Dr Neel Burton – Psychiatrist, philosopher, writer,
Hello everyone. I mostly live in an attic in Oxford, so you’ll forgive me for being completely outside my environment tonight. I am afraid I am not going to be terribly funny like the previous speakers. That’s partly because psychiatrists aren’t very funny people. Freud famously said that there’s no such thing as a joke.
But, no, actually it’s because that my topic tonight doesn’t lend itself very well to jokes and my topic is actually a very serious topic. It’s depression. Now, most people think of depression as a mental disorder that is a biological illness of the brain. Today, I’m going to argue that the concept of depression as a mental disorder has been over extended, has been unhelpfully over extended to include all manner of human suffering.
And, more controversially, that depression or “depression” as broadly understood, can actually be good for us, an idea that I explored, that I developed in my recent book “The Meaning of Madness.”
Now let us begin by thinking very broadly about depression. There are important geographical variations in the prevalence of depression. And these can in large part be accounted for by socio-cultural rather than biological factors. In traditional societies, human distress is more likely to be seen as an indicator of the need to address important life problems 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 with which to talk or think about depression. And many people in traditional societies with what may be construed as depression present instead with physical symptoms, such as fatigue, or headache, or chest pain. So, for example, Punjabi women, who have recently emigrated to the United Kingdom and given birth find it baffling that a health visitor should pop around to make sure that they haven’t developed post-natal depression. I mean, not only had they never conceived of giving birth as anything but a joyous event but they don’t even have a word with which to translate the concept of depression into Punjabi.
Now, in modern societies such as the UK and the USA, people talk about depression very freely, very readily, very openly. As a result, they are far more likely to interpret their distress in terms of depression and also far more likely to seek out a diagnosis of the illness. At the same time, groups with vested interests, such as pharmaceutical companies or indeed, so called mental health experts promote the notion of ‘saccharin happiness’ as a natural, default state and of human misery, of human distress as a mental disorder.
The concept of depression as a mental disorder can be useful – can be useful for some of the more severe intractible cases that are treated by hospital psychiatrists. But probably not for the vast majority of cases which are relatively mild and short-lived and easily understood in terms of life problems, 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 themselves which have become increasingly individualistic and divorced from traditional values. For many people living in our society today, 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 a mental disorder our society may be subtly implying that the problem lies not with itself, but with them, fragile and failing individuals that they are.
Now, of course, many people prefer to buy into this reductionist, physicalist explanation rather than, I suppose, confront their existential angst. However, thinking of human distress in terms of a mental disorder can be counterproductive because it can prevent people from identifying and addressing the important psychological or life problems that are at the root of their distress.
Now, all this is not to say that the concept of depression as a mental disorder is bogus, not at all, but only that the diagnosis of depression has been overextended to include far more than just depression, the mental disorder. If like the majority of medical conditions depression could be diagnosed according to its etiology or pathology, that is, according to its cause or effect, then such a situation, such a problem would never have arisen. Unfortunately, depression cannot as yet be diagnosed according to its etiology or pathology but only according to its clinical manifestations or symptoms.
Given this, a doctor cannot base a diagnosis of depression on anything so objective as, for example, a blood test as in malaria, or a brain scan as in stroke but only on his subjective interpretation of the nature and severity of the patient’s symptoms. If some of these symptoms happen to tally with a diagnostic criteria for depression, then, you know, bingo, the doctor is justified in making a diagnosis of depression.
Now, the problem here is that the definition of depression is circular, the concept of depression is based on the symptoms of depression, and the symptoms of depression, in turn, are based on the concept of depression. Thus, it is impossible to be certain that the concept of depression maps onto any distinct disease entity.
And, particularly since a diagnosis of depression can apply to anything from mild depression to depressive psychosis, and depressive stupor and overlap with a number of other mental disorders, including anxiety disorders, dysthymia, and adjustment disorder. One of the consequences of our menu of symptoms approach to diagnosing depression is that two people with absolutely no symptoms in common – absolutely no symptoms in common, not even depressed moods, can both end up with the same diagnosis of depression.
For this reason especially the concept of depression has been attacked for being little more than a socially constructed dustbin for all manner of human suffering.
Now, let us grant – let us grant as the orthodoxy has it that every person inherits a certain compliment of genes that make him or her more or less vulnerable to developing depression or a state that may be diagnosed as depression during his or her lifetime. And let us also begin to refer to this state rather than depression as the depressive position to include both clinical depression and milder forms of depressed moods.
A person enters the depressive position if the amount of stress that he comes under is greater than the amount of stress that he can tolerate given the compliment of genes that he has inherited. Now, genes for potentially debilitating disorders such as depression tend to pass out of a population over time, over a very, very long period of time — we’re talking hundreds of generations — because affected people have fewer children or fewer healthy children than non-affected people. The fact that this has not happened for this – depression — suggests that the genes are being selected for despite their potentially debilitating effects in a significant proportion of the population and therefore that these genes must be conferring some important adaptive advantage.
Now, before talking about what important adaptive advantage these genes could be conferring I think it’s important to note that there are other instances of genes that both predispose to an illness and confer an important adaptive advantage and the most quoted or most studied example is usually I would say sickle cell disease.
In sickle cell disease, red blood cells assume a rigid sickle cell that restricts their passage through narrow blood vessels. This leads to a number of serious physical complications, and in traditional or historical societies to a radically curtailed life expectancy. At the same time, however, carrying just one allele for the sickle cell gene prevents malarial parasites from reproducing inside red blood cells, and thereby confers immunity to malaria.
The fact that the gene for sickle cell disease is particularly common in populations from malarial regions suggests that at least in evolutionary terms, a debilitating illness in the few can be a price worth paying for an important adaptive advantage in the many.
Now, what important adaptive advantage could the depressive position be conferring? Now if I’ve made you fall asleep, I hope I haven’t, but if I have made you fall asleep then please wake up now because I think this is going to be the most interesting part of my talk. So what important adaptive advantage could the depressive position be conferring? Just as physical pain has evolved to signal injury and to prevent further injury, so the depressive position may have evolved to remove us from damaging, distressing, or futile situations. The time and space and solitude that the adoption of a depressive position 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 meaningful to us and relate to them more meaningfully and with greater compassion.
In other words, the depressive position may have evolved as a signal that something is seriously wrong and needs working through and changing or at least processing and understanding. Sometimes we can become so immersed in the humdrum of our everyday lives that we no longer have time to think and feel about ourselves and so lose sight of our bigger picture. The adoption of the depressive position can force us to cast off the pollyannish optimism and rose-tinted spectacles that shield us from reality; to take a step back, to reevaluate our priorities, and to formulate a realistic or the modest plan for fulfilling them.
Now although the adoption of the depressive position can fulfill what I would unfortunately call such a mundane purpose, it can also enable us to develop a more refined perspective and deeper understanding of ourselves, of our lives, and of life in general. From an existential standpoint, the adoption of the depressive position obliges us to become aware of our mortality and freedom and challenges us to exercise the latter within the framework of the former.
By meeting this difficult challenge, we are able to break out of the mold that has been imposed upon us, discover who we truly are, and in so doing, begin to give deep meaning to our lives. Many of the most creative and insightful people in our society suffer or suffered from depression or a state that may or would have been diagnosed as depression. They include the politicians Winston Churchill and Abraham Lincoln. The poets, Charles Baudelaire, Elizabeth Bishop, Hart Crane, Emily Dickinson, 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 Green, Leo Tolstoy, Evelyn Waugh and Tennesee Williams and the list just goes on and on and on.
To quote Marcel Proust, who himself suffered from very severe depression, “Happiness is good for the body, but it is grief which develops the strength of the mind”. I take it that the clapping is for Marcel Proust.
Now you see, people in the depressive position are often stigmatized as failures or losers. Of course, nothing could be further from the truth. If these people are in the depressive position, it is just 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 these people are in the depressive position, it is because their world was simply not good enough for them. They wanted more, they wanted better and they wanted different. And not just for themselves, but for all those around them.
So if they are failures or losers, this is only because they’ve set the bar far too high. They could have swept everything under the carpet and pretended, as so many people do, that all is for the best in the best of possible worlds. However, unlike most people, they had the strength and the honesty to admit that something was amiss, to admit that something was not quite right. So rather than being failures or losers, they are all the opposite. They are ambitious, they are truthful and they are courageous and that is precisely why they became ill.
To make them believe that they are suffering from some mental disorder or some chemical imbalance in the brain and that their recovery depends entirely or even mostly on popping pills is to do them and to do us an immense disfavour. It is to deny them the opportunity not only to identify and address important life problems, but also to deny them the opportunity to develop a more refined perspective and deeper understanding of themselves and of the world around them and therefore, to deny them the opportunity to develop their highest potential as human beings.
