Robin Williams’s suicide has led many to open up about depression in an effort to raise awareness about how many people are living in misery. One of the most common themes in this public discussion has been that depression is a disease like any other.
In the days after the news of Williams’s death broke, Tony Blair’s former communications director, Alistair Campbell, wrote:
Depression has nothing to do with how popular or famous, unpopular or unknown, you are. It just is. Like cancer is. Like asthma is. Like diabetes is. Some people get it, some people don’t. It is a truly horrible illness, and must be viewed and treated as such.
But is depression just like cancer, asthma or diabetes? Making these comparisons can be useful in a personal sense, but if the analogy is not backed up by research, it may be standing in the way of helping people in need.
To be clear at the outset, some of us some of the time are so profoundly distressed about our lives that we may consider suicide or carry it through. Most of us at some time in our life will experience distress and that experience might include low mood and a pessimistic outlook. Some people inhabit that distressed state from time to time, others will experience it chronically. Some of us experience it more profoundly and more often than others.
This social-existential spectrum can be called a disease. But to call something a disease is only worthy if it illuminates our humanity rather than dims our sense of what it is to be human and if turning profound sadness into a medical condition brings with it the prospect of corrective action.
So before we medicalise misery consider the following things.
No test for depression
Depression has no blood test to validate it as a medical condition. Like other psychiatric diagnoses it is defined using presenting complaints (symptoms) to make the diagnosis. The problem is, these symptoms are then explained by the existence of the putative disease. This circular logic goes something like this:
Q: How do we know that this woman is depressed?
A: Because she has very low mood and a deeply pessimistic outlook on life.
Q: Why is she so miserable?
A: Because she is suffering from depression.
The diagnosis of depression is now so common that it has entered the vernacular, and so it has become a self-evident fact for us all. However, as American psychologist Martin Seligman famously commented, “depression is the common cold of psychiatry, familiar yet mysterious.”
The problem of definition
Depression commonly occurs in conjunction with other symptoms, especially anxiety. Some psychiatrists now argue that another diagnosis of common neurotic misery would be more valid. Until the late 20th century, neurotic misery was not even designated by many psychiatrists as a proper mental illness. Now even bereavement is being designated by the American Psychiatric Association as a mental disorder called depression.
Depression has been framed by medicine sometimes as a form of madness (psychosis) and sometimes as common misery (neurosis).
Do the drugs work?
Depression can be treated medicinally but the outcome is unpredictable. If a person with type 1 diabetes receives insulin, their distressing symptoms disappear and their measurable blood sugar alters at once. Without insulin they soon die. If a person with a diagnosis of depression is prescribed an antidepressant it may or may not have a beneficial impact. Sometimes it does and sometimes it does not. Sometimes the adverse effects of the drugs make patients feel worse.
According to research, those treated with a combination of drugs and psychological therapy are more likely to improve, but relapse is common, even in optimally treated cases. Some who improve still report low grade misery in their lives.
Other ways to help
All of this suggests that human misery is common, recurring and fairly impervious to clinical intervention. It ebbs and flows, mainly because it relates to personal circumstances, such as poverty, bereavement, divorce, job loss or the development of painful illness. A simple diagnosis of depression as a matter of “brain chemistry” can render the complex politics of daily life irrelevant. Poverty, domestic violence, child abuse, insecure employment can be ignored as sources of distress and dysfunction in troubled lives.
Depression is bound up for us all in the condition of being alive among inequality, oppression and multiple forms of recurring loss. Why would we expect to convert all of that complexity into a simple disease that can be measured and manipulated by medical technology just like diabetes or asthma?
Instead of making depression a disease like any other, to be treated with a technological fix, we must stand back and find a way of appreciating the role of suffering in human life and of helping ourselves and others when we are miserable.