The depression misconception

Leading health authorities promote misunderstandings about depression, and it's harming depressed people and their loved ones.

One of the best things about Substack is the Comments section! I've been fortunate to attract some highly intelligent subscribers, who post thought-provoking comments in response to my articles. The following comment was left by one such subscriber, and as you'll see, it was so on-point that I actually edited the article in response to it:

This brief online conversation with Simonde prompted me to return to a topic that I've written about in many previous articles, in the light of a recently-published paper which takes leading international health organisations to task for "misleading the public" into harbouring potentially harmful misconceptions about depression, and to elaborate on my own understanding of what depression is, and is not.

The circular reasoning trap

The paper's title - 'A Descriptive Diagnosis or a Causal Explanation? Accuracy of Depictions of Depression on Authoritative Health Organization Websites' - contains the germ of the authors' critique. They assert that publicly available information on depression provided by many professional organisations, academic institutions and health authorities, is marred by the logical fallacy of circular reasoning (also known as begging the question/assuming the answer/petitio principii). That is, depression, which is a purely descriptive term that does not explain the depressed mood and accompanying psychomotor and behavioural signs and symptoms, is inaccurately presented as the cause of those signs and symptoms.

To clarify this point, the authors use the analogy of headache. In a press release for the study, co-author Jani Kajanoja explained:

"Depression should be considered as a diagnosis similar to a headache. Both are medical diagnoses, but neither explains what causes the symptoms. Like a headache, depression is a description of a problem that can have many different causes. A diagnosis of depression does not explain the cause of depressed mood any more than a diagnosis of headaches explains the cause of pain in the head."

Misleading Information on Depression Hampers Understanding

How would you react if you went to the doctor complaining of persistent headaches, and the doctor explained that the reason you're experiencing pain in your head is because you have a condition known as "headache"? You would no doubt conclude that your doctor was a complete idiot, and hightail it out of his or her office in search of someone more competent.

And yet that's exactly what happens to people who are experiencing low mood, sleep and appetite disturbances, loss of interest in the activities they normally enjoy, and persistent feelings of worthlessness and hopelessness. Almost invariably, these people are told that these symptoms are caused by a condition known as "depression"... and more often than not, they walk out clutching a prescription for an antidepressant which, they're assured, will "treat" this "condition".

As the authors of the new paper discovered, this circular reasoning is not only engaged in by doctors and other health professionals. On their websites, major health organisations and institutions mislead the public about depression by engaging in this logical fallacy of conflating cause with effect.

The authors analysed the top 30 web pages retrieved by Google searches for depression-related queries, that were managed by organisations of medical professionals, universities and governmental and non-governmental health organisations in English-speaking Western countries. Depression-related content was classified into three categories:

1. Causally explanatory, that is, content that explicitly described depression as causing the symptoms, for example: "Depression causes feelings of low mood, loss of pleasure, fatigue..."

2. Descriptive, that is, content that explicitly presented depression as a description of a cluster of symptoms, for example: "Depression describes a pattern of psychiatric symptoms including low mood, loss of pleasure..."

3. Unspecified, that is, content in which the nature of the causal relationship was ambiguous, for example: "People with depression experience a low mood, loss of pleasure..."

The results of the content analysis do not inspire confidence in the ability of supposed health authorities to provide high-quality information on "mental health" to the public:

"Surprisingly, none of the organizations in the analyzed texts presented depression explicitly as a descriptive label for a cluster of symptoms although this would have been scientifically accurate. By contrast, 16 (53%) of the analyzed institutions either explicitly described depression as causally responsible for the symptoms or used language that was both descriptive and causal."

A Descriptive Diagnosis or a Causal Explanation? Accuracy of Depictions of Depression on Authoritative Health Organization Websites

Websites providing misleading descriptions of the causation of depression included "those managed by the most authoritative mental health organizations worldwide, such as The World Health Organization, American Psychiatric Association, National Institute of Mental Health, and the National Health Service in the UK." This is particularly egregious in the case of the American Psychiatric Association, which literally wrote the book on diagnosis of psychological conditions, the Diagnostic and Statistical Manual of Mental Disorders (DSM):

"The American Psychiatric Association, in the DSM-5, makes explicitly clear that the diagnostic criteria of mental disorders are descriptive in nature because the underlying pathologies are not known [15, p. XLII]. Yet their own public website claims otherwise. This analysis demonstrates that when seeking to understand what depression is, people are very likely to meet misleading information from leading health authorities."

A Descriptive Diagnosis or a Causal Explanation? Accuracy of Depictions of Depression on Authoritative Health Organization Websites

I'm shocked, shocked I tell you, that "leading health authorities" can't be trusted to present accurate information.

How does circular reasoning on depression harm patients?

Is this focus on identifying circular reasoning just nit-picking? Isn't it OK for "the experts" to just dumb things down a bit when they're talking to regular folk, who don't have the benefits of a medical education? No way, say the authors. Their concerns about misleading presentations of the causes of depression are so cogently articulated that I'm going to quote them at some length:

"The pervasiveness of circular causal claims is concerning. The websites of professional health organizations are a highly impactful form of science communication, and it is important for several reasons that this messaging be scientifically accurate. First, scientific accuracy is critical for maintaining public trust in science and medicine. Misleading information can weaken public trust, which in turn can erode compliance with recommended health behaviors, jeopardizing the success of public health interventions [23]. Second, it is important to be able to identify the source of one’s suffering to respond to it effectively. If people are given inaccurate information about the causes and effects of medical conditions that leads them to misconstrue the sources of their suffering, they will not be able to make informed choices about their lives... a recent study which tracked people’s strategies for regulating their emotions showed that the better people were aware of the causes of their suffering, the better and the more successful were their strategies for regulating their negative emotions [24]. Evidence also indicates that people are often not aware of the causes of their negative emotions [24], making them vulnerable for misleading causal attributions—especially when these claims are presented as objective biomedical fact.

In the examples shown in this study, lay readers are misleadingly guided to believe that a known pathological disease process, external to their lives, is causing their suffering, when this is in fact not true [13, 22]. This may discourage them from looking for the actual causes of their low mood; disincline them from conceptualizing, understanding, and making meaning of their mental distress [5,24-26]; and promote prognostic pessimism and impair outcomes [27-30]. Although the circular claims may sound inconsequential at first glance, they may thus effectively hinder emotion regulation by creating an illusory causal explanation that undermines attempts to identify the true sources of the suffering and effectively obscure the links between mental distress, personal history,meaning, and cultural context [5, 18, 22, 24-26]."

A Descriptive Diagnosis or a Causal Explanation? Accuracy of Depictions of Depression on Authoritative Health Organization Websites

Depression as failure feedback

Depression is not a medical disorder. It is, as I stated in my response to Simonde, failure feedback. That might sound pretty harsh at first hearing, so allow me to explain what I mean.

Humans are goal-oriented creatures. Even those of us who don't consciously set goals and systematically work to achieve them, still have goals - such as getting a well-paying job, securing a pleasant place to live, finding a life partner or even just obtaining a tasty meal or getting to the dentist on time - and we experience emotional distress when we fail to achieve our goals.

Trivial failures, like bombing on your first attempt at a new recipe, or arriving late for the dentist because you didn't allow enough time to get through traffic, produce minor emotional distress in a psychologically healthy person - just some transient disappointment or frustration.

But failures that have major implications, such as being dumped by a romantic partner, missing out on a long-sought promotion, or losing your home due to bankruptcy, may precipitate much more profound and prolonged psychological distress, including the pattern of symptoms and behaviour that we call depression. Significant losses that don't result from our personal failings, such as becoming widowed or physically disabled, constitute major obstacles to our ability to achieve our life goals, and can thus induce the depression response. And finally, depression can, quite paradoxically, occur after a person has achieved a major goal, but then found that it didn't result in the outcome that they expected. In this case, the failure feedback occurs as the individual realises that they had, to borrow Stephen Covey's immortal phrase, climbed the ladder of success, only to realise it was leaning against the wrong wall.

It may sound shocking to people who have been inculcated with the narrative of depression-as-mental-illness, but depression is actually a functional, adaptive response to each of these categories of failure.

How so? Firstly, one of the hallmarks of depression is rumination, an obsessive focus on one's problems. Some evolutionary psychologists have argued that the highly analytical thinking style that characterises rumination is actually a useful approach to problem-solving (at least, up to a point), and that the behavioural manifestations of depression such as social withdrawal, loss of interest in usual activities and physical lethargy, are adaptations to facilitate this intense mental focus on one's problems:

"The analytical rumination hypothesis proposes that depression is an evolved response to complex problems, whose function is to minimize disruption and sustain analysis of those problems by (a) giving the triggering problem prioritized access to processing resources, (b) reducing the desire to engage in distracting activities (anhedonia), and (c) producing psychomotor changes that reduce exposure to distracting stimuli. As processing resources are limited, sustained analysis of the triggering problem reduces the ability to concentrate on other things."

The bright side of being blue: Depression as an adaptation for analyzing complex problems

Secondly, the obvious changes in behaviour of the depressed person attract the concerned interest of their loved ones. Friends and family members who notice that the depressed person is uncharacteristically withdrawn, downcast and unkempt, will (hopefully!!!) reach out to them and invite them to talk about their problems. Discussing one's problems with a skilled listener who cares enough about you to give honest and constructive feedback - not just validation and sympathy - can help you gain insight into your failures. Your former romantic partner may have dumped you because you're a real pain in the ass. That's useful to know. You can work on being less critical, whiny and demanding, and more generous and empathetic, so that you're more appealing to be around. Alternatively, you may have been dumped because your ex is the town bike, and you were just the latest stage in their Tour de Pants. Also useful to know. Watch out for that type, in future.

Friends and family members who are concerned about the depressed person will also encourage them to re-engage with the world. As I wrote in my response to Simonde, this social support can help the depressed person to accept reality, and reorient themselves to a more achievable goal. Didn't make the cut for professional sports? That's a real bummer, but the truth is, it was always a long shot. How about becoming a personal trainer or exercise physiologist instead? Dumped by that hottie from the gym, who's now dating a Mr Universe contestant? Let's face it, she was out of your league, and you knew it all along. How about a date with that nice girl from work who told your colleague that she's really into you?

You might think of depression as analogous to a young lion who unsuccessfully challenged the pride male, retreating to lick his wounds, until he has recovered sufficiently to venture out again. When he finally emerges to re-engage in the competitive business of life, he will do so with the benefit of less bravado and more wisdom.

Mental illness, or failure feedback?

What are the implications of framing depression as a "mental illness" vs framing it as failure feedback? The authors of the paper critiquing circular reasoning on depression have some rather strong opinions on the subject:

"Depression can be described as an adaptive response or a functional signal to adverse circumstances [54-58]. Contrary to the erroneous causal beliefs that circular claims promote, this approach underlines that low mood and/or loss of pleasure are often meaningful reactions to life events, and that they can be meaningfully understood. This approach is not only scientifically more accurate than claiming that symptoms are caused by their descriptive label, but it also has important beneficial effects for patients in practice. A recent preregistered randomized controlled study showed that framing depression as an adaptive response to life events led to less self-stigma among patients, stronger beliefs in their own agency over their symptoms, and more adaptive beliefs about the symptoms relative to framing it as a medical disorder [54]. This is likely at least in part because attributing the symptoms to an illness external to one’s life reinforces the beliefs that the problem is immutable and that the individual has little or no control over their suffering [59-60]—beliefs that can easily become self-fulfilling prophecies—but perhaps also (in part) because framing the problem as an adaptive response does not impede attempts by the individual to understand the singular sources of their suffering."

A Descriptive Diagnosis or a Causal Explanation? Accuracy of Depictions of Depression on Authoritative Health Organization Websites

The framing of depression as a medical disorder is a relatively recent occurrence; historically, depression was seen as a sickness of the soul rather than of the body. But once physicians staked their claim to the territory formerly occupied by village elders, shamans and priests, depression transformed from an episodic to a chronic condition. In his explosive book Anatomy of an Epidemic, Robert Whitaker presents a remarkable assemblage of quotes from psychiatrists and researchers in the pre-antidepressant era:

"Depression is, on the whole, one of the psychiatric conditions with the best prognosis for eventual recovery, with or without treatment. Most depressions are self-limited."

Jonathan Cole, National Research Council, 1964

"In the treatment of depression, one always has as an ally the fact that most depressions terminate in spontaneous remissions. This means that in many cases regardless of what one does the patients eventually will get better."

Nathan Kline, Director of Research at Rockland State Hospital, New York, 1964

"Assurance can be given to a patient and to his family that subsequent episodes of illness after a first mania or even a first depression will not tend toward a more chronic course."

George Winokur, psychiatrist at Washington University, 1969

"Most depressive states are self-limiting (Klerman and Barrett, 1973); that is, they will run their course and terminate with virtually complete recovery without specific intervention. Rennie (1942) reported a 95 percent recovery rate prior to the advent of antidepressant drugs or ECT. It is difficult, therefore, to judge the efficacy of a drug, a treatment (e.g., ECT), or psychotherapy in depressed patients."

Dean Schuyler, head of the depression section at the National Institute of Mental Health, 1974

What did these august doctors know, that their contemporary counterparts have forgotten? Depression is a normal and natural response to life's setbacks, and most people recover from it without the need for any 'treatment' at all, after they have worked through the setback in their own fashion.

Aside from the medicalisation of human suffering, there are other factors that contribute to the dramatically increased prevalence and chronicity of depression in our times. Ultraprocessed food, sedentary and indoor lifestyles lived under artificial light, insufficient quantity and/or quality of sleep, and social isolation, rob people of the requirements for health that I discussed in last week's post, generating chronic inflammation that perpetuates the psychophysiological disturbances seen in depression.

That's why any approach to "treating" depression must be both grounded in an accurate understanding of its initiating and perpetuating factors, and comprehensive enough to address all of these factors, at a pace that is manageable for the depressed person. Effective therapy directs the depressed individual to forthrightly face the failure or loss that precipitated the depressive episode; to carefully analyse its causes, discarding inaccurate interpretations along the way; to forge a sense of meaning or purpose out of the failure or loss; to develop and implement a realistic plan to solve the problems created by the failure or loss; and to support themselves through this process by securing all of the requirements of health and avoiding the causes of disease.

As the originators of the analytical rumination hypothesis of depression put it,

"Depression is nature’s way of telling you that you’ve got complex social problems that the mind is intent on solving. Therapies should try to encourage depressive rumination rather than try to stop it, and they should focus on trying to help people solve the problems that trigger their bouts of depression... When one considers all the evidence, depression seems less like a disorder where the brain is operating in a haphazard way, or malfunctioning. Instead, depression seems more like the vertebrate eye—an intricate, highly organized piece of machinery that performs a specific function."

Depression's Evolutionary Roots

At the risk of stating the bleeding obvious, no pill or procedure can perform that "specific function" of facilitating problem-solving; in fact, antidepressants and ECT hinder problem-solving by blunting the emotions and impairing concentration, and thus increase the likelihood that a bout of depression will turn chronic. A cynic might suspect that the medical-industrial complex was engaging in market expansion rather than striving to assuage human suffering. Bahahahaha.

As always, I'm interested in your feedback. Does this model of depression-as-failure-feedback accord with your own experiences of depression, or your observations of depression in others? You know what to do:

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And finally, this post has taken me approximately 15 hours to research and write. I make all my posts freely available to all readers, because I believe we all deserve access to information that helps us to take greater control over our health. But I rely on my small core of paid subscribers to provide this service to those who genuinely can’t afford it.

For information on my private practice, please visit Empower Total Health. I am a Certified Lifestyle Medicine Practitioner, with an ND, GDCouns, BHSc(Hons) and Fellowship of the Australasian Society of Lifestyle Medicine