Depression: Situational vs Clinical, Mind or Brain

Patient Expert

In a 2007 article, Gordon Parker of the University of New South Wales observed:

Depression is a diagnosis that will remain a non-specific "catch all" until common sense brings current confusion to order. As the American journalist Ed Murrow observed in another context: "Anyone who isn't confused doesn't really understand the situation."

Let's get confused:

According to conventional wisdom, the DSM-III of 1980 heralded the "modern era" of diagnostic psychiatry. Suddenly, "major depressive disorder" could be diagnosed using a nine-symptom checklist. So easy was its applicatioon that any layperson could do it at home, though this was not encouraged. The DSM-III checklist is preserved virtually intact in the current DSM-IV and soon-to-be-published DSM-5.

The "ancient DSMs I and II of 1952 and 1968, by contrast, are virtually impossible to read and understand. A highly skilled psychiatrist would be hard put to make a definitive diagnosis, much less your home do-it-yourselfer. Yet, I strongly urge you to dig out these old DSMs. Confused you will be, but remember, confused is good. Confusion is our first step to understanding.

The old DSM-II of 1968 distinguished between "endogenous" and "exogenous" depression. "Endogenous" referred to a type of depression occurring as a result of the mysterious biological processes of the brain while "exogenous" referred to depression as a result of how one reacts to one's environment.

Although the DSM does not recognize the distinction, it is applied informally in clinical practice and in support groups. The other day, over the phone, I asked someone, "What was going on in your life just prior to your most recent depression coming on?" Chances are, someone - friend, therapist, psychiatrist - has asked you a very similar question.

Yes, there is a biological component to every depression, and we will discuss these in future posts. But inevitably, we will find the biology interacting with our environment. Back in Oct 2005, I began my first post ever for HealthCentral with the words: "I am the original crying clown."

The strain of attempting to set up a state DBSA organization back in New Jersey (where I used to live) was getting to me. To slightly oversimplify matters, I turned around to discover three knives in my back planted by three different people. As I wrote:

For me, working on the state organization was toxic. My stupid pride and misplaced optimism had blinded me to this brutal fact of life.

The solution, of course, was to change my environment, not my meds. I immediately severed all involvement with the state organization. My depression, needless to say, no more immediately lifted than removing your hand from a hot stove immediately lifts the burning sensation. The pain was still there. But I was on the road to recovery. I knew I would get better. If depression is the absence of hope, then in one sense I no longer had depression. Time would be the healer.

The DSM-II naively assumed "exogenous" depressions took place inside a strange metaphysical construct called the mind. As such, the mind could fix the mind. These days, we are taught that depression is a "chemical imbalance of the brain," as if our environment has nothing to do with the situation, as if all it takes to fix a chemical imbalance is the right dose of the right chemical.

Both views are equally ludicrous. Yet, both views have a good deal of validity. The trick lies in reconciling both these views. Confused? Good. You are beginning to understand.

More confusion to come ...