People suffering from depression are often stigmatised as ‘social and moral failures’. However, many people who suffer from depression do so not because they have failed, but because they have high standards and expectations for themselves and for life in general, and have come to be disillusioned by the comparative baseness or hopelessness of their life circumstances, human nature, or the human condition.
In such cases, the onset of depression is not so much a sign of failure as it is a sign of ambition, and even of nobility.
Furthermore, the experience of depression may enable a person to recognise and to address difficult life problems, and, in so doing, to develop a more refined perspective and deeper understanding of her life and of life in general (much more on this in a future post). 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, and Tennessee Williams – to name but a few.
Doctors often tell people starting on an SSRI such as fluoxetine or paroxetine that they have a 55-70% chance of responding to their medication. However, a recent paper by Turner et al in the New England Journal of Medicine (358(3), 252-260) suggested that the effectiveness of SSRIs is greatly exaggerated as a result of a bias in the publication of research studies. Of 74 studies registered with the United States Food and Drug Administration (FDA), 37 of 38 studies with positive results were published in academic journals. In contrast, only 14 of 36 studies with negative results were published in academic journals, and 11 of these were published in such a way as to convey a positive outcome. Thus, whilst 94% of published studies conveyed a positive outcome, only 51% of all studies (published and unpublished) actually demonstrated one.
Another paper by Kirsch et al in Public Library of Science Medicine combined 35 studies submitted to the FDA before the licensing of four antidepressants, including the SSRIs fluoxetine and paroxetine. The authors of the study found that, whilst the antidepressants performed better than a placebo, the effect size was very small for all but very severe cases of depression. Furthermore, the authors attributed this increased effect size in very severe cases of depression not to an increase in the effect of the antidepressants, but to a decrease in their placebo effect.
If, as these studies suggest, the efficacy of SSRIs has been greatly exaggerated, their cost-benefit urgently needs to be re-evaluated. In any case, there can be little doubt that at least some of the benefit of an antidepressant is attributable to its placebo effect.
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.
A person’s beliefs, attitudes, and values (henceforth, ‘beliefs’) are stored in his brain in the form of nerve cell pathways. Over time and with frequent use, these neural pathways become increasingly worn in, such that it becomes difficult to alter them and so the beliefs that they correspond to. If these beliefs are successfully challenged, the person begins to suffer from ‘cognitive dissonance’, which is the psychological discomfort that results from holding two or more inconsistent or contradictory beliefs (‘cognitions’) at the same time. To reduce this cognitive dissonance the person may either (1) adapt his old beliefs, which is difficult or (2) maintain the status quo by justifying or ‘rationalising’ his new beliefs, which is not so difficult and therefore more common. The ego defence of rationalisation involves the use of feeble but seemingly plausible arguments either to justify one’s beliefs (‘sour grapes’) or to make them seem ‘not so bad after all’ (‘sweet lemons’). ‘Sour grapes’ is named after one of the fables attributed to Aesop, The Fox and the Grapes.
One hot summer’s day a Fox was strolling through an orchard till he came to a bunch of Grapes just ripening on a vine which had been trained over a lofty branch. ‘Just the thing to quench my thirst’, quoth he. Drawing back a few paces, he took a run and a jump, and just missed the bunch. Turning round again with a One, Two, Three, he jumped up, but with no greater success. Again and again he tried after the tempting morsel, but at last had to give it up, and walked away with his nose in the air, saying: ‘I am sure they are sour.’
In the case of Aesop’s fox, the cognitive dissonance arises from the cognitions ‘I am an agile and nimble fox’ and ‘I can’t reach the grapes on the branch’, and the rationalisation, which is a form of ‘sour grapes’, is ‘I am sure the grapes are sour’. Had the fox chosen to use ‘sweet lemons’ instead of ‘sour grapes’, he might have said something like, ‘In any case, there are far juicier grapes in the farmer’s orchard.’ Another example of rationalisation is the student who fails his exams and who blames the examiners for being biased. In this case, the cognitive dissonance arises from the cognitions ‘I am an intelligent, capable person’ and ‘I failed my exams’, and the rationalisation, which is once again a form of ‘sour grapes’, is ‘I am sure the examiners are biased’. Had the student chosen to use ‘sweet lemons’ instead of ‘sour grapes’, he might have said something like, ‘In any case, failing my exams has given me more time to study / gain experience / examine my career options / enjoy student life.
One of the most famous examples of rationalisation comes from Leon Festinger’s book of 1956, When Prophecy Fails, in which Festinger discusses his experience of infiltrating a UFO doomsday cult whose leader had recently prophesised the end of the world. When the end of the world failed to materialise, most of the cult’s members dealt with the cognitive dissonance that arose from the cognitions ‘the leader prophesised that the world is going to end’ and ‘the world did not end’ not by abandoning the cult or its leader, but by introducing the rationalisation that the world had been saved by the strength of their faith.
Human beings are not rational, but rationalising animals. If they find it frightening to think and painful to change, this is in large part because thinking and changing represent major threats to the beliefs that make up their sense of self. Given this state of affairs, any tectonic shift in a person’s outlook is only ever going to occur incrementally and over a long period of time. Moreover, such a tectonic shift is likely to be provoked by an important deterioration in the person’s circumstances which overwhelms his ego defences and leaves him with no alternative but to adopt the depressive position. In Remembrance of Things Past, the early 20th century novelist Marcel Proust tells us, ‘Happiness is good for the body, but it is grief which develops the strengths of the mind.’