as yet be defined according to its aetiology or pathology, but only according to its clinical manifestations and symptoms. For this reason, a doctor cannot base a diagnosis of depression on any objective criterion such as a blood test or a brain scan, but only on his subjective interpretation of the nature and severity of the patient’s symptoms. If some of these symptoms appear to tally with the diagnostic criteria for depression, then the doctor is able to justify making a diagnosis of depression.

One important problem here is that the definition of ‘depression’ is circular: the concept of depression is defined according to the symptoms of depression, which are in turn defined according to the concept of depression. Thus, it is impossible to be certain that the concept of depression maps onto any distinct disease entity, particularly since a diagnosis of depression can apply to anything from mild depression to depressive psychosis and depressive stupor, and overlap with several other categories of mental disorder including dysthymia, adjustment disorders, and anxiety disorders. Indeed, one of the consequences of the ‘menu of symptoms’ approach to diagnosing depression is that two people with absolutely no symptoms in common can both end up with the same diagnosis of depression. For this reason especially, the concept of depression has been charged with being little more than a socially constructed dustbin for all manner of human suffering.

An adaptive role?

Every person inherits a certain complement of genes that make her more or less vulnerable to developing depression during her lifetime. A person suffers from depression if the amount of stress that she comes under is greater than the amount of stress that she can tolerate, given her vulnerability to developing depression. Genes for potentially debilitating disorders such as depression usually pass out of a population over time because affected people have, on average, fewer children than non-affected people. The fact that this has not happened for depression suggests that the responsible genes are being maintained despite their potentially debilitating effects on a significant proportion of the population, and thus that they are lending an important adaptive or evolutionary advantage.

There are other instances of genes that both predispose to an illness and lend an important adaptive advantage. In sickle cell disease, for example, red blood cells assume a rigid sickle shape that restricts their passage through tiny blood vessels. This leads to a number of serious physical complications and, in traditional societies, to a radically shortened life expectancy. At the same time, carrying just one allele of the sickle cell gene (‘sickle cell trait’) makes it impossible for malarial parasites to reproduce inside red blood cells, and so confers immunity to malaria. The fact that the gene for sickle cell anaemia is particularly common in populations from malarial regions suggests that, in evolutionary terms, a debilitating illness in the few can be a price worth paying for an important adaptive advantage in the many.

What important adaptive advantage could depression have? Just as physical pain has evolved to signal injury and to prevent further injury, so depression may have evolved to remove us from distressing, damaging, or futile situations. The time and space and solitude that depression affords prevents us from making rash decisions, enables us to see the bigger picture, and – in the context of being a social animal – to reassess our social relationships, think about those who are significant to us, and relate to them more meaningfully and with greater understanding. Thus, depression may have evolved as a signal that something is seriously wrong and needs working through and changing or, at least, understanding. Sometimes people can become so immersed in the humdrum of their everyday lives that they no longer have the time to think and feel about themselves, and so lose sight of their bigger picture. The experience of depression can force them to stand back at a distance, re-evaluate and prioritise their needs, and formulate a modest but realistic plan for fulfilling them.

Sorrow’s children

Although the experience of depression can serve such a mundane purpose, it can also enable a person to develop a more refined perspective and deeper understanding of her life and of life in general. From an existential standpoint, the experience of depression obliges the person to become aware of her mortality and freedom, and challenges her to exercise the latter within the framework of the former. By meeting this difficult challenge, the person is able to break out of the mould that has been imposed upon her, discover who she truly is, and, in so doing, begin to give deep meaning to her life. Indeed, many of the most creative and most insightful people in society suffer or suffered from depression. They include the politicians Winston Churchill and Abraham Lincoln; the poets Charles Baudelaire, Hart Crane, Sylvia Plath, and Rainer Maria Rilke; the thinkers Michel Foucault, William James, John Stuart Mill, Isaac Newton, Friedrich Nietzsche, and Arthur Schopenhauer; and the writers Charles Dickens, William Faulkner, Graham Greene, Leo Tolstoy, Evelyn Waugh, Tennessee Williams, and many, many others.

The curse of the strong

People with depression are often stigmatised as ‘failures’ or ‘losers’. Of course, nothing could be further from the truth. If anything, the sorts of people who are most vulnerable to developing depression are all the opposite of failures or losers. If they are suffering from depression, it is most probably because they have tried too hard or taken on too much, so hard and so much that they have made themselves ill with depression. In other words, if they are suffering from depression, it is because their world was simply not good enough for them. They wanted more, they wanted better, and they wanted different, not just for themselves, but for all those around them. So if they are failures or losers, this is only because they set the bar far too high. They could have swept everything under the carpet and pretended, as many people do, that all is for the best in the best of possible worlds. However, unlike many people, they had the honesty and the strength to admit that something was amiss, that something was not quite right. So rather than being failures or losers, they are just the opposite: they are ambitious, truthful, and courageous. And that is precisely why they got ill. Getting ill is never a good thing, but in the case of depression it can present a precious opportunity to identify and to address some very challenging life problems, and to develop a deeper and more refined understanding and appreciation of one’s life and of life in general.

A note of caution

Depression should not be romanticised, sought out, or left unattended simply because it may or may not predispose to problem-solving, personal development, or creativity. The most severe forms of depression have a strong biological basis and are not related to a person’s life circumstances or aspirations. All forms of depression are drab and intensely painful, and most people who suffer from depression would never wish it on anyone, least of all themselves. In some cases, depression can lead to serious injury or even to death through accident, self-neglect, or self-harm. Even highly successful people who suffered from depression such as Hart Crane and Sylvia Plath ended up committing suicide in the end, and most people who attempt suicide do so because they are suffering with some form of depression.

Ingredients (serves 6)
1. 3 eggs
2. 3 tablespoons caster sugar
3. 3 tablespoons marsala wine or madeira or sherry
4. 250g mascarpone
5. savoiardi (lady fingers) biscuits
6. amaretti biscuits
7. expresso coffee
8. cocoa

1. Separate the egg yolks from the whites
2. Beat the yolks together with the sugar and gradually fold in the mascarpone and marsala wine
3. Beat the whites into stiff peaks and fold into the above mixture
4. Layer a dish with a small fraction of this combined mixture
5. Make expresso coffee, ideally in a cafetière
6. Dip the savoiardi and amaretti biscuits into the coffee and lay them out in the dish (see picture below)
7. Add a second layer of the combined mixture
8. Add a second layer of coffee-soaked biscuits
9. Add a third layer of the combined mixture
10. Dust with cocoa
11. Put in the fridge for at least 2 hours

Thanks to James Flewellen, author of the Oxford Wine Blog, for teaching me this wonderful recipe.

The second layer of the mascarpone mixture is about to go on

People with a high level of anxiety have historically been referred to as ‘neurotic’. The term ‘neurosis’ derives from the Ancient Greek neuron (nerve) and loosely means ‘disease of the nerves’. The core feature of neurosis is anxiety, but neurosis can manifest as a range of other problems such as irritability, depression, perfectionism, obsessive-compulsive tendencies, and even personality disorders such as anankastic personality disorder. Although neurosis in some form or other is very common, it can prevent us from enjoying the moment, adapting usefully to our environment, and developing a richer, more complex, and more fulfilling outlook on life. The psychiatrist Carl Jung (1875-1961) believed that neurotic people fundamentally had issues with the meaning and purpose of their life. In his autobiography of 1961, Memories, Dreams, Reflections, he noted that ‘The majority of my patients consisted not of believers but of those who had lost their faith’. Interestingly, Jung also believed that neurosis could be beneficial to some people despite its debilitating effects.

The most original, influential, and contentious theory of neurosis is that of Sigmund Freud (1856-1939). Freud attended medical school at the University of Vienna from 1873 to 1881, carrying out research in physiology under the German scientist Ernst von Brűcke and later specialising in neurology. In 1885-86 he spent the best part of a year in Paris, and returned to Vienna inspired by the French neurologist Jean-Martin Charcot’s use of hypnosis in the treatment of ‘hysteria’, an old-fashioned term referring to the conversion of anxiety into physical and psychological symptoms. Freud opened a private practice for the treatment of neuropsychiatric disorders but eventually gave up the practice of hypnosis, instead preferring the method of ‘free association’ which involved asking patients to relax on a couch and say whatever came into their minds. In 1895, inspired by the case of a patient called Anna O, he published the seminal Studies on Hysteria with his friend and colleague Josef Breuer. After publishing The Interpretation of Dreams in 1899 and The Psychopathology of Everyday Life in 1901, both public successes, Freud obtained a professorship at the University of Vienna where he began to gather a devoted following. He remained a prolific writer throughout his life, publishing (amongst others) Three Essays on the Theory of Sexuality in 1905, Totem and Taboo in 1913, and Beyond the Pleasure Principle in 1920. After the Nazi annexation of Austria in 1938, he fled to London, where he died the following year of cancer of the jaw. His daughter, Anna Freud, became a distinguished psychoanalyst who developed the concept of ego defense mechanisms (see other posts on this blog).

In Studies on Hysteria, Freud and Breuer formulated the psychoanalytic theory according to which neuroses have their origins in deeply traumatic and consequently repressed experiences. Treatment requires the patient to recall these repressed experiences into consciousness and to confront them once and for all, leading to a sudden and dramatic outpouring of emotion (catharsis) and the gaining of insight. This can be achieved through the methods of free association and dream interpretation, and a relative lack of direct involvement by the psychoanalyst so as to encourage the patient to project his thoughts and feelings onto him – a process called ‘transference’ (by contrast, in ‘countertransference’ it is the psychoanalyst who projects his thoughts and feelings onto the patient). In the course of analysis, the patient is likely to display ‘resistance’ in the form of changing the topic, blanking out, falling asleep, coming late, or missing an appointment; such behaviour merely suggests that he is close to recalling repressed material but afraid of doing so. Other than dream interpretation and free association, other recognized routes into the unconscious are parapraxes (slips of the tongue) and jokes. For this reason, Freud famously noted that ‘there is no such thing as a joke.’

In The Interpretation of Dreams (1899), Freud developed his ‘topographical model’ of the mind, describing the conscious, unconscious, and a layer between the two called the preconscious which, though not conscious, could be readily accessed. Freud later became dissatisfied with the topographical model and replaced it with a so-called ‘structural model’ according to which the mind is divided into the id, ego, and superego (see figure). The id is fully unconscious and contains our drives and repressed feelings and emotions. It is dominated by the ‘pleasure principle’, and so seeks out immediate gratification. The id is opposed by the partly conscious superego, a sort of moral judge arising from the internalisation of parental figures and, by extension, of society itself. In the middle sits the mostly conscious ego. Dominated by the ‘reality principle’, the function of the ego is to reconciliate the id and the superego and thereby enable us to engage with reality. Neurotic anxiety arises when the ego is overwhelmed by the demands made upon it by the id, the superego, and reality. To cope with these demands, the ego employs defense mechanisms to block or distort impulses from the id, thereby making them more acceptable and less threatening. A broad range of ego defence mechanisms have since been recognised.

Freud's structural and topographical models of the mind

For Freud, the drives or instincts that motivate human behaviour (‘life instinct’) are primarily driven by the sex drive or ‘libido’ (Latin, I desire). This life-instinct is counterbalanced by the ‘death instinct’, the unconscious desire to be dead and at peace (the ‘Nirvana principle’). Even in children the libido is the primary motivating force, and children must progress through various stages of psychosexual development before they can reach psychosexual maturity. Each one of these stages of psychosexual development (except the latent stage) is focussed on the erogenous zone – the mouth, the anus, the phallus, or the genitals – that provides the greatest pleasure at that stage. For Freud, neuroses ultimately arise from frustrations encountered during a stage of psychosexual development, and are therefore sexual in nature. Freud’s stages of psychosexual development are summarised in the table below.

The Oedipus/Electra complex is arguably the most controversial of Freud’s theories, and can be interpreted either literally (as Freud intended it to be) or metaphorically. According to Freud, the phallic stage gives rise to the Oedipus complex, Oedipus being a mythological King of Thebes who inadvertently killed his father and married his mother. In the Oedipus complex, a boy sees his mother as a love-object, and feels the need to compete with his father for her attention. His father becomes a threat to him and so he begins to fear for his penis (‘castration anxiety’). As his father is stronger than he is, he has no choice but to displace his feelings for his mother onto other girls and to begin identifying with his father/aggressor – thereby becoming a man like him. Girls do not go through the Oedipus complex but through the Electra complex, Electra being a mythological Princess of Mycenae who wanted her brother Orestes to avenge their father’s death by killing their mother. In the Electra complex, a girl this time sees her father as a love-object, because she feels the need to have a baby as a substitute for the penis that she is lacking. As she discovers that her father is not available to her as a love-object, she displaces her feelings for him onto other boys and begins to identify with her mother – thereby becoming a woman like her. In either case, the main task in the phallic stage is the establishment of sexual identity.

Although much derided in his time and still today, Freud is unquestionably one of the deepest and most original thinkers of the 20th century. He is credited with discovering the unconscious and inventing psychoanalysis, and had a colossal influence not only on his field of psychiatry but also on art, literature, and the humanities. He may have been thinking of himself when he noted that, ‘The voice of intelligence is soft, but does not die until it has made itself heard.’ (‘Die Stimme des Intellekts ist leise, aber sie ruht nicht, ehe sie sich Gehör verschafft hat.’)

Jung in a Nutshell