The Search for Meaning: Creative Responses to Depression
October 2007
Banner photo: Davis McCardle/Getty Images
Understanding Depression
Dr. Gordon Parker, author of Dealing with Depression, is a leading international expert on depression and mood disorders. He is Scientia Professor of Psychiatry at the University of New South Wales, Australia, and executive director of the Black Dog Institute, an educational, research, clinical and community-oriented facility dedicated to improving understanding, diagnosis and treatment of mood disorders. See www.blackdoginstitute.org.au
SGI Quarterly: How widespread is the problem of depression? Are we just diagnosing it more?
Gordon Parker: It is commonly thought that about one in four women and one in six men will experience an episode of clinical depression over their lifetime. This of course depends on how you define clinical depression. The data seems to suggest that most of the increase in mood disorders that we see is a consequence of destigmatization and people being happier to talk about mood disorders and seek help, and because of a distinct broadening in the definition of clinical depression in the last 30 years. However, studies have shown quite a big and definite increase in the incidence of bipolar disorder, particularly in people under the age of 30.
Not a Single "It"
SGIQ: How is depression defined?
GP: The North American model--introduced in 1980 and which is the most popular model--has been to regard depression as a single condition that merely varies by severity. Clinical depression, therefore, comprises having depression for a certain period of time, a certain number of features and also some impairment of functioning. But it's a very rubbery definition and can lead to overdiagnosis, while it doesn't recognize that there may be quite differing types of depression that have differing causes and, in fact, quite differing responses to therapy.
The trouble with this unitary model is that it then becomes very much dependent on who is trying to explain "it" as depression. So when you listen to medical practitioners, they tend to describe it as reflecting a chemical imbalance, neurotransmitter perturbations, and requiring medication. On the other hand, if you listen to psychologists, you nearly always get a more cognitive model where they say "it" is a reflection of dysfunctional attitudes or cognitive schema, whereby the individual sees the world in a way that is negative and as a consequence becomes depressed and, therefore, needs cognitive behavior therapy. And if you go to another professional group, you get a different explanation. So it's a bit like professional groups looking at the elephant and some concentrating on the trunk and some on the tail.
This is a very unfortunate model, in my view. It is like no other area in medicine, in that an individual with depression type "x" or type "y" essentially gets a diagnosis more dependent on the background, discipline and training of the practitioner, rather than on any characteristic of the depressive disorder itself. So with depression type "x" you might, if you see a medical doctor or a psychiatrist, get a drug. Conversely, if you see a psychologist with exactly the same type of depression, you might get cognitive behavior therapy, or if you see a counselor, you'll end up getting counseling.
My model of depression is neither binary nor unitary; it's a composite model. It assumes that there are some depressive disorders, like melancholia and psychotic depression, that are categorical and disease-like and where there is a neurotransmitter problem as the primary factor, usually reflecting a genetic contribution. Conversely, there are some people who get depressed because they have had a very severe stressor, such as their partner walking out on them. On the other hand, there may be people whose personality style is such that they are predisposed to becoming depressed, so somebody who is an anxious worrier is highly likely to develop depressive reactions as a result of their anxiety.
For the first group, where I assume there is a primary biological problem, I would argue that a drug-based approach is appropriate. In the second instance, where somebody is experiencing a psychosocial-caused event, then empathic support, some counseling and maybe some problem-solving therapy, would strike me as being the right approach. For the person who has the personality predisposition, you might do something about the trigger for the depression, but more importantly, you would try to redress their predisposing personality style. So our model asks what the cause or driver is, and tries to do something about that.
SGIQ: If your approach was implemented, would this result in less widespread use of pharmaceuticals?
GP: It's hard to know. We're seeing evidence of both overtreatment and undertreatment. What I mean by undertreatment is at two levels: there are people in the community who have depressive disorders that don't step forward because they don't know they are depressed, or there's stigma, or they are hesitant about medication. The second example is where I see someone with, to my mind, indisputable biologically-based depression who hasn't been receiving a drug but receiving talking therapy. It's like someone who's had their thyroid out but is receiving counseling rather than thyroid hormones.
Then of course we get examples of overtreatment where people either do not have a condition that is going to respond to an antidepressant, or have a minor condition, being treated with an antidepressant.
Recognizing Depression
SGIQ: How can someone experiencing a feeling of depression identify the point at which they need professional help?
GP: First, the depressed state must have some severity to it: you not only feel depressed but you are not getting much or any pleasure out of life, you can't be cheered up and you feel everything's pretty bleak, and you are failing to socialize as you would normally do.
Second, it is impairing your functioning. Either you can't get to work or, more commonly, you get to work but you can't fire up, and you are not able to interact with people.
Third, there must be a minimum duration to it. In the DSM [Diagnostic and Statistical Manual of Mental Disorders], for major depression this is two weeks. I think this is a pretty reasonable period because that gets around the fact that everybody gets depressed at some stage in their lives, but most of us have the benefit of what is called spontaneous remission. Our boss tells us we're hopeless and we're going to get fired, and we might feel pretty dreadful. But for most people, within a few days they have processed it and they've said, "Well, my boss is an idiot," or "Oh, it doesn't matter." Eighty percent of the community has this capacity for spontaneous remission, and so we don't want to go diving in there and start treating people with drugs, or being overly zealous in terms of treatment at that stage.
Those, then, are the triad of criteria that I would use for clinical depression: severity, duration and impairment.
SGIQ: What about people who have gone through a clear trauma--divorce or losing a parent?
GP: Here it gets a bit difficult, because knowing the cause doesn't always tell you about the diagnosis or the treatment. For instance, somebody might have a partner walk out on them and they might experience a grief reaction, or they might experience a reactive depression or, if they have a biological predilection to biological mood disorder, they might develop melancholic depression.
Grief is easy to distinguish from depression. In the pure state of grief there's no drop in one's self-esteem, whereas with depression the central feature is a drop in one's self-worth. That doesn't mean that grief is less serious or less severe, but for somebody who's mourning the loss of another person, their self-esteem will generally be OK.
SGIQ: There is tremendous pressure in our society to be energetic and on top of things. What relationship do you see between those social norms and depression?
GP: I would come at this in two ways. The first is the concept of anomie, which was introduced by the sociologist Durkheim over 100 years ago. He basically said that communities are either integrated or disintegrated. You have integration when you've got mooring posts and people feel closely affiliated--via church or other community groups, and/or when they're opposed against an external oppressor.
When the community integration is high, you have lower rates of depression. In the Western world, we're finding the mooring posts, the integrating components, losing their relevance. So this concept of anomie--a sense of social disintegration--could explain increased rates of depression.
Then, in the last few decades it has been noticed that as levels of material wealth have gone up, happiness levels have commonly decreased. There are now indices of happiness across differing regions. We are being constantly encouraged to chase happiness by consumer marketing campaigns, but when we have a value system in which people believe that you can chase happiness, then, paradoxically, you get a drop in well-being in the community.
SGIQ: What about depression in non-Western or indigenous societies?
GP: It's not really the area of my expertise, but the general finding when people have gone into non-Western regions is that the apparent lower levels of depression have a lot to do with the stigma of talking about it. Also, when people in those regions do step forward to seek help, they tend to somatize--so they won't go to a doctor and say they feel depressed; they will say, "I've got a headache."
SGIQ: Do you think depression might sometimes be a necessary or important experience for an individual?
GP: I think that at times it is important for us to have a look at ourselves and say, "Why am I feeling like this? What does it mean?" I think there's a capacity to turn it into something positive-just the same as when people have serious physical conditions. Lance Armstrong, for example, after his operation for testicular cancer, said, given the choice, if he lived his life over, he would prefer to go through that again, because he learned value and so many things.
So I buy the argument up to a certain level, but severe, melancholic depression is so serious and such a horrible state that I don't see any such argument holding for it.
SGIQ: For people who have a loved one with depression, it's often very difficult to know how to effectively offer support.
GP: We have just published a book called Journeys with the Black Dog. We've had over 600 people tell us how they came out of depression and what helped them. The most consistent advice that people found beneficial was somebody very kindly and gently saying to them, "This will pass." And there are two components to that spoken phrase. First, it's not judgmental and it's supportive. And second, the metacommunication--the signal that you're giving--is an important one. I am not going to say to you, "Pull up your socks and get on with things"--the kind of comment that shows I have no understanding of what you're suffering. I am going to say, "This will pass and I will be with you, and don't feel under pressure."
It comes down to empathy and compassion, knowing when to support, and how to support. And sometimes that can be just sitting with the person, or it can be saying to the person, "Tell me how can I be of help." The message is one of support at the verbal level. But at the metacommunication level the message is one of "I'm with you."
