Sunday, May 3, 2015

Why I Question the Disease Model for Depression (and Why You Should Too)

Why I Question the Depression as
a “disease” Model
(and why you should too)

With large events like the Germanwings incident and the subsequent discovery that the copilot who commandeered the craft into a mountainside suffered from "depression" (clearly something else was amiss with the young copilot other than depression) as well as celebrities committing suicide and it being revealed that they had battled depression, we get the calls to understand that depression is a disease. Even one my favourite neuscientists Robert Sapolsky wrote an impassioned piece for the LA Times imploring that mental illness was a terrible disease

But is it? Is depression a disease that runs some terrible inevitable course? Is any mental illness necessarily a disease?

I can assure you that I completely understand how hard a bout of depression is. I know deeply well how difficult my various disorders are (very advanced bipolar disorder type I with severe depressive episodes, Borderline Personality Disorder, at times Major Anxiety Disorder). It is not possible for the vast majority of the population to have suffered depression any worse than the worst of bipolar depression or major depressive disorder (both of which together make up only a small percentage of depression cases) so yeah, I do understand how hard it is. Trust me, I DO. To the point I was willing – nay, driven - to take a knife to my throat or jump in front of a train to make it all stop. So yeah, I get how hard it is to suffer through. I get that it is suffering.

Yet there are several problems with the disease model. Chief among them is that there exists no scientific evidence for depression starting out as a disease in the sense that, say, MS does. Literally tens of thousands of researchers around the globe doing the most advanced brain research in the history of mankind and yet no proof, no smoking gun for a disease marker or any biological marker that leads to a single cause or root for depression. So sorry, until you have a solid biological and physiological marker, it is simply not true nor scientifically or medically valid to state that depression is a “disease”.

An enormous part of the problem, I've found is the semantics of the word "depression" itself. 

There is a whole spectrum to this largely psychological phenomenon that we experience as "depression" with a wide variety of possible causes or triggers. We don't have the time or space to get to that today but it is essential to understand there is no one single experience or physiological or neurological basis for this mental experience. 

Another huge issue I have with the disease model as it is generally understood is that it's largely a construct of the alliance (yes, it is an alliance) between the psychiatric industry (yes, it is an industry) and the pharmaceutical industries. And in the grand tradition of capitalist “marketing” (propaganda and misinformation are more accurate but those terms tend to be too provocative), the “disease” model has been sold as a vehicle to put money in the pockets of pharmaceutical companies, their executives, their sales reps and the doctors who flog their products to an unsuspecting public that is desperate for answers to their suffering. 

Sorry, but I have a huge issue with corporations (or any of the quacks out there for that matter) profiteering off of the suffering of others. Or, as I like to say, you may as well trust McDonald's research and models for "nutrition". The odds are about the same that massive multi-billion dollar corporations really give a shit about your mental health (or nutritional needs). What corporations care about is that they do - and sell - anything, and I mean anything, to meet their quarterly sales projections, satisfy their shareholders and make Wall Street happy. Don't for a moment kid yourself that they give a shit about what you're going through (nor the sales reps trying to make their sales quotas and make their house payments).

But the biggest reason I vehemently oppose the “disease” model of depression or mental illness isn't because there's no scientific proof, nor even that massive multinational corporations are profiteering off of our suffering (and regular readers here will know what a massive bee in my bonnet that is). No, it's neither of those two things. It's for the simple reason that, ironically, it's causing more people to suffer. It's causing more people to suffer longer. And – worst of all – it's causing more people to die.

And that is my biggest issue of all.

Like any decent human, I hate to see suffering and death. I hate even more to see completely needless suffering and death.

There is no question that depression is a major and widespread problem (and again I'll outline why as we go along). Those of us who follow the issue all know the numbers – one in four will suffer a significant depressive episode (not to be confused with the clinical definition of major depressive disorder) in their lives, all the thousands of lost work days, all the billions of dollars of lost wages and so on. And worst of all, the suicide deaths (to the tune of over 35,000 a year in the US and Canada combined).

So no, nobody - least of all, me - is arguing that it's not a problem and you can trust me when I say that I take depression or other mental health disorders more seriously than 99.9% of the people on the planet. But the number one worst way to make a serious problem hundreds of times worse and to prolong solving or alleviating it a hundredfold is to completely misunderstand the problem and stubbornly and steadfastly apply the wrong solutions.

That, folks, is the definition of insanity. And insane is exactly what the present day “mental health care” system and approach is.

If you study the history of mental health, you'll discover that depression as we know it today was very rare as recently as the fifties. Prior to that, the numbers of severely depressed people requiring hospitalization was very, very low and the numbers of people who never came out of it almost unheard of. And no, the medical and psychiatric establishments weren't so unsophisticated that they didn't recognize severe cases of depression. And prior to the fifties it's not like they didn't, you know, have things to get depressed about. I mean in the several decades prior to the fifties (from whence psychiatric problems began to skyrocket) there were only two world wars, the 1918 flu endemic (that took more lives than both world wars combined), the Great Depression, massive amounts of social injustice, no social safety nets and so on.

No, if you examine the history of depression (and there is very good literature on it going back to the genesis of Western medicine of Hippocrates' time), it never existed to the depth and breadth that does now. Depression is not getting better under the psychiatric/pharmaceutical disease model, it's exploding.

Then we're sold on the idea that it's a disease and that it's endemic. And the corporations and pill pushers laugh all the way to the bank. And we continue to suffer.

So yeah, I have a problem with that (and you should too). And the disease model is contributing to the problem becoming worse.

How is that?

I thought you'd never ask.

When people are convinced their depression is a “disease”, two things are likely to happen.

One is that they're going to be put on a merry-go-round of drugs or are subjected to ineffectual and potentially brain damaging treatments like electro convulsive therapy (or ECT as it's commonly known).

There are two problems with this approach. One is that no scientific proof for either the neurochemical basis for all anti-depressants exists nor are there any studies that show improved long term outcomes for drug therapy nor has any anti-depressant in history been able to outperform a placebo. (you can scour the world's scientific data banks and you'll find none of these).

So to begin with, people are being prescribed and are taking medications that are by all objective and scientific measures, completely ineffectual.

We may as well be performing blood letting to cure illnesses. Seriously, it's just like that.

Secondly, what you will find if you dig enough is all kinds of health problems – mental and physical – that are caused by anti-depressants (and virtually all psychotropic or psychoactive pharmaceutical drugs). I cannot possibly summarize the vast amounts of data and evidence that has been compiled over the past several decades but it is extensive, very well compiled and very, very real.

So that is a huge contributor to our “endemic” right there.

The other is very simple. If you keep following a certain model and applying the wrong solutions, that means you're not applying the right solutions.

Now it turns out that the vast majority of symptoms and causes of those symptoms are psychological in nature.

Now please keep in mind that I suffer from the worst form of bipolar there is and the defining feature of the worst form of bipolar is that it generates nuclear powered depressive phases. 

And when I got off the drugs that were killing me and started working – note that word working – on my depression, I realized that the vast majority of symptoms were being generated by my mind (one of the reasons bipolar is so tenacious and pernicious is that it's particularly “good” at generating nuclear powered thoughts).

What I found was that virtually everything I was suffering from was stuff I could work on (the one thing that is most outside the control of major bipolar or major depression sufferers and which is physiological in nature I outline in a highly acclaimed three part series starting here).

And I can one hundred percent guarantee that if you do not work on these things, then your chronic depression is very unlikely to get better.

The truth is that one the greatest contributor to depressive feelings is cognitive distortions, or distorted thoughts. And it is these distorted thoughts that set off the cascade of physiological symptoms and distorted dark "realities" in our minds.

And there are reasons for you experiencing these distorted thoughts (which is going to take a separate column to get into). If you are not exploring and becoming aware of what these reasons are (or triggers in psychology parlance), you are literally going to be their bitch.

So that's a huge problem with taking pills to solve emotional/psychological problems – they mask the real problems which means you don't work on the real problems which means depressive episodes will continue to make you their bitch no matter how much of the pharmacy you gobble down every day. Trust me, I have closets full of “been there, done that t-shirts” for that. And in the number of years I've been in the mental health care system I've seen hundreds of others going through the same thing. Lots of doctors, lots of pills, NOT getting better. I've seen very, very good people go through this and personally witnessed their stunning decline. It's sickening to watch (unbearable almost).

The other problem with the “disease” model is – and here's a new word for you – the very, very real nocebo effect. Now I need you to really, really understand the concept of nocebo. It's very real. And very deadly.

Nocebo, briefly, is the opposite of placebo and is tied to our very powerful belief generating neuronal networks. Both are incredibly powerful. And very well scientifically and medically studied and documented. There is no shortage of literature available on it.

Placebo is the more widely known of the two. Placebo is the MASSIVE elephant in the boardrooms of pharmaceutical companies (contrary to what you might think, they are painfully aware that none of their drugs can outperform placebos (and hence their misinformation marketing campaigns). Placebo is the belief of a positive outcome for something. Believe a pill or medication will make you better, and poof, it very well might. This is not just true for psychological problems, it's true for even serious medical problems. The placebo effect is so powerful that surgery can be performed with a placebo anesthetic and the patients will experience no pain. Placebo knee surgeries have been performed and the patients were thrilled with how their painful symptoms “disappeared”. This is all very well studied and documented.

The flip side is nocebo in which you believe in negative outcomes and those negative outcomes materialize for no other reason than the negative power of belief.

Take, for example, the belief system built up around a simple bone in a remote aboriginal tribe in Australia.

The man who discovers he is being “boned” by the shaman is indeed a pitiful sight. He stands aghast, with his eyes staring at the treacherous pointer, and with his hands lifted as though to ward off the lethal medium, which he imagines is pouring into his body. His cheeks blanch and his eyes become glassy and the expression on his face becomes horribly distorted ... He attempts to shriek but the sound chokes off in his throat, and all that one might see is froth at his mouth. His body begins to tremble and the muscles twitch involuntarily. He sways backward and falls to the ground, and after a short time appears to be in mortal agony.

After a while he becomes very composed and crawls to his wurley (hut). From this time onward he sickens and frets, refusing to eat and keeping aloof from the daily affairs of the tribe. Unless help is forthcoming in the form of a counter charm administered by the village medicine man, his death is only a matter of a comparatively short time.

  • anthropologist Herbert Brooks in a 1925 account witnessed in his earlier observations of Australian tribes people

So nothing has been done to the man, merely a bone being waved in his direction and some words uttered. But he so firmly believes in the shaman and the "deadly" curse of the bone that he did indeed get sick and die.

Ha-ha, I know what you're thinking! You're thinking we in the West are much more clever than that and would never fall for something like that. Guess again.

Take the case of “Mr. A”.

Mr A had been depressed for several months after his girlfriend broke up with him. He had a chance to take part in clinical trials for a new anti-depressant that was being tested at the time and decided to enter the trial. During the first month he felt that his mood had improved considerably and he experienced no troubles from the capsules.

During the second month he had another fight with his girlfriend and he decided to commit suicide by swallowing 29 of the capsules. But after doing so, he changed his mind and asked a neighbour to take him to the hospital.

He arrived there shaking and pale. His blood pressure was low and he was breathing rapidly. He was injected with a normal saline solution to maintain an adequate arterial tension, and his blood pressure rose; but it dropped again when the infusion was slowed. Lethargic, he received nearly two hundred ounces of saline over a period of four hours. At this point, a doctor from the clinical trial, who'd found out what had happened, arrived and told Mr A that he had taken a placebo. Mr. A expressed surprise followed by tearful relief. Within fifteen minutes, he was fully alert and his blood pressure and heart rate returned to normal. 

All these symptoms – and even death – and there is not a single physiological basis for either of them whatsoever.

And so this is what often (though not always) happens with the disease model of depression; the more people believe they have an “illness” that's “permanent” the more they'll a) believe they are more sick than they have any medical or physiological basis for and b) they'll refuse to recognize and work on the things they need to work on. ("These are not just “thoughts”, this is a serious illness!!”, etc).

And you'll almost always see worsening outcomes over time, a worsening outcome because a) they believe they are helpless because it's a “disease”, b) they leave "treatment" up to demonstrably ineffectual antidepressant medications and c) because they think it's disease, they ignore or do nothing about the real underlying causes.

Now it's true – and I can certainly vouch for this – what we experience in the worst throes of depression feels “real”. But it's not. It's virtually all created by our minds and the distorted thoughts we become subject to. (At some point I'll get to what is real when we're depressed – it's not all just thought distortions. I do get to the physiological basis for one symptom - the mental and physical fatigue - in that three part series I linked to above plus there are a number of other possible factors that I briefly outline in my post debunking quick fixes for psychiatric and mood disorders).

During my worst period of “mental illness” - a thirty month hell between July of 2010 when I was first diagnosed as bipolar and put on medications and the end of 2012 - a great deal of my worst suffering was, I discovered afterward, my full and complete belief that I had an “incurable” mental “illness”. Vast amounts of my hopelessness were because of this. And meanwhile I wasn't identifying or working on any of my triggers and underlying issues.

Everything I do now revolves around being aware of and controlling my thoughts. And again, there is no more powerful distorted thought generator than severe bipolar (more severe than even schizophrenia because of the sheer variety and polar opposite thoughts and beliefs).

And this is what I find tragic about so many cases of mental health breakdowns. People's outcomes become far worse because they're applying the wrong solutions to the wrong problems and are not aware of their real problems and real, doable solutions. All because they're so sure they have a "disease" and, like the nocebo examples we looked at, the more they believe this, the worse they get.

And the thing that I find empowering by not assuming the disease model is that it gives the power to turning around my depressive mental states to me. Not an uncaring doctor, not a harmful chemical compound in a pill, but me.

And this is what I see in the vast majority of depressive cases – people feeling totally disempowered to do anything about it and, as I'll outline in another column, the more disempowered we feel about our lives, the worse we'll suffer depression.

And THAT is a tragedy.

So look, I am NOT telling you that what you or a loved one are going through isn't serious. It absolutely is and I take it very seriously.

But I am a) sickened when I see worsening outcomes for no good reason at all (and even deaths by suicide) and b) I want you to feel empowered and inspired by the knowledge that you can do something to live a life not being depression's bitch.

For further reading along the same vein, please see the piecIs Depression an Illness?  by an acquaintance of mine, Dr Jeffrey Rubin.


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    1. Thank you for reading and for your feedback.