Is There a Best Way to Treat Depression?
Take two people from different cultures. Both have depression. The first person is from a Western culture and the second from the East. When the Westerner describes their symptoms there is an emphasis on cognitions. They will describe negativity, feelings of inadequacy, hopelessness, helplessness, self-blame, confusion and pessimism. The person from the East is far more likely to place emphasis on physical symptoms such as fatigue, weakness and poor sleep. Both actually share the same symptoms yet the language used and the choice of emphasis differs.
It's a simple illustration but it's a starting point in acknowledging that depression means many different things to different people, including the people who treat it. At an everyday level it can sometimes take a while to establish whether the person is actually referring to depression or something else. If I speak to a clinician about depression I'm pretty confident how they view the term. To a clinician the term depression refers to a debilitating syndrome that has at least some genetic predisposition. To the person in the street, depression more commonly refers to sadness or maybe anxiety or stress. Usually they are really referring to dysphoria, that uncomfortable mix of unease and unhappiness that accompanies situations that leave us thwarted or unsatisfied. People may refer to having been left ‘depressed' because they missed the end of a movie, or find they had to pay more for car repairs than they expected. Furthermore the symptoms of depression may vary from mild to extreme forms. The very fluid nature of the word depression leads to confusion and misunderstanding. At worst it can trivialize the truly devastating nature of major clinical depression.
Despite what may sometimes appear as clear and distinctive criteria relating to depression, these are descriptions of the symptoms, not proof as to its cause. Often we infer the possible cause or causes of depression based on the variety of attempts at treatment. Sometimes it can seem little more than a form of backwards engineering. If something positive comes out of the treatment we then speculate as to the possible causes.
So, let's look at the treatments for depression. The use of antidepressant medication appears to give a clear signal that depression is a biological disease. But it only appears this way. It's true that antidepressants can dampen the most severe depressive symptoms in some people - but not always. People who take antidepressant medications invariably find the underlying depression rumbles on. Over half will find their depression returning with the duration between subsequent depressive episodes decreasing each time. Other interventions like electroconvulsive therapy (ECT) may work for a time, but it is not a permanent solution. This points to some underlying issue and this is where psychological therapies come in.
The psychotherapist Stephen Diamond, Ph.D., uses the metaphor of the multi-headed hydra to describe depression. The only way to defeat the beast is to get to the heart of the problem, he argues. Diamond suggests at the heart of depression lies repressed hatred, anger, resentment, rage, abandonment, betrayal and discouragement. It is to do with unresolved grief, meaninglessness and loss of faith. The problem with the mythical hydra is that it can never actually be killed, only subdued. At the moment the two-pronged attack of medication and psychotherapy seems the best way to suppress the predisposition towards further depressive episodes although in milder cases it can sometimes consitute a cure.
For doctors, psychiatrists, psychologists and other therapists, getting on the same page as someone with depression is more than simply encouraging them to accept a particular explanation or theory of depression. Yet this is all too common. Many patients feel their personal narrative is viewed as secondary to the ‘real' issue behind their depression. Yet these narratives, to borrow Diamond's example, may be the real heart of the hydra. The patient is trying to offer the key to their pain and an explanation as to its cause. It's undeniably difficult to listen to the protracted and painful stories that people sometimes have to share, but this may well be part of the deal to successfully treat, or at least suppress, the very worst effects of depression.
Diamond, S. (2008) Is Depression A Disease? Psychology Today.