Julian Sheather: Is depression a problem of meaning or of medicine?

Julian Sheather In a recent article in the BMJ Paul Biegler returns to a familiar theme in some of the more reflective literature on depression. Should an episode of depression be seen primarily as a biochemical problem, a problem of brain chemistry, or is it a problem tied to the individual’s understanding of the world?

As Biegler points out, evidence suggests that in relation to less severe forms of depression, antidepressants and psychotherapy are about equally effective. It would seem to follow from this that depression can be alleviated both by changing a person’s brain, and by changing a person’s mind.

Biegler argues strongly in favour of a psychotherapeutic approach. He roots his preference in the principle of autonomy.

One of the primary goals of psychotherapy is self-knowledge. An understanding of the factors that precipitated the depression can furnish the individual with the skills necessary to avoid its recurrence.

In Biegler’s language, the self-knowledge that psychotherapy brings can lead to a more adaptive response to life’s inevitable stresses. This is something that medication alone is unable to provide.

Reflecting on my own experience, I say two cheers for Biegler. Enlightened self-government is no doubt a wonderful thing, and it would be difficult to argue with a therapeutic approach that maximises it.

The reason for the lack of a third cheer is because I think the question of autonomy is more mysterious than this. Behind the drugs versus therapy question lies a significant, and perhaps unanswerable philosophical problem, a problem that has deep significance for what it means to be a human being.

Philosophers know it as the mind-body problem. I do not fully understand the problem, but one aspect of it concerns the brain’s mysterious ability to create consciousness out of matter.

How is it that a physical substance can produce mental states, and, looked at the other way, how can mental states effect a physical substance? Depression sheds a certain dark light on this problem. An event in the world, such as the loss of a partner, can precipitate profound depression, complete with changes in brain chemistry.

Similarly, endogenous or ‘melancholic’ depression, which has no obvious external cause, can be effectively treated by antidepressants and a barren world can become meaningful again. It would seem that the same problem can be approached from two very different directions.

Autonomy, or to use a less technical language, the ability to make choices and to act upon them, remains at the heart of the matter, but not in quite the way Biegler sees it.

My twenties were shadowed with depression. Perhaps chief among its many miseries was a gradual dwindling away of the belief that I could change my life for the better.

Biegler writes of a ‘kindling’ effect, whereby depression is triggered at ever lower thresholds of stress. That was my experience. After my first attack it was as if the world had become mined, and it was impossible to say when some trivial-seeming event would trigger off the next bout.

For many years I avoided antidepressants, convinced that the problem was exclusively one of meaning: if I could but find the right way to live, depression would evaporate.

Despite years of expensive psychotherapy the circle of depression tightened. I lived an increasingly fearful life. My ability to make choices was compromised. Morally I became a shadow, as all my energies were directed at avoiding anything that would precipitate a debilitating attack.

And then I started taking the new generation of anti-depressants. Gradually my life began to change. They didn’t – they haven’t – ‘cured’ me of depression. To the best of my knowledge its roots lie deep in my personality, or in my brain chemistry, if that is where we inhere.

What they did was give me back some of the resilience those early attacks had taken away. Gradually I began to make decisions and see them through.

Life’s more ordinary crises did not completely fell me. Difficult decisions essential to my well being – decisions about work, about relationships – that I had been too fearful to make, were gradually made.

Slowly, in Biegler’s terms, anti-depressants gave me back my autonomy. Looking back it strikes me that depression, at least for me, is a problem of both medicine and meaning. Sometimes I look at the pill I take in the morning with a mixture of awe and unease. How is it that this tiny thing can make me feel so human? Does it follow therefore that I am nothing more than a handful of chemicals in need of a little balancing?

But then I push the thought further. Released by medicine from depression’s grip I can again operate in a world of choice and meaning, I can again take part in our human world. It would seem to me that I have both a mind and a brain.

Julian Sheather is deputy head of ethics at the British Medical Association.

Read Julian’s previous blogs:

Does art make people better doctors

Life before death