Melancholy secrets

When I was a young doctor and progressed half a century ago, depression was a rare condition, or at least a condition that was rarely diagnosed, which is not quite the same thing. In its severe forms it was unmistakable. Patients who seem to have everything to live for would turn their faces to the wall, almost literally, if their beds were against a wall; They might even suffer from Cotard Syndrome, the delusional belief that they had or were nothing, that their bodies were rotten, that they were in the final stages of impoverishment even with millions in the bank. I remember one patient who told me that he was already dead and that all that was left of him was the gangrenous tip of his nose. No logical argument could convince him that he was wrong. Electroconvulsive Therapy (ECT) very quickly returned him to his normal state of being a successful and wealthy businessman.

It was impossible to simply picture him as sick. But what about lesser forms of depression and human misery? When did the misery, understandable under the patient’s circumstances, become a disease? At the time there was a lively polemic between those who believed that depressive moods were bimodal and those who believed they were unimodal. Those who believed that there was a bimodal distribution divided the depression into endogenous (ie, due to the patient’s constitution) and reactive (ie, due to the patient’s reaction to his circumstances) shared depression. The former tended to be more severe, extreme, and bizarre than the latter, but it wasn’t necessarily; They admitted that under certain circumstances the circumstances could lead to deep depression, understandable disgust for life, and even suicide.

Interestingly, there was a similarly lively polemic between those who believed that hypertension was bimodal and those who believed it was unimodal. In the bimodal model, there was a separate group of people suffering from an undiscovered disease that resulted in exceptionally severe hypertension, while everyone else had blood pressure that was distributed around a mean.

It is now generally accepted that those who believed in unimodal distributions of both depressed mood and blood pressure won the argument. Personally, I think this is right for blood pressure, but wrong for depression. Once you’ve seen melancholy, as it used to be called, you can no longer confuse it with mood depression, however long. But I am very old fashioned.

In the past forty to fifty years the diagnosis of depression has become so common that up to one-sixth of adults in Western countries are taking antidepressants – or what critics might say, antidepressants. The word misfortune has almost been eliminated from the dictionary and no one complains about it; If they complain at all, it’s depression. A deviation from happiness and contentment, at least for more than two weeks, is now a disease: the standard human attitude is happiness, so to speak.

Of course, anyone who studies the story of Rasselas, Prince of Abyssinia will disagree, but few people care. The question that remains, addressed in this book with no definitive answer (because one cannot be given), is whether the increased number of diagnosed or self-diagnosed people suffering from depression represents a real increase in the prevalence of the disease, better recognition of a condition that was always there but ignored, or maybe a cultural fashion.

Jonathan Sadowsky’s Empire of Depression can only recommend it. It’s short and to the point, the author writes clearly with no jargon to add a false aura of depth to his writing, and he is undogmatic in an area that is not lacking in dogmas and dogmatists. He has clearly read a lot on the subject and in general his reasoning is sound. That’s not to say I agree with all of his judgments, but none of them are unjustifiable.

For example, I think he’s way too generous for general psychoanalysis and Freud in particular. That Freud was often acute in observing humanity is true, but so is La Rochefoucauld and Lichtenberg (actually a much higher percentage of the time and much more concise). Even fortune tellers are often acute observers of their clients, but such acuteness does not require the vast theoretical superstructure that Freud is said to have built on the basis of supposed observations, but actually on the basis of prejudices that are supported (as it has been pretty well by now) (established) through considerable recourse to mystification and outright lies about the results of his treatment. Psychoanalysis was by no means an aid to understanding, but often had a veiled effect on both doctors and patients and, as has often been mentioned, was professionally practiced almost as a religious cult, complete with heresies, heretics, heresiarches, excommunications and anathemas, with which evidence or truth had very little to do with. The observation that depressed adult patients often had emotionally deprived childhoods (if any) could be made without any psychoanalytic theory.

One of the problems with depression as a subject of study is that there are no clear biological markers to distinguish cases from non-accidents. Some endocrinological conditions mimic depression, and some drugs undoubtedly cause it. In the vast majority of cases, however, there are no measurable physical changes, apart from those that are caused by the symptoms themselves: In depression, symptoms and illnesses are at least one thing as far as we know today.

The author tries to avoid false dichotomies: genetic versus ecological, physical versus psychological, social versus individual, endogenous versus reactive. In medicine it is rare that the causes of a disease are both necessary and sufficient; Koch’s famous postulates are often unsatisfied even under relatively simple conditions, let alone in something as complex as depression.

While he says contempt is not helpful in understanding the story, he is somewhat disdainful of the idea that depression has a moral dimension. At no point does he believe that making a conscious effort to be resilient, for example, could play a useful role in preventing depression: He believes that being willing to admit and accept psychological vulnerability is clearly progress. In many cases it might very well be; However, this would be perfectly consistent with a rapid rise in population-based depression. Like a colleague of mine, Dr. Colin Brewer, once said, that misery is mounting to find the means available to alleviate it.

The author does not sufficiently take into account (in my opinion) the cultural meaning of the replacement of the word unhappiness by depression in common parlance. The practical effect is considerable. An unhappy person either has to come to terms with his unhappiness or analyze the reasons for it and try to change himself or his circumstances. The depressed person declares himself sick and transfers responsibility to another person to heal them. In the current medical environment, where physicians have very little time with each patient (and much of it is taken up with entering data or pseudo-data on a computer), a prescription is the most likely outcome.

The author suggests that those who downplay or deny the severity of depression tend to use the term character defect to explain its apparently increasing prevalence. But is there such a thing as a character flaw?

The prescribed pills may or may not help; If so, it may or may not be due to real antidepressant effects. In many cases, however, they don’t even work as a placebo (they can even function as a nocebo, a concept not featured in this book). Fortunately for the doctor, perhaps less so for the patient, there are many different doses and many different pills that can be tried before all pharmacological treatment options are exhausted. A kind of pas de deux can take place between the doctor and the patient over many months. At this point, the feelings of depression may in any case have subsided.

But things are far from easy. At least these days in medicine, it is not uncommon to prescribe drugs to a hundred people who know that it will only work for one of them but never know which one. This is the logic of prescribing antihypertensive drugs and statins, which are more likely to cause minor side effects than do good for any individual patient. However, when they do good, that is a very great good indeed. And precisely because depression is so protean, so vague, and so poorly understood, it is not easy to say which patient will benefit from which treatment. In Heaven, is there more joy in a recovered depressed person than over ninety-nine depressed people who have been given useless or even harmful medication? I don’t think there is or can be a definitive answer.

The author suggests that those who downplay or deny the severity of depression tend to use the term character defect to explain its apparently increasing prevalence. But is there such a thing as a character flaw? If it does not, does it not tend to drain all of human life of moral concern, as critics of overdiagnosis of depression say? In fact, the author is almost implying that the use of the term character mistake could be considered – a character mistake.

However, the situation is complex. I remember a patient in her early seventies who had run out of energy, enjoyed nothing and engaged in moping for about twenty years. As in every life, there were factors that could plausibly explain their misery. Neither treatment worked; it stayed the same. I was about to write her off as a character defect when I prescribed her a monoamine oxidase inhibitor, an old-fashioned drug that requires the patient to swear off certain foods to avoid a potentially dangerous reaction. To my great surprise and joy, but also to my shame at having written her off almost as lacking in character, she recovered from her zest for life, began to play the piano again and became lively. I found it hard to believe that this was just a placebo reaction: Why so late in the day? It is easy to write off people as bad characters, which does not mean that there are no such people.

The story I just told wouldn’t surprise Professor Sadowsky as he has a complex and refined view of depression rather than a simplified and crude view. It’s fairer than polemical, but there are omissions. There is surprisingly little mention of suicide in the book; he does not address the problem of how to distinguish between a plausible and a true cause of a mental state. After all, everyone has a cause for depression, but not everyone is depressed, even if their cause for depression is very strong.

However, I am happy to say that Professor Sadowski is a worthy follower of Hamlet: he does not despise or despise efforts to explain the condition of man, but neither does he believe that the heart of the mystery is about to be ripped out.

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