Depression has a long history and melancholia (the name depression was given prior to the 20th century) is mentioned in the Aphorisms of Hippocrates, the ancient Greek father of modern medicine. And following Hippocrates numerous scholars wrote about the condition, from the Roman physician Galen to the early modern scholar Richard Burton, whose magnum opus, An Anatomy of Melancholy was published in 1621. By the start of the 19th century the term melancholia was starting to be replaced by the word depression, which comes from the Latin ‘deprimere’, meaning ‘to press down’. However while the word may be familiar to us it didn’t necessarily describe exactly the condition it does now and through the 19th century there were up to 30 types of melancholia described in the literature.
In the early 20th century psychoanalytic theories began to be proposed. For instance a 1917 paper by Freud titled Mourning and Melancholia suggested that when objective loss, such as the death of a family member, is experienced as a subjective loss in which the ego is compromised, it can result in long lasting feelings of lack, inferiority and unworthiness. Through the 20th century psychoanalytic theories of depression would abound as the discipline developed, with each new school of thought proposing its own model of depression or reinterpreting those already existing. In 1952 the first edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-1) was published with an entry for Depressive Reaction. This categorised a condition defined primarily in psychoanalytic terms but shortly after the publication of DSM-1 researchers would hypothesize that depression was caused by a chemical imbalance in neurotransmitters in the brain. By the time DSM-3 was published in 1980 depression was defined by a pattern of symptoms, which had the effect of expanding the number of people who could be said to suffer from depression. This expansion, which was not without its critics, mirrors the development and promotion of antidepressants and the biological model of depression, in which brain chemistry rather than psychology was primary.
In the early 1960s depression was thought to afflict perhaps 50 people in a million and was considered a psychotic rather than a neurotic condition, with sufferers commonly hospitalised. (1) . By the 1990s this figure had jumped to as many as 40,000 people per million. However these figures give no indication of the prevalence of mental health conditions in the wider population. In fact in the 1960s most patients presenting with this sort of problem, and there were many, would be diagnosed with anxiety and even depression was commonly seen as a defensive mechanism that served to allay underlying feelings of anxiety.
The medical profession had a ready answer for anxiety with a new class of drugs; tranquilizers. First Meprobamate, but this was soon superseded by the Benzodiazepines; Librium and later Valium. According to a 1973 paper 20% of all American women and 8% of all American men reported using a tranquilizer at some point in a given year. However these drugs had major drawbacks, not least that they were highly addictive, and, as these drawbacks became more apparent, their widespread use was called into question. At this point it seems there was a need to both continue to meet the needs of patients presenting with mental health concerns and to protect the profits of drug companies.
In the late 60s and early 70s there was a movement in psychiatry to better define mental health diagnoses. It was this that would lead to the defining of depression as a pattern of symptoms in DSM-3. It also coincided with a tightening of the regulation of pharmaceutical drugs following the thalidomide scandal of the early 60s, after which drugs had to specify their active ingredients, the outcomes sought and the time period for attaining those outcomes. The diagnostic criteria developed in the 70s and which appear in DSM-3 lent themselves to this approach. The first drugs marketed as anti-depressants had been developed as anti-histamines but they seemed also to affect mood, energy and anxiety, the very symptoms now used to diagnose depression. But there was also a need to educate the medical profession and when the pharmaceutical company Merck developed the drug amitriptyline as a treatment for depression they purchased 50000 copies of Frank Ayd’s book ‘Recognizing the Depressed Patient’ to distribute to GPs. (2)
So it seems the development of pharmaceutical treatments for depression and the expansion of its diagnostic criteria have gone hand in hand. This is in no way to suggest that those prescribed anti-depressants aren’t suffering in a variety of ways. To me it seems more that how that suffering has been labelled and understood has been shaped in ways that may serve interests other than simply those of the patients.
When DSM-3 was published the diagnostic criteria it provided for depression would make a promising target for a new class of anti-depressant drugs developed in the 1980s. These were the selective serotonin reuptake inhibitors (SSRIs), for which Prozac would become the poster child. The use of these drugs increased rapidly following their introduction. By 2000 10% of the US population was taking them (3) and in 2005 traces of Prozac were found to be present in tap water in the UK (4). And the expansion in the diagnosis of depression and the associated use of anti-depressant medication continues. In the UK prescriptions for antidepressants rose from 36 million in 2008 to almost 71 million ten years later (5), while globally the market for these drugs is now worth almost $15 billion (6) and depression is seen as one of the largest causes of ill health globally.
The World Health Organisation says there are more than 264 million people suffering from depression globally, that it’s now one of the leading causes of disability and a major contributor to the overall global burden of disease. According to the mental health charity Mind, in any given week in England 3% of the population will be suffering from depression and 8% suffering with a mixture of anxiety and depression. And quick search online will turn up numerous statistics about the economic costs of depression in the UK. These statistics hide the misery depression inflicts on individuals and their nearest and dearest but they lead me to ask why treatment for those suffering from depression isn't better?
In the UK the National Institute for Health & Care Excellence (NICE) recommendations for the treatment of depression include medication for even mild to moderate depression and a range of psychosocial interventions, mostly based on Cognitive Behavioural Therapy (CBT), which may be delivered by computer. A 2015 study by York University found that while CBT delivered by a trained therapist was an effective intervention for those suffering from depression they found there was little benefit when the therapy was delivered by a computer (7). Why anyone would be surprised by that I’m not sure but what it means is that most people with depression will end up being prescribed medication, which to me seems problematic.
I want to be clear here that the research shows that for those with severe and life threatening depression anti-depressant medication can be life-saving and, if one has been prescribed such medication, one should only stop taking it after discussion with your doctor. That said the wider efficacy of selective serotonin reuptake inhibitors (SSRI) and serotonin and norepinephrine reuptake inhibitors (SNRI) has been widely questioned. A 2008 study by Kirsh et al (8) suggested that the clinical significance of such drugs in the treatment of mild to moderate depression was low. There were significant criticisms of that study but the doubts about these drugs persist. A 2015 study found that even meta-analyses (studies that examine a large number of clinical trials and on which doctors often rely for guidance about the utility of particular treatments) looking at the efficacy of these drugs were subject to hidden bias and undisclosed conflicts of interest stemming from funding by drug companies. The clinical trials themselves aren’t problem free either, with more than two thirds of studies being industry funded and those studies up to four times more likely than independent research to find in favour of the drugs.
Despite these issues these drugs continue to be prescribed in ever increasing amounts and, due to high rates of relapse in depressive symptoms when patients stop taking the drugs, they’re often prescribed over long periods. Again this practice is based on research that some consider to be structurally flawed (9), while the long term use of these drugs may have negative side effects including aggression and suicidal ideation that have been widely under-reported in industry funded trials (10). My own view is that perhaps, particularly in view of the high relapse rates associated with them, there’s a deeper problem with both CBT and antidepressant medication. The high relapse rate suggests that these interventions suppress the symptoms of depression while leaving deeper causes unaddressed.
The writer Charles Eisenstein has suggested that the use of medication (and possibly CBT as well) in the treatment of depression is based on the idea that the patient’s perception and understanding of the world is in some way faulty (be that a deficiency of certain neurotransmitters in the brain or a badly constructed cognitive process). Eisenstein goes further asking if the converse might be true and that depression might not be an inappropriate response to the world we’ve created (he cites political polarisation, global warming and species extinction, the loss of meaningful work i.e. real vocation etc.) but a perfectly rational one. In all this he’s following the spiritual teacher Krishnamurti who famously said “It is no measure of health to be well adjusted to a profoundly sick society”. And these ideas seem to be supported by a 2013 study that found Afghanistan to have the highest rates of diagnosed depression in the world (11). It’s a view that seems to reassert the primacy of a psychological approach in which the patient’s subjective experience is once more given greater significance and is understood as more than a simple set of symptoms.
There’s much here that I’m inclined to agree with. However my concern as a practitioner of Chinese medicine is that this isn’t an immediately empowering insight for those suffering from depression. In part two I’m going to look at how traditional oriental medicine and particularly the 5 Element tradition might approach this.
Bruce Bell is a 5 Element acupuncturist working from clinics on the edge of Midsomer Norton, Radstock and Bath.