| The question came to me: in what way do these people have a disease? Certainly not in the way that someone going to the hospital in a diabetic coma has a disease, or someone who has cancer or who has had a heart attack. It’s just not the same kind of experience. So I began to question how this was a disease and the answers I got were not terribly satisfactory. Also, as I read about it, I didn’t see that there was any evidence of anatomical lesions. I had worked in pathology, I had done autopsies, and I knew that there were anatomical lesions for disease states. But there weren’t any for depression. I also discovered that people could move through it. They were depressed for a period of time and then they stopped being depressed, sometimes without any particular kind of treatment. And I wondered, what kind of disease exactly is that? There’s no pathogen that’s been discovered, there’s no anatomical lesion, there’s no fixed biochemical abnormality, there’s no particular downhill course for this condition. What makes it a disease?
I wanted to understand the experience of people who were diagnosed as being depressed so I began to talk with them and to hear their experiences. Some of these people had what we then called “endogenous” depressions, which at the time were considered distinct from the “reactive” depressions when you became depressed, had all the signs and symptoms, the weight loss or weight gain, lack of pleasure in life, a sense of hopelessness, fear about the future, discouragement and sometimes suicidal feelings. There were some people who experienced these things clearly as a reaction to events in their lives, but there were other people for whom these signs and symptoms just appeared, who were said to have an endogenous depression.
But when I talked with those people at length, I found that in their lives, too, things had gone on that made them significantly more depressed now than they were six weeks or six months before. And I began to read the psychological literature, Freud and Abraham, and to think about some of the theories about depression. And it just didn’t seem to be a disease. When I found myself depressed, at times it felt overwhelming in the way an illness did, but there was no illness. I realized these were ways I was looking at the world, things I was feeling. Primarily a sense of loss and a sense of confusion after losing a relationship.
In Unstuck, you quote Freud as writing that replacing neurosis with ordinary unhappiness is a worthy goal. You also point out that many psychopharmacologists praise the restoration of the “pre-morbid personality.” I was struck by how low the bar can be set. How realistic is it to set it higher?
If you think about those phrases, they’re pretty discouraging. [Laughter]. The bar is set extremely low. My own experience is that depression is the beginning. They’re talking about a state or a terrible condition. Their model is that it’s sort of like an infection, where you may have pneumonia now, and we’ll give you antibiotics for it, and your lungs will come back to what they were before. That’s the “restoring the pre-morbid personality.”
But depression is part of life. It’s not a particular disease state and there are lessons that it is bringing to us. If we can learn those lessons, then we can move ahead with our lives in ways that may be very different from the way we’ve lived before. For me, it’s entirely reasonable to set the bar far higher, to see that this is a wake-up call. Depression was a wake-up call for me and it is for the patients and people I see. If you view it as a disease state, then you’ll be perfectly happy to restore the pre-morbid personality. If you view it as a sign that something needs to change, then what you’re going to want to do is work for that change. To ask what needs to change, and what can I do as a person who is depressed. Or what can I do as a clinician to help promote that change.
In your book, you tell the stories of patients you’ve seen who worked their way through depression, some of them slowly and others surprisingly quickly. The story that moved me most was that of a man you called Milton, who came to you after two years of suffering through the breakup of his marriage and the fact that his wife moved with his son to California, 3000 miles from Washington, DC, where he lived. Please tell us that story. |
