The True Cause Of Depression
About two years ago a patient of mine, Mr. Burndt (not his real name), committed suicide. When his wife, who was also my patient, told me the news at one of her visits, I was shocked. Fully aware that 40% of older patients who are suicidal visit their primary care doctors within one week of killing themselves, I found myself wondering over and over how I’d missed recognizing the severity of his distress. I’d known he’d been suffering from depression but had thought it mild.
But even more shocking than the news of his suicide was the reason his wife gave for it: six months earlier, he’d been involved in a car accident and had inadvertently killed a pedestrian. In the end, he simply couldn’t live with the guilt.
WHAT IS DEPRESSION?
The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) classifies depression into the following types (there are even more, but these cover the basics):
- Dysthymia. In essence, having a depressed mood on most days for at least two years.
- Major Depressive Disorder. In addition to feeling “down” as in dysthymia, other characteristics may include excessive feelings of guilt and suicidal ideation, as well as various physical symptoms like loss of hunger and fatigue. It can be mild, moderate, or severe.
- Adjustment Disorder with Depressed Mood. This is grief due to a loss of some kind (which itself can be classified as normal or complicated).
- Depression NOS (not otherwise specified). Includes things like premenstrual depression and seasonal depression (SAD).
- Secondary depression. Depression due to an underlying medical disorder like Cushing’s disease or hypothyroidism.
Though not in DSM-IV, some practitioners further classify depression into two broad types:
- Endogenous (or chemical) depression to denote depression that arises without an obvious identifiable cause, thought to reflect some kind of “chemical imbalance” in the brain.
- Exogenous (or external) depression which is thought to arise from a specific, identifiable external cause.
Given this confusing and non-parallel classification scheme it’s astonishing doctors don’t become depressed themselves as they try to figure out into which bucket their patient’s depression fits!
How can we make sense of all this and, more importantly, understand the real cause of depression in order to augment the effectiveness of currently available therapies?
MIND VS. BRAIN
First, we need to recognize the distinction between chemical and external depression has become outdated. Many neuroscientists have suggested that the mind arises from, and is actually caused by, the physical brain, meaning chemical and electrical reactions somehow give rise to thoughts and emotions. Evidence in support of this theory can be found in numerous studies that show altering brain chemistry with anti-depressant drugs (chemicals) can make depressed people feel better emotionally. The same is true for anxiolytics (like Valium) and their effect on anxiety.
But recently, with the advent of functional MRI scans (fMRI), we now have proof the opposite is equally true, that changes in thinking cause significant, measurable changes in brain chemistry and functioning. In one study, patients suffering from spider phobia underwent fMRI scanning before and after receiving cognitive behavioral therapy aimed at eliminating their fear of spiders. Scans were then compared to normal subjects without spider phobia. Results showed that brain function in patients with spider phobia before receiving cognitive behavioral therapy were abnormal compared to subjects without spider phobia but then changed to match normal brain patterns after cognitive behavioral therapy. This may represent the best evidence to date that changes made at the mind level are able to functionally “rewire” the brain, and that the brain and the mind are more mutually influential than we’d previously thought. It certainly supports the Buddhist view that brain and mind are in fact only two sides of the same coin, or different ways of viewing the same single thing.
DEPRESSION ALWAYS HAS A CAUSE
Where, then, does the true cause of depression lie? I would argue that depression arises at its core from a belief that we’re powerless to solve our problems.
This is clearly true with people who know why they’re depressed: invariably, once they figure out how to solve their particular problem, their depression lifts. But I would also argue this holds true for people who are depressed for no reason they know. Why? Because thoughts can trigger feelings that remain stirred up long after the thoughts themselves have been forgotten. Some studies have suggested people think upwards of 12,000 thoughts per day. How could we ever remember them all? Yet a fleeting thought we might have had this morning about the possibility of losing our job can and often does leave an emotional residue that lasts hours, days, weeks, or even longer. I would argue, therefore, any depression that appears to be “chemical” is more likely caused by a thought that simply isn’t remembered—a thought about a problem we don’t believe we can solve.
Further, sometimes what appears to be a “chemical” depression is caused by a thought that isn’t directly or consciously recognized. These thoughts are often about problems that seem so unbearably awful and unsolvable we literally don’t want (and often refuse) to think about them (such as our becoming jobless or the prospect of our own death).
Finally, I believe the commonly accepted idea that some forms of depression like depression NOS and secondary depression (#4 and #5 above) are caused by chemical or hormonal abnormalities overstates the case. I’d suggest an alternative explanation, that these forms of depression have a chemical or hormonal influence—reducing our ability to believe we can solve our problems but not entirely eliminating it. At first glance this might not appear to be a significant distinction given how incredibly difficult it is to believe in our ability to solve problems, for example, when experiencing premenstrual syndrome. But knowing intellectually we can win even if we’re having a hard time believing it can help to sustain the most valuable thing depression tends to reduce: hope.
HOW CAN WE HELP OURSELVES?
None of this is by any means to say we can simply decide to believe we can solve a particular problem when no solution is obvious or forthcoming. Changing any belief, whether consciously recognized or not, is literally one of the hardest things to do. But armed with a clearer understanding of the true cause of depression we can consider the following steps to help ourselves:
- Find a way to raise your life-condition. Your inner life state has more to do with your ability to believe you can solve your problems than anything that may be actually going on in your life. If your thoughts are swirling in despair, take action to break free of them and attain a fresh perspective. Become immersed in a great book that moves you or watch a movie that transports you. Exercise. Go where it’s warm. Chant Nam-myoho-renge-kyo. In short, do what you know from experience bounces your thinking to a more optimistic place.
- Identify the problem or problems you don’t think you can solve. It’s amazing how often you don’t know why you’re depressed and how helpful it can be to figure it out. Making a list of everything that’s bothering you—a sort of stream-of-consciousness rant on paper—can be a fantastically helpful exercise. Or if you do know why you’re depressed, recognizing the cause isn’t that you have a problem per se but rather that you have a problem you don’t believe you can solve can be remarkably empowering. Also, sometimes we become depressed not because we have one problem we believe we can’t solve but because we have multiple problems we believe we can’t solve. Handling challenges can be likened to balancing a “plate” of a certain size: if we pile too many problems onto it, not only do we risk having it topple over, we often find ourselves wanting to pitch the whole thing on purpose. When this is the case, allow yourself to only worry about and focus on solving one problem at a time.
- Identify the reason a problem seems unsolvable. As I pointed out in a previous post, Changing Poison Into Medicine, many things erroneously cause us to conclude we’re deadlocked, chief among them our inability to identify a solution to our problem right now.
- Recognize that your thoughts are profoundly influenced by your mood. Once depression has established itself, it takes on an insidious life of it’s own, further diminishing your belief in your ability to solve problems, your ability to plan, and your ability to have hope for the future. In this way the cause of any depression always reinforces itself.
- Remember that your depressed self is not your true self. Whatever life-condition you find yourself in at any one moment always feels like the only life-condition you’ve ever had or will have. But your life-condition can and often does change literally from moment to moment.
- Understand that anti-depressants only treat the symptoms of depression. None of the foregoing has been intended as a denial that anti-depressant medication plays a critical role in the treatment of depression. In the right patient, anti-depressants reduce the symptoms of suffering exceptionally well and can be literally life-saving. But they can’t make anyone actually happy because happiness isn’t merely the absence of suffering. The best approach, in my view, is to treat the symptoms of depression with anti-depressants (or cognitive therapy or even electroconvulsive therapy) at the same time you address the underlying cause of the depression itself.
I fully recognize that as a means to battle depression—especially a deep, all-consuming depression—these suggestions are inadequate. My point in making them, however, is to emphasize that the single most effective means to resolve a depression is to find a way to tap into our immense power to solve problems.
In a sense, we’re all on a journey to find just such a way. For me, the practice of Buddhism has been a consistently effective means by which to win over obstacles I didn’t believe I could, a tool that has enabled me to manifest wisdom, courage, and most importantly concrete solutions I don’t believe I would have stumbled upon had I not been practicing. If you have a different means that your experience has demonstrated works, stick with it. If not, spur yourself on to explore other paths until you find one that proves it has real power.
In retrospect, I wish I’d suggested to Mr. Burdnt that he think about his guilt over the death of the pedestrian he caused as a problem to be solved—and more importantly as a problem that could be solved. Perhaps had I also begun him on an anti-depressant medication to stave off what were obviously strong suicidal thoughts, he might have had time to work through his guilt. Perhaps he could have shaken loose from its grip in time to forgive himself, and his depression might have lifted. But I’ll never know. And that’s a problem I have to solve for myself.
NEXT WEEK: Overcoming The Fear Of Death
Posted on March 8th, 2009
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Alex: a very profound discussion of what infects so many of us in these modern days. A lot of people suffer from mild depression, because their life seems to fall short of their expectations. Those patients with more severe underlying causes, such as bipolar (which my son suffers from) need professional help to get them able to recognize problems. An excellent and thoughtful text. Thank you once again.
A wonderful and thought-provoking discussion on depression. There are so many facets to depression, but one major aspect that is not properly addressed is modern human’s propensity for problems breathing while sleeping. This is due to our jaws being too crowded from a major change in our diets, and as a consequence, our airways are more and more compromised. In effect, we can’t stay in deep sleep due to our tongues falling back and obstructing our breathing due to muscle relaxation. Lack of consistent deep sleep can lead to lack of energy and motivation, magnifying external or cognitive triggers. This is why most people with depression or anxiety prefer to sleep only on their sides or stomachs, in order to partially compensate for this airway problem. Later on in life, many go on to develop obstructive sleep apnea and it’s complications such as heart disease.
Steven Y. Park, MD
http://www.doctorstevenpark.com
This is a timely conversation for me. I am 45, have Stage IV ovarian cancer, and we have a 12-year old daughter. Nearly two years since my diagnosis, while going from Stage I to Stage IV upon the discovery of distant metastases, I’m still healthy and central to my family’s health and welfare. Still, depression is a constant shadow. Between the discomfort of cancer treatment and my poor prognosis, I have lost that “I love my life!” feeling that I used to have. I don’t love my life, now. I despair for it. It would be amazing, wouldn’t it, if I could regain such a feeling even under these circumstances?
Being able to sleep changed much of my life, as a lifelong insomniac, and helped stave off my mood disorder. As did medication.
And while I’ll add that I understand and feel that meditation of any kind helps people live healthier lives (as does exercise) I do think folks should understand that it’s NOT a cure for a mood disorder.
I know we disagree on this, Alex, but as someone who chanted hundreds of hours over the course of four or five years before solving my problem in a couple with a prescription, I also feel it’s important to point out.
Dr. Alex, I would like to read this website but it is very hard on the eyes to read grey on black. Can you please change it to a more normal color scheme like black on white? Thank you.
Great article Alex. You have an interesting perspective on things being a physician and a Buddhist. Given that the Buddhist believes that the challenges we face in this life are the result of our actions in previous lives (through the Law of Karma) I would be really interested in reading your thoughts on Karma and it’s relationship with illness…huge topic I know!
I find you blog interesting. I saw it on a link in a NY Times article. I also share your belief in mind as a major Cause. Do you ever read the words of the wonderfully enlightened Mystic Neville Goddard? His lectures are great. You might check him out at http://www.realneville.com/
Having worked as a therapist in psych hospitals for 20 years, suffered my own clinical depression and being a practicing Buddhist at that time, I feel I must comment. Clinically depressed people who kill themselves do not talk about it before hand. They just do it. No one sees it coming. Psych hospitals get suicidal people who don’t really want to die; those that make suicide gestures and create lots of drama in their lives. When I was contemplating suicide as one of my options, I was chanting and seeing a psychiatrist weekly and taking medication. It took a year and several cycles of medication to get me out of the depression. Not once did I disclose to my psychiatrist that I was suicidal. So, Alex, don’t beat yourself up about not seeing it coming. Those who were with him every day didn’t see it coming, either. That is the nature of a truly suicidal person: THEY DON’T TALK ABOUT IT.
[...] a previous post, The True Cause Of Depression, I discussed how having multiple problems at once seems to cause more stress than having only one [...]
A year ago the elderly mother of a friend swerved into oncoming traffic, jumped the curb and killed a beautiful, gifted young woman who was a pedestrian. My friend asked me immediately if she could get a referral from my psychiatrist. He gave her one. He also told me that there is a long history of people who kill others in accidents of committing suicide whether they were at fault or not. Before car accidents were common, it happened with train conductors. One of the first psychiatrists in Buffalo, N.Y. switched from being a surgeon to psychiatry after he killed a pedestrian and made a suicide attempt. Since you are a primary care physician and not all psychiatrists know this, give yourself a break.
Saw your comment about depression on Sanjay Gupta’s blog yesterday. I like the point you made and enjoyed the above article!
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I have been cycling downward lately precisely because I feel powerless. Your post felt like you were talking to me directly. Thank you for the insight. I will try to see all that is within my control, instead of what is not. It will be a process, but I already feel more hopeful. You should do the same—think of all the people you are helping, not the one who got away.
Peace
“…it certainly supports the Buddhist view that brain and mind are in fact only two sides of the same coin, or different ways of viewing the same single thing…”
This is the view of Hinduism as well. The yoga sutras of Patanjali not only define yoga as the “prevention of the distortion of the mind” but also indicate a path and provide a detailed prescription to achieve this.
States of mind such as depression are a kind of “distortion” (the sanskrit word is vritti) and are to be overcome by a directed and willfull effort, i.e., performing right karma.
It is interesting that observations such as fMRI seem to be supporting such a view.
In a video about the life and work of William Kentridge, a contemporary South African artist who has thought long and penetratingly about apartheid, he asks: if you hit a pedestrian with your car and kill him, you’re responsible for his death–but are you guilty of it?
This is a fascinating question, I think. What does it mean to be responsible but not guilty? Could this distinction possibly help people like Mr. Burndt? Is it easier to accept responsibility than guilt? Or are they basically the same thing?
Alex, thank you for your comments. i find them very helpful and comforting. I’ve had a life-long battle with both anxiety and depression. While it became clear to me through cognitive therapy that the depression was connected to feelings of helplessness, just as you suggest, I found other factors as well.
One of these turned out to be allergic reactions (determined by lab tests) to mold and also to soot that had been baked on my apartment windows by the hot sun. (I used to live in New York, which is very sooty.) As soon as the mold or soot had been cleaned up with vinegar, the whole world looked different—literally, of course, but on an emotional level as well. I felt like a different person. It was only after doing this that I realized what had been causing my misery.
Later on, in 1995, tests of neurotransmitter levels in blood and urine showed that I had rock bottom blood levels of serotonin and catecholamines and high levels of them in urine. On my doctor’s advice I began taking L-Tryptophan, which of course is a precursor of serotonin. It helped a lot. As did taking L-Tyrosine on an empty stomach to produce dopamine. A few years ago tests indicated genetic damage that had been caused by exposure to environmental toxins. My body had lost the ability to make the enzymes needed to produce dopamine.
I still find it helpful to take L-Tryptophan and L-Tyrosine daily. The latter eliminated a huge problem with anxiety that I had been unaware of. All of these measures, including cognitive therapy and the avoidance of toxins, have helped but i still need to take care and do the things you have suggested as well. So thank you again for your blog, which I’ve just discovered through the NY Times.
Hi Penelope,
English is not my first language so I maybe don’t understand everything you’re saying, but are you writing that your serotonin levels could be MEASURED? Because my doctor (either my GP or psychiatrist, I don’t remember) was suggesting that you can’t measure it.
That’s also one of the reasons that my psychiatrist and I haven’t decided to start with anti-depressants, because there are some clear underlying reasons to my depression-like feelings. Only I would be really pissed-off if it could partly be cured (or maybe I should write “cured”) by knowing the levels of serotonin in my blood…
Speaking as someone who heads up a research group of cognitive scientists, I’m concerned with your suggestion that cognitive therapy can help everyone. It cannot. Some people can be helped by drugs where everything else fails. They are extremely fortunate at least in having some resource, and trying to go off the medication can cause very severe episodes with the possibility of suicide.
Interesting theory, and it sounds good, but also sounds simplistic. Depression does feel overarching, not just a minor problem that hasn’t been solved but a sense that even if I solve this tiny problem, 20 others like it will crop up tomorrow. When I was a grad student at U of Chicago, it felt like being on an endless treadmill with various milestones, to finish the PhD, to get tenure, to achieve recognition in my field. And the problem was that I wanted the recognition and achievements but also wanted more balance in my life than I was likely to find. To say that I felt my problem unsolvable is true, but it misses the point: someone who is not depressed doesn’t get into that thought loop. I was in a division of 80 grad students, and I doubt more than 10 of them were so good that they could be confident of their career in academia; but the rest of them were okay to take it a day at a time, to do research and take breaks and see what happens. To some degree my problem was unsolvable, but to a larger degree it was just life presenting me with limited choices.
Thanks for your reply. I’m not sure we’re finding common ground, and I’m not sure why. It feels like you’re trying to force your paradigm on my experience with depression. Another way to explain this: Anna Maravelas has a great book on conflict resolution and in it she talks about the fact that life presents us with 10,000 “heart hassles” every day. And in my experience, how I respond to these problems depends on neurochemistry not on the problems themselves. Someone cuts me off in traffic, I’m up two pounds on the scale, a waiter spills water on me—the rational part of my brain knows that these “problems” are unsolvable because they’ve happened and the resulting problem (I have to change shirts) doesn’t require problem-solving skills. Depression feels like an inability to deal with the vicissitudes of life, often a real mental slowing occurs. I’ve had a few of these periods, post-breakup, where I could sense that my ability to think was like stop-and-start traffic. It’s not so much that I had any unsolvable problems; it’s an overall coping ability that was quite simply gone. The point is that when I’m not depressed, the same problems will show up in my life and I will be able to pick from the limited choices and be comfortable with the lack of perfection, “cross that bridge”, etc. When I’m depressed, I’m not more realistic about the lack of perfection, I’m not more hopeless about my ability to cope with the consequences of that imperfection, but there is a kind of “leap of faith” that moves me from the scientific, dissect a problem, to the big-picture, trust my gut. And a depressed brain can’t make that leap of faith; it gets stuck in the endless analysis. A lot of negative issues become magnified—anger is bigger than it is normally, guilt is magnified, anxiety and second-guessing is huge. What it most resembles is that last time you got 2 hours of sleep and had to get through a normal day before you could take a nap. Nothing quite works.
I’m genuinely trying to wrap my brain around what you’re saying, because it sounds so tempting. It sounds like you think there are two distinctly different states, a functioning brain and a depressed brain, that operate very differently where I see more of a spectrum, the way that even one sleepless night can significantly lower coping. I also think you’re confusing correlation and causation, like yo-yo dieters who blame their weight gain on dieting. Stress causes malfunction causes failure causes depression. I suspect your driver’s brain was off-kilter before he hit the pedestrian. The powerlessness is an “obvious” distraction—someone who’s depressed enough to see a doctor probably has failed something in some way.
My depression—I’ve struggled with it for decades—is high-functioning. None of my teachers had the smallest clue that I was actively suicidal in high school. And I do see it like dieting, that I had to retrain my brain away from the thought patterns my parents had handed me, away from workaholism and perfectionism and letting minor setbacks snowball in my head. I had to learn to eat better and exercise often and get plenty of sleep. The ability for a daily run to prevent long-term depression is simply astounding. I had to see the warning signs of stress and learn how to set boundaries earlier—with people, advisors, my own life goals. Being attuned to it, I also realized that I was heavily impacted by light, and Chicago winters took a heavy toll on me. Powerlessness isn’t a theme in my depressions; if anything, there was too much power, too many choices and the sense that my life path rested on those choices.
[...] [...]
Found you via the link in Gretchen Rubin’s Happiness blog. I am glad to find your conversation with RG, as my experience leads me to agree with his spectrum description rather than the either/or view of depression. I am on meds for anxiety/depression, which was diagnosed postpartum. RG’s comment about the “leap of faith” being absent reminded me of the feeling of not being able to access states of being and perspective that I had long counted on—like pathways had been blocked. Were those pathways blocked by my anxiety? Or did the blocked pathways trigger the depression? This is an important distinction for me, because I am not convinced that there is a clear separation of cause and symptoms with regard to depression. If I understand you correctly, you say that depression is caused by the belief that I am powerless to solve my problems. If finding the correct meds restored my feelings of power (which to me felt like restored access to power), thus reducing my anxiety/depression, am I treating only the symptoms?
I have long thought that breakthroughs in medical understanding will come from better clarity regarding cause and effect. For ex., I have seen studies that suggest that drinking too much puts a woman at higher risk for breast cancer. Is it possible that whatever makes a woman drink too much is what triggers the cancer?
Thank you for addressing these questions. I appreciate the discourse.
Alex, you have a wonderful blog and I count myself lucky to have found it. I’ve read many of your posts and have been struck by the wisdom and thoughtfulness in your words. You appear to ground your professional work in your Buddhist practice much as I draw on my own many years of yoga practice and experience to ground me in my profession.
Therefore, it saddens me to read this post and find myself having to say: You don’t know what depression is. You truly don’t know what you’re talking about here. But you have constructed an all-too-familiar refrain, one that is tossed at people with serious depression with wearisome frequency by the non-depressed. Let me gently point out that elaborate speculative theories like those you have constructed above are an expression of your prejudice towards and your social disapproval of depression and people who have it. RG is trying to explain it to you, but you’ve cotton wool in your ears and are refusing to hear him/her.
I say this as someone who developed depression some years ago as a secondary result of a serious and disabling medical condition (pulmonary). I had no history of depression before that time; it was a new (awful) world to me. All of my excellent coping skills (strong mind, strong constitution, long yoga practice) were useless against severe depression. Indeed, as RG tried to explain, the physical disease of depression disables such coping skills, just when you need them most. But this is too long a discussion. In short, I invite you to please seek out and read very recent research—the field is advancing rapidly. Search terms “major depression” and “HPA axis” for starters. For the sake of your own patients, at least.
Chris Bacon (above) also has it right: “Clinically depressed people who kill themselves do not talk about it before hand. They just do it.”
As someone who hails from a genetic pool full of depressed people and who has been diagnosed with many of the things you’ve written about here, I felt the need to comment. I do agree that some depression is self inflicted—that our warped way of viewing and thinking about the world is what brings us down. But I can say from self observation that not all of it depression is caused by our thoughts. There is definitely a chemical component that is not at all related to thoughts. I have days when my life is wonderful and when I think that my life is wonderful, but when I feel very flat. I used the word “flat” to describe this sensation because it has no positive or negative connotation. It’s also exactly what it feels like. There is little exuberance. Smiling and laughing feel forced. Paying attention to what other people are saying? It’s an exercise. I don’t feel like doing anything.
There’s no out thinking it. It’s just something that is there. It’s a crummy feeling that lasts until it stops—usually after I do something that changes my brain chemistry (sleep, aerobic exercise, sex etc). Certain things will bring this state on. They include eating crappy food, alcohol of any type or amount, and fatigue.
In calling it “flat” and knowing that it won’t last forever, it’s not so depressing to feel depressed.
I do agree that our society is very quick to judge all depression as chemical. So many people are taking pills for their depression when they quite possibly could be out thinking it. (Note: I am not medicated and never have been). But I also think it over simplifies things to say that none of it is chemical. It’s a little of both, and if you treat both the thoughts (through CT and problem solving) and the chemical issues (through exercise, abstinence from alcohol, a healthy diet, sex, fun, and so on) you might end up with a winning combination that would help a lot of people feel a lot better.
I think part of the problem is that the term depression in actuality encompasses so many different conditions. It’s analogous to a “syndrome” which is nothing more than a collection of symptoms that some people seem to share. The etiology of the disease may be in fact quite different in different patients thereby altering the treatment. For some people, a sunny disposition is in the genes, for others, not so much. It’s also usually a source of great creativity. How many brilliant authors were cheery? Probably one of the best things I read on depression was Thomas Moore’s “Gift of Depression” in Care of the Soul. It completely changed my view on it.
I’ve had depression since childhood. I am now 60 years old and have obtained four college degrees (science, medicine, and law) despite depression so severe that I am now 100% disabled.
I’m a fighter. I moved to Hawaii to be warm. I used to chant. I learned to sail and lived on a sailboat…I did everything to pull myself out of depression…psychiatrists, CBT, every anti-depressant there is. I have achieved great honors.
I don’t announce I am suicidal, I really try to do it. 250 Tylenol and 2 bottles of whiskey (I don’t even drink), and wasn’t found for 3 days; yet I made it out of the hospital without even liver damage. The second time I tried to decapitate myself by tying my neck to a rope and the rope to a carport and getting in a car and hitting the gas pedal. The timber of the carport gave way to termites.
These are not “attention getting.” I want to die.
I feel completely empty and always have, no matter what great service to mankind I have done; no matter how much powder skiing, sailing to Tahiti, or backpacking I have done, I feel completely despondent and empty.
So now what, doctor?
Alex I think you are right that most people’s psycho-chemistry (does this word exist?) is based on events and their interpretation of events and how this causes the brain to react.
For example, the release of cortisol when we are stressed. I can usually bring myself out of mild depression by accomplishing minor tasks that I have been putting off and once I’ve started this process I can overcome inertia and take on bigger problems. I may not be able to get complete resolution of the problem but I feel better just knowing that I’ve taken action. Is this raising my seratonin level? I believe it does. Of course I am lucky that I do not have severe problems with depression, many of which, I believe, are chemical in nature. Even though I’m a pharmacist, I really feel that antidepressants and most pharmaceuticals are grossly overused. I can remember a colleague telling me that the patients in his small town were not taking to the two new physicians who had recently replaced a retired GP. They were not sending people home with prescriptions for every complaint. He was not happy either because it had caused a depression in his business (which may have caused him to be depressed).
Other issues such as placebo effect, efficacy, side effects, the wisdom of the older physician can be debated, but too often I see patients who are so overmedicated that most of their problems, both physical and psychological, are being caused by the drugs.
I have just found you site and think it is wonderful. Please keep it going.
Thanks Alex, I’m really enjoying your blog. I find it very comforting and encouraging. Thanks for sharing your thoughts!
Your article seems insightful and kind, but the obvious question arises in response: what if the problem really is insoluble? It seems to me that many or most of the problems human beings encounter are not soluble—indeed are probably utterly beyond us—and so maintaining hope that we will solve them is futile. How does a human being solve death? Or the apparent absurdity of life? Or any one of the many tragedies and sufferings we must all undergo as we march toward a certain death? Life brings things that we don’t want and cannot avoid, and to try to convince ourselves otherwise seems to me to be an aspect of the very delusion that Buddhism seeks to dispel.
The first Buddhist insight that “life is suffering” does not disappear after enlightenment. That suggests that depression, at least in the Buddhist context, cannot be banished in any permanent way by maintaining the hope that we will someday solve all our problems and no longer suffer. Perhaps depression is a profound state of insight into the futility of our efforts instead, and so a gateway to some greater form of enlightenment. I don’t know, but something about your approach here seems inappropriate and even lacking in compassion (maybe for you yourself) to me.
I came upon your site through the NYT and was interested in “meeting” or knowing more about a physician who is Buddhist. I have always found it the only “religion” that is attractive and seems compassionate. I am dismayed at what I perceive as the facile dismissal of depression as simply inadequate thinking (forgive the truncated somewhat irritated summation).
Clearly it is your desire to be helpful but there is a stubborn refrain here that disallows a deviation from your strong convictions. These convictions are like any religion, tightly held and unyielding. A parallel is Scientologists believe their methods can cure schizophrenia.
No matter how much compassion anyone attempts to impart along with the belief that depression is basically caused by faulty thinking or beliefs, it will fail because it always leads to the ultimate conclusion: you aren’t trying hard enough or the too often heard, snap out of it. If it is not “easy” then it must be hard; if it is hard then it requires effort; if the effort fails it is not sufficient to the task; the obvious conclusion is you didn’t try hard enough. To compare spider phobia to major depression is off the mark. We are not out of the woods yet in our understanding of this illness. I agree with RG that is a spectrum illness, not an either or. It also manifests in various ways as well as degrees.
I am a licensed therapist and also have suffered with major depression. Until I found a medication that addressed my particular disarray of neurochemicals—too little norepinephrine, not serotonin—I had recurring bouts of such extreme fatigue, physical and mental, I was at times non-functioning. I agree with all the ideas about some depression being helped by cognitive re-arranging, if you will, or good health habits, exercise, etc., but for those who cannot overcome this illness by those means it is unfair for them to have to perceive they are ultimately to blame. I realize you are not consciously intending that but that is the result nonetheless for claiming they just haven’t found the source of their powerlessness beliefs. (It is also possible to have powerlessness beliefs and not be depressed.)
If medication ONLY cures symptoms then what of other illnesses for which we can only cure symptoms? Forgive me, but so what? Some diabetes is cured by changing diet, but not all, so we cure the symptoms. Maybe we will cure the causes one day as we have for other illnesses.
I am of the opinion we humans are often inflated in our beliefs in our special powers of understanding. And we have done a disservice to many thereby. Surely we burned witches at the stake who probably had schizophrenia, bipolar disorder, or something similar, something that was not understood.
It is a form of hubris for any helping professional to be unable to say simply, I don’t know. It would be far more soothing, and respectful, to me than you aren’t trying hard enough. If a doctor does not have a cure, he has not failed. If something works for some there is no guarantee it will work for all. Maybe some patients really do not put forth enough effort. Maybe some have a chemical imbalance that cannot be budged by these methods.
Very few people are truly empathic about depression or those who suffer with it. Many therapists moan they hate working with people with depression; it is too tedious. Ministers admonish their flocks to avoid “negative” people.
Hopefully we will find out more about all problems in the brain one day but until then, I am empathic and sympathetic to those who truly suffer with this illness. For me, the hope is more people will try to understand, be accepting of the person, supportive and not judge. We don’t admonish someone in a wheelchair: why don’t you get up and walk?
(I wrote much more on this because I am passionate on this subject but have spared you the additional verbiage….)
Thank you for an excellent article and a fascinating forum of discussion. I think you are on the right track, Alex. What I am observing intuitively is that its not just a question of interpreting and decoding belief, it’s also a question of our personality orientation and how we both form and imbue our personal judgment into our interactions in the world and the meanings attached. What I have taken from my study of personality theory, and find particularly well reflected in the enneagram personality typology, is that at the core of every person is a basic belief about their relationship to the outside world. Essentially its a wounding so to speak, and the concomitant development of the person’s personality style from childhood involves developing certain traits and certain types of behaviour to compensate for it. In a certain light our personality type is a style of focusing, thinking and behaving to keep at bay awareness of a fear that we were particularly sensitive to in our early years. It becomes the theme to the story we tell ourselves about what is “really important” which supports behaviour choices we make. Something with a reflexive property that is so habitual its largely unconscious to someone. What I am wondering is if perhaps some of the misunderstandings about depression and its causes is brought about because it is experienced and manifests itself differently in many ways according to life situation and personality type.
Alex, this is the first time I read your blog, and your article rings true with me. Since my 55th birthday 4 months ago, I’ve been overwhelmed with the feeling that my life is pretty much over. I feel increasingly irrelevant, and despite my accomplishments of an advanced degree, good job, and loving family (I’m a single parent), I ache with a loneliness and despair that I will never be able to have what I’ve always felt I’ve lacked. As I get older, I have to face the fact that it may never happen. I ask myself do I want to go through my the rest of my life feeling this bad? I feel if I could change my thoughts, I could stop the tapes that run in my head about worthlessness and unlovability and failure. I think that sometimes change can be acceptance of a situation or condition because not everything can be fixed. Is acceptance giving up? I don’t know. I’ve had years and years on and off therapy and at times I’ve been on antidepressants. I just want to be able to accept things I can’t change and find peace with that. But I want to be sure that what I think can’t be changed, really can’t be changed before I just accept it.
Does Buddhism really teach us to solve our problems? My understanding is that Buddha encourages us to become more deeply aware and accepting of the inevitable pain of living. It is precisely the resistance to our pain, the attempt to solve it, that perpetuates suffering. I know first-hand that depression is a bitch. But at the same time, I’ve come to recognize it as an enormous opportunity. Our pain demands that we pay attention! It teaches us to be aware…of who we are and what we are doing.
I’m with you—depression is a profound contraction of the spirit, an attempt of the body and mind to hide from the emotional consequences of our belief that we are helpless, hopeless, worthless. But solving depression doesn’t work. Trying to solve a mistaken belief doesn’t make any sense. It just gives the belief that much more weight, legitimacy. You just make it more real. In that way depression is like a black hole. The more we try to fight it, the heavier it gets, and the stronger its pull.
The great thing about deep emotional pain is that it teaches you that fighting negative emotions is useless and only makes things worse. Sooner or later, when you get really sick of it, you learn acceptance (which, I think, is another word for love). Depression deeply accepted has no power to harm. DT Suzuki, the noted Zen scholar, once wrote, it is only though the *willingness* to suffer that suffering may be transcended. Another Zen story…A master was once approached by a student who pleaded, “Please help me, my body and mind are burning.” The master replied with great kindness, “Go sit in the middle of the fire.” What a profound lesson. It may be that it is pain itself that opens us to our deepest potential for happiness. A broken heart is an open heart. Ultimately it is our wounds that heal us not the other way around.
Dr. Lickerman:
I am responding to the September 9th comments by “Helen of Hawaii.”
Upon reading about her failed suicide attempt because the timber of her carport collapsed due to termite damage, I immediately recalled Kurt Vonnegut’s intention to sue the manufacturer of Pall Mall cigarettes for breach of promise.
He considered the habit of smoking their unfiltered cigarettes to be a “classy way to commit suicide.”
After smoking Pall Malls all his life, his guaranteed death from lung cancer failed to occur. He was disappointed and disillusioned by the corporation’s lack of integrity and by their blatant mendacity.
Vonnegut claimed he was entitled to monetary compensation, since the company’s product didn’t kill him. He was still alive—and still smoking Pall Malls.
Some of your readers may know the eventual cause of Vonnegut’s 2007 death: he slipped in his bathroom; his head struck a bathroom fixture; he fell to the floor—and died several weeks later from irreversible brain injuries.
I wish there were even the slightest possibility of life after death, because I’m sure Vonnegut would still be chuckling about the manner of his departure.
To date, I find Helen of Hawaii’s remarks the most memorable ones posted about your article. I have a very certain expectation she has a profoundly interesting personality and a valuable sense of humor.
If she isn’t yet writing her autobiography, I hope she begins immediately. She may want to die, but I’m asking her to keep us company and share her story.
With both your and her permission, I would like to correspond with her—if this is allowed and possible according to the rules of your website.
You may give to Helen of Hawaii my email address. I will respond to her reply.
Jack Dakota
Skanee, Michigan
Alex,
Thank you so much for a wonderful blog and a great post. Your compassionate and thoughtful replies (especially to criticisms) are a reminder to me of what a dialogue could be.
My personal experience of cyclothymia is well-aligned with the theory. Looking back, pretty much all of my “downs” came from some loss, some setback which led to me to lose the sight of the goals I wanted to achieve and felt like I couldn’t achieve and that it didn’t make sense to try. And as a result, much smaller things became very difficult, small decisions became unbearable.
I also found it very hard to have people understand how certain beliefs can profoundly affect one’s experience.
I would also extend your theory to explain hypomanias/manias, at least as I experienced them. Hypomanias come as a result of some of the negative, rigid beliefs breaking down. Once those depression-producing beliefs (walls) were down, I realized that I stayed in the cage for so long for no real reason and a lot of positive, productive energy got unleashed. That lead to productivity, search for new ways of living, new goals. Having read accounts of manic people, their experiences are similar, just way more extreme and having to deal with deeper existential/spiritual beliefs.
This also led me to think more and more about attachments and reading your post on it confirmed my ideas. Attachments become a tight-rope. Too strong and depression follows if attachment is breaking. Too weak and there is no drive to take care of it. I found my cyclothymia mostly to do with cognitive processes—that’s why reading your blog is so fascinating.
Hi, Alex,
Very interesting post. However I have to disagree with the following point:
“I’d suggest an alternative explanation, that these forms of depression have a chemical or hormonal influence—reducing our ability to believe we can solve our problems but not entirely eliminating it.”
I have adrenal insufficiency, diabetes and thyroid disease and have found that the ‘depression’ that comes with these illnesses is very much grounded in the physical reality of hormonal imbalance.
Your brain needs both mineral- and glucocorticoids, insulin and T3/T4 to function normally. When you have too much or too little of these hormones, your brain simply doesn’t function properly. Simple cognitive tasks like word-retrieval or memory recall become very difficult when your brain doesn’t have enough hormones.
For the hormonally-deficient, no amount of CBT, meditation or other therapeutic intervention will make up for the chemicals that are missing. When you start replacing hormones, it is like having a light switched on.
The problem remains that artificial replacement of hormones is an inexact science and doctors remain over-dependent on blood values, paying little attention to how patients actually feel.
It’s easier in these instances for doctors to say ‘it’s all in your mind’ than to question the validity of blood test results that simply capture one point in time and don’t convey the daily fluctuations experienced by the patient. Similarly, blood tests for hormonal values tell you what’s happening in the blood but don’t tell you how well the tissues are responding to hormone replacement.
The best doctors for people with hormone problems are doctors who have personal experience of hormone problems. Doctors with experiential knowledge of hormonal disease do not make the kind of assumptions that you do about the personal coping skills of people who lack the hormones necessary to function normally.
An easy way for doctors to test out their ‘it’s all in your mind’ theories would be for them to dose themselves up on carbimazole for a year and see how far their coping skills get them. Of course, I doubt there would be many volunteers.
Dr. Alex,
I read a good part of this discussion. I didn’t hear any mention of mental illness (depression, etc.) being hereditary. It exists in three generations of my family, starting with—that I am aware of—my father’s nephews (brothers), four of my 7 siblings and me, in 2 nephews, 1 niece, and 1 grand niece. I have been chanting Nam-myoho-renge-kyo since 1983. Although my journey with bipolar depression has been arduous, it has been fascinating in terms of the gunk that has emerged and dissipated from my life. My life condition is light-years ahead of where it was when I joined. Mystically, I have discovered many deep-rooted, internal causes for my psychic pain. I have broken through them. I still purge on occasion, and I am mystified when I experience a bout of the same intensity as I did in years past. How do we account for the generational aspect?
Social comments and analytics for this post…
This post was mentioned on Reddit by lwoodnj: Philosophizing about the causes is nice and all, but this seems to have little substantial evidence to back it up. I suppose if it inspires someone to do some research though it might be acceptable…
Dear Alex,
I always think it is tricky for someone who has never experienced depression to write about what causes it or how best to attempt to cure it. I have a mild case (in clinical terms), but I suffered through 6 months of very little sleep and an inability to function normally—I could not have held a job—before I found a medication that, I feel, brought back the real me.
Since I am naturally an optimistic person, and never gave up searching for a solution (I tried holistic therapies, exercise, meditation, acupuncture—you name it), perhaps I found my balance again quickly once the chemical problems were solved. However, until you have tried and tried to figure out why you are suffering, and then find that a daily pill relieves your suffering, I don’t know if you are qualified to suggest what is happening internally.
I understand that you want to help people, but since depressed people tend to cling to possible solutions without a great deal of rational thought, please be careful when taking on this delicate topic.
Hi Alex,
It’s me again. I just read more of your replies, where you describe dealing with your own depression. I didn’t know that when I wrote my first post.
As I am sure you know, this is a sensitive subject, especially for those who have an ongoing problem. I’m sorry I didn’t understand your experiences before I wrote my post.
Before I began to understand some of the things mentioned in this article, I would point to a series of events that occurred in quick succession as the cause of a long battle with depression. Only recently have I come to understand that it wasn’t the events themselves, it was my reaction to them. I eventually decided that there wasn’t much in life worth doing, because nothing I did made anything better. In short, I felt powerless.
Since I didn’t believe I had power, I decided I didn’t care about much. If I didn’t care about people/things, nothing could bring me more pain. That, in itself, was it’s own kind of pain, because it also diminished my capacity for joy, which fed my depressed state.
Perhaps because of my personal experiences, and where I currently am in my journey, I fully understand the points made in the article, even if I could never explain them as well. I’ve spent the last few years feeling trapped by my life, yearning for a freedom I couldn’t fully explain. Now I understand that the freedom I seek is inside me, and is not dependent on any external factor. The path to this freedom requires that I closely examine various beliefs I’ve held over the past few years. What I am finding is that many of these beliefs were tucked away in some nether region of my mind, yet still affecting my life in some way. In essence,I must free myself from delusions, as the doctor mentions above.
“…we only relinquish our delusions when the pain that comes from continuing to believe them exceeds the pain of letting them go…” is EXACTLY what happened to me. I couldn’t have described it better.
I had/have to examine how I really felt about various things. It was my thoughts, not the actual events (as painful as they were), that led to my depression. We often shy away from being completely truthful with ourselves regarding our feelings and beliefs, if we even acknowledge them at all. Sometimes we have to dig deep and find that we thought we believed one thing, but we really believed something else and the belief we haven’t acknowledged is the one that actually drives our actions and our state of being.
Oddly enough, I could see none of this when I was in the depths of depression. It was only when I focused on trying to change one particular circumstance that I started to (very) slowly get to the point that I was ready to accept that I had to challenge some of my beliefs before I could move forward. Before I could search for answers, I had to understand what questions were necessary.
Once we start down that path (which I imagine can be very difficult for many of us), we start to gain wisdom. It is key to being able to lead a joyful life even as life brings us painful experiences. At least, that has been my experience (and my uneducated opinion).
I get it, even if I can’t articulate it very well yet. I just found this site today, and I am so grateful I did. So many things I’m reading either clarify things that are on the edge of my consciousness, or validate things I’ve already figured out. Thank you!
PS—sorry to be so long winded.
This approach is, for me anyway, seductive, but it ultimately leads to more suffering. To regard life as a problem that requires a solution is a formula for more pain and frustration in life. Life is not a problem, although it is full of difficulties. Life is full of mysteries and dilemmas, triumphs and tragedies; these are not problems.
I am speaking from my own experience, and everyone has to find out for themselves. My experience is that approaches like yours lead to more depression. I have suffered from “depression” (dysthymia) for much of my life, and the only sustained times of joy and peace for me have come when I let go of my Problem. I don’t mean give up, of course, but instead seek to transcend the problem in the way that art transcends life. A human being is a sacred cosmos, full of contradiction and conflict; and ultimately a far greater reality than the “problem” that one perceives.
A great work of art does not expunge a life problem by solving it; instead, it uplifts the problem into its true nature, which is joyful, even when it is painful.
“Better to have loved and lost…”, right? Is a broken heart, for example, a problem that should be solved, perhaps by erasing one’s memory of the painful relationship? I am a songwriter and singer, and I cherish my broken heart.
I try to cherish all of life’s “problems,” if I can.
“Accept honors and disgraces as surprises,
Treasure great misfortunes as the body.”
- Dao De Qing 13
Treasure one’s misfortunes as one treasures one’s own body and one’s own life, because misfortunes and life come to us at once.