Thirty years ago, I submitted a manuscript for publication and received the following response from the editor: “There is nothing new here, but some ideas warrant repeating.” The manuscript was published.
I have already written about the problems in reframing psychiatric disorders as brain disorders, but I was inspired to write yet another post about depression more specifically when I read a passage that resonated with me—especially intriguing because it was not penned by a mental health professional but rather by a philosopher, Alva Noe, who also has acquired expertise in cognitive science and neuroscience.
In the preface to his book, Out of Our Heads: Why You Are Not Your Brain and Other Lessons from the Biology of Consciousness, he wrote the following about the idea that depression is a brain disease:
“In one sense, that is obviously true. There are neural signatures of depression. Direct action on the brain—in the form of drug therapy—can influence depression. But in another sense, it is obviously not true. It is simply impossible to understand why people get depressed—or why this individual here and now is depressed—in neural terms alone. Depression happens to living people with real life histories facing real life events, and it happens not only against the background of these individual histories but also against the background of the phylogenetic history of the species. The dogma that depression is a brain disease serves the interest of drug companies, no doubt; it also serves to destigmatize the struggle with depression, which is a good thing. But it is false.”
I think Noe has the perspective just right and expressed it eloquently. Unfortunately, as I’ve written in previous posts, he was wrong about one thing: construing psychiatric disorders as brain disorders has not ameliorated stigma.
The only solid rationale for the brain-disorders view is the plain truth in it, as Noe states. But this truth can obscure another truth that Noe has firmly in mind: in conjunction with genetic risk, disordered brains develop from disordered lives.
As my colleague, Tom Ellis, PsyD, ABPP, pointed out when he read this line, we should keep in mind that this adverse influence goes both ways; in his words, “Disordered lives damage brains no less than disordered brains damage lives.” The disorders in lives relate extensively to problematic relationships throughout the lifespan. Traumatic experiences in attachment relationships, earlier or later in life, are a particularly significant risk factor for depression. More broadly, I think of a pile-up of stress over the course of the lifetime as the major contributor to disordered brain functioning in depression, as it is in many other psychiatric disorders.
Simply put, the danger in the brain-disorders view of depression is that patients will focus solely on medical treatment (primarily, medication) and will not adequately address the stressful life experiences and relationships that play such a significant role in depression. The worst-case scenario is patients feeling hopeless because they are told they suffer from “treatment-resistant” depression owing merely to poor response to medication.
I feel fortunate to work in a hospital where treatment-resistant depression is addressed not only by refining the medication regimen but also through extensive education coupled with individual and group therapy along with family work—all in a therapeutic milieu that supports engagement in healing relationships with staff members and peers. Similarly, in outpatient settings, treatment with medication is optimally coupled with psychotherapy; marital and family therapy is always something to consider as well.
We need to attend to the health of the brain, but never to the neglect of the life of the person—who, as Noe emphatically states in his book, should never be reduced to a brain.
Allen, J.G. (2006). Coping with depression: From catch-22 to hope. Washington, DC: American Psychiatric Publishing.
Noe, A. (2009). Out of our heads: Why you are not your brain, and other lessons from the biology of consciousness. New York: Farrar, Straus and Giroux.