The Myth of Biological
Depression
by Lawrence Stevens, J.D.
Unhappiness or "depression" alleged to be the result of
biological abnormality is called "biological" or
"endogenous" or "clinical" depression. In her book The Broken Brain: The Biological Revolution
in Psychiatry, University of Iowa psychiatry professor Nancy
Andreasen, M.D., Ph.D., says "The older term endogenous
implies that the depression `grows from within' or is
biologically caused, with the implication that unfortunate and
painful events such as losing a job or lover cannot be considered
contributing causes" (Harper & Row, 1984, p. 203).
Similarly, in 1984 in the Chicago Tribune newspaper
columnist Joan Beck alleged: "depressive disorders are
basically biochemical - and not caused by events or
environmental circumstances or personal relationships"
(July 30, 1984, Sec. 1, p. 16).
The concept of biological or endogenous depression
is important to psychiatry for two reasons. First, it is
the most common supposed mental illness. As Victor I. Reus,
M.D., wrote in 1988: "The history of the diagnosis and
treatment of melancholia could serve as a history of psychiatry
itself" (appearing in: H. H. Goldman, editor, Review of
General Psychiatry, 2nd Edition, Appleton & Lange, 1988,
p. 332). Second, all of psychiatry's biological
"treatments" for depression - whether it is drugs,
electroshock, or psychosurgery - are based on the idea that the
unhappiness we call depression can be caused by a biological
malfunction rather than life experience. The erroneous
belief in biological causation justifies the otherwise
unjustifiable use of biological therapies. And the
biological therapies justify the existence of psychiatry as a
medical specialty distinguishable from psychology or
counselling.
Many professional and lay people today think depression can be caused
by "chemical imbalance" in the brain even though none
of the "chemical imbalance" theories of depression have
been verified. Some of them are discussed by Dr. Andreasen
in her book The Broken Brain.
One of the theories she describes is the belief
that "depression" (what I think should be called
simply unhappiness or severe unhappiness) is the result of
neuroendocrine abnormalities indicated by excessive cortisol in
the blood. The test for this is called the
dexamethasone-suppression test or DST. The theory behind
this test and the claims of its usefulness were found to be
mistaken, however, because, in Dr. Andreasen's words, "so
many patients with well-defined depressive illness have normal
DSTs" (pp. 180-182). An article in the July 1984
Harvard Medical School Health Letter reached a similar
conclusion. The article, titled "Diagnosing
Depression: How Good is the `DST'?", reported that
"For every three office patients with an abnormal DST, only
one is likely to have true depression. ... [And] a large
fraction of people who are depressed by other criteria will still
have normal results on the DST" (p. 5). Similarly, in
an article in the November 1983 Archives of Internal
Medicine three physicians concluded that "Data from
studies currently available do not support the use of the
dexamethasone ST [Suppression Test]" (Martin F. Shapiro,
M.D., et al., "Biases in the Laboratory Diagnosis of
Depression in Medical Practice", Vol. 143, p. 2085). In 1993 in her book If It Runs In Your Family:
Depression, Connie S. Chan, Ph.D., acknowledges that
"There is still no valid biological test for
depression" (Bantam Books, p. 106). But despite its
having been discredited, some biologically oriented
psychiatrists are (apparently) so eager for biological
explanations for people's unhappiness or "depression"
that they continue to use the DST anyway. For example, in
his book The Good News About Depression, published in
1986, psychiatrist Mark S. Gold, M.D., says he continues to use
the DST. In that book Dr. Gold claims the DST is
"highly touted as the diagnostic test for biologic
depression" (Bantam, p. 155, emphasis in original).
In The Broken Brain, Dr.
Andreasen also describes what she calls "the most widely
accepted theory about the cause of depression...the
`catecholamine hypothesis.'" She emphasizes that
"the catecholamine hypothesis is theory rather than
fact" (p. 231). She says "This hypothesis
suggests that patients suffering from depression have a deficit
of norepinephrine in the brain" (p. 183), norepinephrine
being one of the "major catecholamine systems" in the
brain (pp. 231-232). One way the catecholamine hypothesis is
evaluated is by studying one of the breakdown products of
norepinephrine, called MHPG, in urine. People with
so-called depressive illness "tended to have lower
MHPG" (p. 234). The problem with this theory,
according to Dr. Andreasen, is that "not all patients with
depression have low MHPG" (ibid). She accordingly
concludes that this catecholamine hypothesis "has not yet
explained the mechanism causing depression" (p. 184).
Another theory is that severe
unhappiness ("depression") is caused by lowered levels
or abnormal use of another brain chemical, serotonin. A
panel of experts assembled by the U.S. Congress Office of
Technology Assessment reported in 1992 that "Prominent
hypotheses concerning depression have focused on altered
function of the group of neurotransmitters called monoamines
(i.e., norepinephrine, epinephrine, serotonin, dopamine),
particularly norepinephrine (NE) and serotonin. ...
studies of the NE [norepinephrine] autoreceptor in depression
have found no specific evidence of an abnormality to date.
Currently, no clear evidence links abnormal serotonin receptor
activity in the brain to depression. ... the data currently
available do not provide consistent evidence either for altered
neurotransmitter levels or for disruption of normal receptor
activity" (The Biology of Mental Disorders, U.S.
Gov't Printing Office, 1992, pp. 82 & 84).
Even if it was shown there is some
biological change or abnormality "associated" with
depression, the question would remain whether this is a cause or
an effect of the "depression". At least one
brain-scan study (using positron emission tomography or PET
scans) found that simply asking normal people to imagine or
recall a situation that would make them feel very sad resulted
in significant changes in blood flow in the brain (Jose V.
Pardo, M.D., Ph.D., et al., "Neural Correlates of
Self-Induced Dysphoria", American Journal of
Psychiatry, May 1993, p. 713). Other research will
probably confirm it is emotions that cause biological changes in
the brain rather than biological changes in the brain causing
emotions.
One of the more
popular theories of biologically caused depression has been
hypoglycemia, which is low blood sugar. In his book
Fighting Depression, published in 1976, Harvey M. Ross,
M.D., said "In my experience as an orthomolecular
psychiatrist, I find that many patients who complain of
depression have hypoglycemia (low blood sugar). ... Because
depression is so common in those with hypoglycemia, any person
who is depressed without a clear cut obvious cause for that
depression should be suspected of having low blood sugar"
(Larchmont Books, p. 76 & 93). But in their book Do
You Have A Depressive Illness?, published in 1988,
psychiatrists Donald Klein, M.D., and Paul Wender, M.D., list
hypoglycemia in a section titled "Illnesses That Don't Cause
Depression" (Plume, p. 61). The idea of hypoglycemia as
a cause of depression was also rejected in the front page
article of the November 1979 Harvard Medical School Health
Letter, titled "Hypoglycemia - Fact or
Fiction?"
Another theory of a physical disease causing psychological unhappiness
or "depression" is hypothyroidism. In her book
Can Psychotherapists Hurt You? psychologist Judi
Striano, Ph.D., includes a chapter titled "Is It Depression
- Or An Underactive Thyroid?" (Professional Press, 1988). Similarly, three psychiatry professors in 1988 asserted
"Frank hypothyroidism has long been known to cause
depression" (Alan I. Green, M.D., et al., The New
Harvard Guide to Psychiatry, Harvard Univ. Press, 1988, p.
135). The theory here is that the thyroid gland, which is
located in the neck, normally secretes hormones which reach the
brain through the bloodstream necessary for a feeling of
psychological well being and that if the thyroid produces too
little of these hormones, the affected person can start feeling
unhappy even if no problems result from the endocrine (gland)
problem other than the unhappiness. The American Medical
Association Encyclopedia of Medicine lists many symptoms of
hypothyroidism: "muscle weakness, cramps, a slow heart rate,
dry and flaky skin, hair loss ... there may be weight
gain" (Random House, 1989, p. 563). The
Encyclopedia does not list unhappiness or
"depression" as one of the consequences of
hypothyroidism. But suppose you began to experience
"muscle weakness, cramps...dry and flaky skin, hair loss
... weight gain"? How would this make you feel
emotionally? - depressed, probably. Just as hypothyroidism
(hypo = low) is a thyroid gland that produces too little,
hyperthyroidism is a thyroid glad that produces too much.
Therefore, if hypothyroidism causes depression, then it
seems logical to assume hyperthyroidism has the opposite
effect, that is, that it makes a person happy. But
this is not what happens. As psychiatrist Mark S. Gold,
M.D., points out in his book The Good News About
Depression: "Depression occurs in hyperthyroidism,
too" (p. 150). What are the consequences of
hyperthyroidism?: Dr. Gold lists abundant sweating, fatigue, soft
moist skin, heart palpitations, frequent bowel movements,
muscular weakness, and protruding eyeballs. So both hypo-
and hyper- thyroidism cause physical problems in the
body. And both cause "depression". This is
only logical. It is hard to feel anything but bad
emotionally when your body doesn't feel well or work
properly. It has never been proved hypothyroidism affects
mood other than through its effect on the victim's experience of
feeling physically unhealthy.
Some people think chemical imbalance related to hormonal
changes must be a possible cause of "depression"
because of the supposed biological causes of women's moods at
different times of their menstrual cycles. I don't find
that argument convincing, because I've known so many women whose
mood and state of mind was consistently unaffected by her
menstrual cycle. Psychology professor David G. Myers,
Ph.D., labels premenstrual syndrome (PMS) a myth in his book
The Pursuit of Happiness (William Morrow & Co., 1992,
pp. 84-85). Of course, some women experience physical
discomfort due to menstruation. Feeling lousy physically
is enough to put anybody in a bad mood.
Some people believe women experience undesirable
mood changes for biological reasons because of
menopause. However, a study by psychologists at University
of Pittsburgh reported in 1990 found that "Menopause
usually doesn't trigger stress or depression in healthy women,
and it even improves mental health for
some". According to Rena Wing, one of the psychologists
who did the study, "Everyone expects menopause to be a
stressful event, but we didn't find any support for this
myth" ("Menopausal stress may be a myth", USA
Today, July 16, 1990, p. 1D).
It is also widely believed that women go through a
period of depression for biological reasons after giving birth to
a child. It's called postpartum depression. In his book
The Making of a Psychiatrist, Dr. David Viscott quotes
Dr. George Maslow, a physician doing an obstetrical residency,
making the following remark: "Come on, Viscott, do you
really believe in postpartum depression? I've seen maybe
two in the last three years. I think it's a lot of shit you
guys [you psychiatrists] imagined to drum up business"
(Pocket Books, 1972, p. 88). A woman who had given birth to
eight (8) children, which in my opinion qualifies her as an
expert on the subject of postpartum depression, told me what she
called "postpartum blues" are real, but she attributed
postpartum blues to psychological rather than physiological
causes. "I don't know about the physiological
causes", she said, but "so much of it is
psychological." She said "You feel awful about
your looks", because in our society a woman is
"supposed" to be thin, and for at least a short time
after giving birth a woman just isn't. She also said after
childbirth a woman feels considerable "physical
exhaustion". Childbirth also is the beginning of new
or increased parental obligations, which if we are honest we
must admit are quite burdensome. The arrival of new or
additional parental obligations and the realization of the
negative ways new or additional parenthood obligations will
affect a woman's (or man's) life is an obvious non-biological
explanation for postpartum depression. It may not be until
the actual birth of the child that parents realize how
parenthood changes their lives for the worse, but a letter from
a female friend of mine who at the time was only three months
pregnant with her first child illustrates that depression
associated with childbirth may come long before the postpartum
period: She said she was frequently breaking down in tears
because she thought with a child her life would never the same
and that she would be a "prisoner" and wouldn't have
time to do what she wanted in life. A reason these
psychological causes are often not candidly acknowledged and
postpartum (or pre-partum) blues instead attributed to unproven
biological causes is our reluctance to admit the downside of
parenthood.
Another theory of biologically
caused depression is based on stroke damage in
the left front region of the brain causing depression. What
makes it seem possible this might be neurologically caused
rather than being a reaction to the situation a person finds
himself in because of having had a stroke is stroke damage in
the right front of the brain allegedly causing "undue
cheerfulness." However, a careful reading of books
and articles about neurology for the most part doesn't support
the allegation of undue cheerfulness from right front brain
damage. Instead, what most neurological literature
indicates sometimes results from right front stroke-related brain
damage is anosagnosia, usually described as lack of concern or
inability to know their own problems, not happiness or
cheerfulness (e.g., Dr. Oliver Sacks in The Man Who Mistook
His Wife for a Hat and Other Clinical Tales, Harper &
Row, 1985, p. 5).
Perhaps the most often heard argument is that antidepressant drugs
wouldn't work if the cause of depression was not
biological. But antidepressant drugs don't
work. As psychiatrist Peter Breggin, M.D., said in 1994,
"there's no evidence that antidepressants are especially
effective" (Talking Back to Prozac, St. Martin's
Press, p. 200). In studies placebos often do as
well. Even if so-called antidepressants did help, that
wouldn't prove a biological cause of "depression" any
more than would feeling better from taking marijuana or cocaine
or drinking liquor.
A careful reading of the books and articles by psychiatrists and
psychologists alleging biological causes of the severe
unhappiness we call depression usually reveals purely
psychological causes that explain it adequately, even when the
author believes he has given a good example of biologically
caused depression. For example, in Holiday of Darkness: A
Psychologist's Personal Journey Out of His Depression (John
Wiley & Sons, 1982), an autobiographical book by York
University psychology professor Norman S. Endler, Ph.D., he
alleges his unhappiness or so-called depression "was
biochemically induced" (p. xiv). He says "my
affective disorder was primarily biochemical and
physiological" (p. 162). But from his own words it's
obvious his depression was due primarily to unreturned love when
a woman he got emotionally involved with, Ann, decided to
"wind down" her relationship with him (pp. 2-5) and
when he suffered a career setback (loss of a research grant) at
about the same time (p. 23). Despite his claims of
biochemical causation, nowhere does he cite any medical or
biological tests showing he had any kind of biological,
biochemical, or neurological abnormalities. He can't,
because no valid biological test exists that tests for the
presence of any so-called mental illness, including allegedly
biologically caused unhappiness (or
"depression"). Similarly, in The Broken
Brain, psychiatry professor Nancy Andreasen gives the
example of Bill, a pediatrician, whose recurrent depression she
thinks illustrates that "People who suffer from mental
illness suffer from a sick or broken brain [emphasis
Andreasen's], not from weak will, laziness, bad character, or
bad upbringing" (p. 8). But she seems to overlook the
fact that Bill's allegedly biologically caused recurrent
depressions occurred when his father died, when he was not
permitted to graduate from medical school on schedule, when his
first wife was diagnosed with cancer and died, when his second
wife was unfaithful to him, when he was arrested for public
intoxication during an argument with her and this was reported
in the local newspaper, and when his license to practice
medicine was suspended because of stigma from psychiatric
"treatment" he received (pp. 2-7).
One of the reasons for theorizing about
biological causes of severe unhappiness or
"depression" is sometimes people are unhappy for
reasons that aren't apparent, even to them. The reason this
happens is what psychoanalysts call the unconscious:
"Freud's investigations shocked the Western world ...
Comparing the mind to an iceberg, largely submerged and
invisible, he told us that the greater part of the mind is
irrational and unconscious, with only the tip of the preconscious
and conscious showing above the surface. He maintained that
the larger, unconscious part - much of it sexual - is more
important in guiding our lives than the rational part, even
though we deceive ourselves into believing it is the other way
around" (Ladas, et al., The G Spot And Other Recent
Discoveries About Human Sexuality, Holt, Rinehart &
Winston, 1982, pp. 6-7). In An Elementary Textbook of
Psychoanalysis, Charles Brenner, M.D., says "the
majority of mental functioning goes on without consciousness...
We believe today that...mental operations which are decisive in
determining the behavior of the individual...even complex and
decisive ones - may be quite unconscious" (Int'l Univ.
Press, 1955, p. 24). A news magazine article in 1990
reported that "Scientists studying normal rather than
impaired subjects are also finding evidence that the mind is
composed of specialized processors that operate below the
conscious level. ...Freud appears to have been correct
about the existence of a vast unconscious realm" (U.S.
News & World Report, October 22, 1990, pp. 60-63).
People's unhappiness or so-called depression being caused by life
experience is not always obvious, because the relevant mental
processes and memories are often hidden in the unconscious parts
of their minds.
I believe unhappiness or so-called depression is always the result
of life experience. There is no convincing evidence
unhappiness or "depression" is ever biologically
caused. The brain is part of our biology, but there is no
evidence severe unhappiness or "depression" is
sometimes biologically caused any more than bad TV programs are
sometimes electronically caused. "[T]he question is
not how to get cured, but how to live" (Joseph Conrad,
quoted by Thomas Szasz, The Myth of Psychotherapy,
Syracuse Univ. Press, 1988, title page). "When mental
health professionals point to spurious genetic and biochemical
causes," of depression and recommend drugs rather than
learning better ways of living, "they encourage
psychological helplessness and discourage personal and social
growth" of the sort needed to really avoid
unhappiness or "depression" and live a meaningful and
happy life (Peter Breggin, M.D., "Talking Back to
Prozac" Psychology Today magazine, July/Aug 1994, p.
72).
THE AUTHOR, Lawrence Stevens, is a lawyer whose practice has included representing psychiatric "patients". His pamphlets are not copyrighted. You are encouraged to make copies for distribution to those who you think will benefit.
1998 UPDATE:
"...there are no clinical
tests for the 'chemical imbalances' that may contribute
to depression." Harvard Men's Health Watch (published by
Harvard Medical School) December 1998, page 6 (underline
added).
2000 UPDATES
"Brain scans cannot distinguish a depressed person from a nondepressed person and they have not located a cause for any psychiatric disorder. Indeed, they are mainly used in biopsychiatry to promote the profession to lay audiences by giving the false impression that radiological technology can distinguish between normal people and those with psychiatric diagnoses. The usual sleight of hand involves comparing photographs of a brain scan of a depressed patient and a nondepressed patient where there happen to be other differences between the two brains. Sometimes the differences simply reflect normal variation and sometimes they reflect drug damage. Brain scans cannot show differences between the brains of depressed and normal patients because no such differences have been demonstrated." Peter R. Breggin, M.D., in his book Reclaiming Our Children (Perseus Books, Cambridge, Mass., 2000), page 293.
"A serotonin deficiency for depression has not been found. ... Still, patients are often given the impression that a definitive serotonin deficiency in depression is firmly established. ... The result is an undue inflation of the drug market, as well as an unfortunate downplaying of the need for psychological treatments for many patients." Joseph Glenmullen, M.D., clinical instructor in psychiatry at Harvard Medical School, in his book Prozac Backlash (Simon & Schuster, New York, 2000), pages 197-198.
2001 UPDATE
"Part 6/Psychiatric Disorders
"ENDOGENOUS DEPRESSION AND MANIC-DEPRESSIVE DISEASE
"Etiology
...
"Biochemical Theories The biogenic monoamines (norepinephrine, serotonin, and dopamine) are the key elements in these theories. ... However, the aforementioned CSF [cerebro-spinal fluid] findings have not been consistent; in some patients with depressive illness, the CSF concentrations of bioamine metabolites are entirely normal. Most of the neurochemical theories of depression have been the result of reasoning backwards from the known effects antidepressants on various neurotransmitters. ...serotonin and its pathways are currently most strongly implicated in the genesis of depression; however, the reader should be reminded that only a decade ago it was widely held that depletion of norepinephrine fulfilled this role. ...
"[T]he biogenic amine hypothesis...leaves several fundamental questions unanswered. ... Why are the therapeutic results so inconsistent with the use of tricyclic antidepressants, the MAO inhibitors, and the serotonin reuptake inhibitors, all of which should favorably influence the balance of biogenic amines at the proper receptor sites? And why are the clinical effects of these drugs delayed for weeks while the biochemical reactions are almost immediate? ... At the present time, it must be conceded that there is no reliable biologic test for depression. ...
Psychosocial theories ... Among patients with primary depressive disorders, life events of a stressful nature were found to have occurred more frequently in the months preceding the onset of depression than in matched control groups. In the study of Thomson and Hendrie, this was equally true of patients with a positive family history of depression and those without such a history. Nor did patients with endogenous depression differ in this respect from those with reactive depression." (In other words, even people with supposedly endogenous depression had good reason, in terms of life-experience, to feel despondent or "depressed.")
Maurice Victor, M.D., Professor of Medicine and Neurology, Dartmouth Medical School; and Allan H. Ropper, M.D., Professor and Chairman of Neurology, Tufts University School of Medicine, Adams and Victor's Principles of Neurology - Seventh Edition, McGraw-Hill Medical Publishing Division, New York, 2001, pp. 1616-1618.
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