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New research shows medications work for depression, but only modestly. Only a third of patients robustly respond to antidepressants. This news from the latest comprehensive meta-analysis of antidepressant clinical trials is neither surprising nor comforting.
The World Health Organization deems depression the fourth leading contributor to global burden of disease, affecting 350 million people. The giddiness of the halcyon 1970s hard science approach to understanding depression spurred research for a neurochemical cure.
This research helped to better understand how the brain works, but it also created a dubious bio-industrial complex and direct-to-consumer sale pitches. It is true, however, that the majority of people with depression are not receiving adequate, or any treatment at all.
What Many Depressed People Are Lacking
In the nimbus fog of the neurological advancements, we temporarily lost sight of the mind and the gardening tools necessary for its proper growth: enriching experiences, appropriate challenges and favorable environments.
As a medical school associate dean and an active clinician, I witness ravages of depression from groups as disparate as mostly privileged medical students to some of the most socially disadvantaged, depressed people in Chicago.
Both groups can suffer from lack of belongingness, loneliness, lost sense of value, purpose, meaning and the feeling of a less than secure future. But there are important differences.
For the past two decades, I’ve listened to, absorbed and passed on stories of woe, as background data for people’s state disability claims. In this capacity, we consult with people due to absent, inadequate or undocumented health care.
The ‘Invisible People’
Physical and mental health problems unfortunately go hand-in hand. Fifty percent of all inpatient medical health care coincides with 10 percent of people with significant psychiatric issues — largely depression, substance abuse and anxiety. Most of the claimants are denied state assistance on the first pass.
In talks, I’ve called these individuals “Invisible People.” Not only are they not part of our economy, they are not visible at all. They reside in Chicago, the hills of West Virginia, the great Southwest, Salt Lake City, everywhere. They suffer quietly in families’ or friends’ basements or backrooms. Some funnel in and out of shelters, jails or nursing homes.
My top priority when seeing them is to create a safe space and invoke permission for them to tell their life stories. For many, it’s the first time they voice — with any coherence — their powerful words to anyone. The stories are often rich and painful to hear, but not as painful as they are to live.
These are emotional stories of neglect, sexual or physical abuse, failed schools, governmental betrayal, witnessed or self-experienced trauma. Loss of loved ones from illness or gun trauma flood the narratives.
For some, telling their stories allows them to breathe, however briefly, and connect to their own unpacked lives. There is no illusion that this is a cure for anything, but simply voicing one’s story can be an important start.
Where Depression Comes From
It’s not necessary, however, to encounter the stress of medical school or horrible life circumstances to suffer from depression.
There may be inherited brain processes that make some people vulnerable to bouts of depression without obvious triggers. We always ask about family history of depression, as families may have a strong genetic component.
However, epigenetics, or how life experiences and environment turn on and off genes, begins to explain how environmental dynamics affect mind and brain. We are beginning to understand the dance of nature and nurture; who is doing the leading, who is following. We are discovering that social determinants of health are crucial to mental and physical health.
Depression’s Side Effects
Depression as a feeling can be useful. It signals that something is amiss, something needs attention.
But when the feeling is chronic, it causes compensatory mechanisms, rebound effects that may become the symptoms of the depressive disease itself. These result in social withdrawal, negative hypervigilance, ruminations — to name a few.
As medical school administrators, we endeavor to lessen the toxic stressors of medical school by listening to students, being thoughtful in response and employing considerable resources to the problem. I feel less empowered to change the river banks of life for my disability folks I meet with every Saturday.
It is not helpful, however, to objectify their lives or their brains.
More Powerful Than Drugs
Johann Hari, in his recent book, Lost Connections, concludes that belongingness, feeling valued, experiencing purpose and meaning and having sense of a reasonably secure future — in the grand scheme of things — are more powerful factors than drugs.
We might advance the frontiers of neuroscience, but in the absence of Hari’s building blocks and the hierarchy of needs Abraham Maslow described over a half a century ago, we will forever be hampered in our quest to spite the disease. Listening to their stories — non-judgmentally — is a start.
The cure for depression will never be solely found in a physician’s prescription pad. It is up to society and culture to foster the sense of belongingness, value, meaning and security we all crave as humans.
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