Myths about depression

(List of abbreviations at the end).

ABC radio recently carried an interview on depression, entitled Nine big myths about depression — busted. The speaker was their usual go-to-man on matters mental, Prof. Ian Hickie, co-director of Health and Policy at Sydney University's Brain and Mind Centre. Prior to that, he was director of BeyondBlue, subtitled the national depression initiative. It's a very suburban interview which serves to confirm the view that if you don't like everybody else's myths, make up your own. However, we should let the good professor speak, even though at times he appeared to be babbling in response to light-weight questions from the very sympathetic interviewer (in the intro, Hickie says he's been in psychiatry 40 years. Interviewer: "Oh wow... so you really know what you're talking about." As a statement, not a question).

He starts by saying "...things have really changed in a really positive way in the four decades now that I've been in (psychiatry)" but quickly indicates things are actually worse. In the old days, meaning pre-DSM III, he says, there were about fifteen types of depression but in 1980, "the Americans" decided there was only one type, the Major Depressive type, that "...would all be explained by the stress arousal system. It didn't matter what the cause was. This would be the explanation for everything" i.e. by biology. He agrees with that, making it quite clear that depression causes bad life events, not the other way around:

Hickie: ... you are depressed. That's why you're having trouble with intimate relationships, kids, work, finances ...

Interviewer: ...it's not that your work stress is causing your depression. You're having issues at work because you're depressed ... a lot of people do think that depression is caused by life events.

Hickie: This is the number one myth ... The depression came first ... (but the crisis in life) is not the cause (of the depression), it's the consequence.

The interviewer interrupts: "So there's no cases in which, like a marriage breakdown or anything big like that leads to depression. It may lead to low mood, but not depression. Is that what you're saying?" Hickie doesn't give a clear answer but is quite clear that "chronic stress" is a much more potent cause of depression than single, acute events, which is true but hardly news. Now it starts to get murky as he doesn't explain "stress," either acute or chronic, nor give any indication how it works on humans, but he believes "chronic stress" has an effect on human physiology, as in: "... a chronically stressful situation, you're caring for somebody or a chronic financial situation if you're in a bad, intimate relationship."

This appears to be a very clear statement that psychological pressures can cause severe depression, but he immediately denies it: the next myth to bust is that depression is psychological. His evidence is that since you can't talk yourself out of a bad depressive state, it must be physiological. "A chemical imbalance?" the interviewer asks. Oh no, he replies, that's all so very 80s, "...the serious research ... never never said (that)." The interviewer comes to life:

“So if depression isn't caused by an acute life stressor, it's not the result of wonky psychology and it's not the result of a chemical imbalance, what causes it?”

When in doubt, start spraying statistics around. Realising he had wandered off script, Hickie announced: "... at a population level, 30% is genetic, 10% is about childhood risk factors, 50% is about the current context, and 10% is we don't know." Now he has to retrieve his narrative: "Only trouble is, the genetics turns out to be really complicated. Not what we thought," the implication being "Only we serious scientists could ever understand it so let's not bother the listeners." Of course, the reality is: "We have never found anything that could in any way count as a genetic factor in depression."

Next, he gets rid of childhood risk factors: "And for most people, (childhood) is not the cause (of depression)." That does seem to fly in the face of the evidence. My understanding is that there is a very clear association between adverse childhood experiences and adult mental disorder [1, 2] but, of course, association is not causation. The only problem is that proving direct causation would involve an experiment exposing children to massively traumatic events, which is hardly ethical. Oh, we've got several of them running around the world right now? That's interesting, I'm sure the psychiatric epidemiologists will be swarming.

We move on, to "other environmental risk factors," meaning the 50% of causation that he called "current context." The only examples he gives are physical conditions: Covid, cancer, infections, medication for other illnesses, drugs and alcohol. The things we would normally consider "current context... environmental risk factors," like home, work, school, etc, have already been excluded. This leads to his critical point:

“... people come in and (ask), what caused it? I (say) we're never really going to know the answer to that.... let's not dwell on that, okay? Let's stop blaming your mum. Let's stop, because we'd probably never really going to know.”

That is, depression is a bit of a mystery except we're clear on one point: Even though we don’t have a model of mental disorder, it isn't a matter of psychology. But he quickly reminds us that what counts is treatment, which is determined by the type of depression you have. Except those pesky Americans decreed decades ago there's only type of depression ("... Americans can be quite dominant in their single beliefs" which seems to me a considerable understatement). The most common type is "anxious depression, which responds best to psychological therapies and SSRI antidepressants, "So it's good that the most commonly prescribed treatments also connect with the most people." This seems a bit strange, a matter of luck that the treatment works, but he moves on to his own project, "... circadian depression. It is your body clock. It's not your wife, it's not your background ... It is the change of seasons. It is travel." Biology strikes again, as these people "... do badly with cognitive therapy because they're not a cognitive problem." And there are other types but, he admits, psychiatry has done itself a disservice by "marketing" the idea that there's only one type of depression, because it meant lots of people got the wrong treatment.

At this, the interviewer interjects: "So knowing what type of depression a person has is key to treating them properly. But before you even get to treatment, there's a myth they (drugs) don't actually work." Obviously, she'd read the cheatsheet beforehand as she knew all the myths he was going to talk about. He agrees: people need the right treatment otherwise they won't get better but, he insists, antidepressants do work, which is lucky because untreated depression causes brain damage. He was ready for this question and launched into arguing that depression is just like heart attacks and renal infections, the more bouts you have, the more damage you get:

“Well guess what? Your brain's the same. Now we have evidence of depression as a risk factor to dementia, so treating depression helps to reduce the risk of dementia because in truth there is a physiology and a damaging one. There's stuff going on there neurobiologically during depression, which is bad for your brain. It doesn't just feel bad or look bad, it is bad ... episodes of depression do end, but they often do great damage (to the brain).”

Next the interviewer leads to the widespread notion that, early in treatment for depression but before the real effect is felt, the person can become sufficiently energised to attempt suicide. Yes, the psychiatrist says:

"... in the first few weeks ... some people become, if they're particular anxious, become more agitated, okay. And some people who are having suicidal thoughts say those suicidal thoughts are more intense and some people become more motor active ... some people become more activated, agitated, and they may express suicidal ideas ... but it's uncommon."

There is no mention of the word "akathisia," an intense inner mental and physical agitation that people describe as "torture" which is far more common than psychiatrists like to admit. Akathisia is a common, early side-effect of psychiatric drugs and, combined with their emotionally numbing effect, it causes people to attempt suicide. There is also good reason to believe it is a major factor, if not the only factor, in the occasional unplanned and pointless homicides seen in people taking psychiatric drugs. In his view, it's a matter of trying different drugs to get the right one, which leads the interviewer to ask about psychedelics. He seems to resent the way these drugs were licensed so abruptly without anybody asking him but it gives him the chance to talk about ketamine:

“... the other problem with our antidepressant stuff is the slow rate of onset of effect. We say to people, you feel terrible, you want to kill yourself, but it's going to take 4 to 6 weeks to help ... (but) you'll get side effects tomorrow. It's really not a great therapeutic message ... But (ketamine) has an immediate effect. People do say, wow, that depression, that black cloud lifted, I can see the light. I want to go out to dinner. I want to go out and have sex with my colleagues.”

Does he mean "like my colleagues," as in "Why don't we all go to the knockers?" or does he mean actually "with my colleagues," as in "like they all do in Parliament"? We'll never know but it gets him back to talking about the biology of depression:

“Now, that's not to say that social risk factors don't matter. They do. But it's like saying heart attack or cancer is just social or Covid is just social. Because it's spread by social factors ... social factors allowed Covid to move around the world, but they did not cause Covid.”

And so it fades out. The take home message is: there are all sorts of depression, which need different treatments, since what works for one isn't going to work for the next, but don't think it's got anything to do with your childhood or psychology or inner conflict because it's all biology. OK, chronic stress is a factor but that works biologically and needs biological treatment too.

I don't know Hickie, I met him once, 30 years ago for ten minutes and he clearly didn't see why he had to waste his time talking to somebody from the bush, but obviously this wasn't his best interview. Let's see what he was saying:

Depression is real; it's a huge and growing problem; but we've got all these wonderful effective treatments and suicide rates are going down; except they don't all work on everybody so, since those Americans messed it up in 1980 with their "Major Depressive Disorder," we have to sort out all the subtypes to see which treatment works best; but it's all biological anyway, nothing to do with what's happened in your life or who you are; and if you get better with talking, you weren't really depressed at all; but look out, you'll get dementia if you didn't take our drugs.

Start at the beginning. Yes, depression is real but when people say things like "My football team lost, I'm so depressed," they don't know the meaning of the word. There's a profound difference between "depression" and the glums, as shown by Horwitz and Wakefield (sociologists, not psychiatrists) nearly twenty years ago [3]. Depression is a growing problem, but only in western societies, which may give the clue. Yes, more and more people are taking antidepressants and Australia is up there with the best in dishing out ECT but oh dear, suicide rates are actually going up, not down [4]. And yes, there has always been strong opposition to the (American) idea that there's only one type of depression, the biological type. Except Hickie believes it's all biological anyway, even though all those expensive genetics studies haven't told us anything we didn't already know so, if you don't take personality factors and so on into account, then good luck with sorting it into its subtypes. Agreed, "chronic stress" can eventually wear you down but the overwhelming majority of people taking the drugs are not under any particular "stress," however it's defined. An anxious person is, but Hickie doesn't accept that personality factors can cause depression, because personality factors are psychological, after all.

The bit where he says childhood factors aren't significant is bizarre. Why does he think we have laws on how to treat children and what not to do or expose them to? Does he think that sexual abuse of minors is just a moral or aesthetic matter, like rocking up to church half-drunk from the night before? We abhor it because it's damaging, just like the effects of war on children, or on women, or on the men, for that matter. The children of Gaza, meaning everybody under the age of twenty, are undergoing their sixth onslaught by vastly superior forces, with no means of defence, on top of a blockade which means they have never seen a river or a mountain and will never be educated to their potential or have a decent job. Does that matter? I believe it does but he says No, if they get depressed, it's all biology. As for untreated depression causing brain damage, yes, Professor, and that's what they said about masturbation, too.

Go back to where the interviewer asks:  "So if depression isn't caused by an acute life stressor, it's not the result of wonky psychology and it's not the result of a chemical imbalance. What causes it?" Alert readers will have realised that ... Hickie doesn't answer.

Strip away the bluster and what emerges from this car crash interview is that Hickie firmly believes depression is a biological disease of the brain which will not get better without drugs, under penalty of dementia. He talks of "current context... environmental risk factors" but has no theory of mind or of mind-body interaction that would allow any rational understanding of them. He doesn't allow personality factors, but we know he doesn't have a theory of personality or a model of personality disorder anyway.

Remember that Prof. Hickie has any number of degrees and medals and contacts with the Powers That Be (and conflicts of interest) and would no doubt count himself equal most influential psychiatrist in the country. However, when it comes to the crunch, all he can say is: "Mental disorder is brain disorder, so take your tablets and don't argue with a scientist of my standing."

The philosopher of science, Karl Popper, said: "The method of science is bold conjectures and stringent attempts at their refutation" [5]. Hickie wants us to believe it's all biological, and his research is designed to prove this point, not test it. That's not science, that's ideology [6]. Material, such as this interview, disseminated in the service of an ideology is rightly known as propaganda.

*****

References:

1. Giampetruzzi E et al (2023). The impact of adverse childhood experiences on adult depression severity and treatment outcomes. Journal of Affective Disorders, 333, 233-239.

2. Li D, Chu CM & Lai V (2020). A developmental perspective on the relationship between child sexual abuse and depression: A systematic and meta‐analytic review. Child Abuse Review, 29(1), 27-47.

3. Horwitz AV, Wakefield JC (2007). The Loss of Sadness: how psychiatry transformed normal sorrow into Depressive Disorder. New York: Oxford University Press.

4. McLaren N (2017). Electroconvulsive Therapy: A Critical Perspective. Ethical Human Psychology and Psychiatry 19: 91-104.

5. Popper KR (1972). Conjectures and Refutations: the growth of scientific knowledge. London: Routledge.

6. McLaren N (2013). Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18.

*****

Abbreviations:

APA: American Psychiatric Association.

DSM: Diagnostic and Statistical Manual of Mental Disorders, issued by the APA. DSM-I was issued in 1952 and was heavily influenced by psychoanalysis; as was DSM-II in 1968. The biologically-oriented DSM-III was released in 1980, DSM-IV in 1994, and DSM-5 in 2013. There have been numerous revisions along the way.

OPCAT: Optional Protocol to the UN Convention Against Torture

NIMH: National Institute for Mental Health, Bethesda, Maryland, USA.

RANZCP: Royal Australian and New Zealand College of Psychiatrists

RCPsych: Royal College of Psychiatry (UK).

UNCAG: UN Convention on the Prevention and Punishment of the Crime of Genocide.

UNCAT: UN Convention Against Torture and Other Cruel, Inhuman or Degrading Treatment or Punishment.

UNCRPD, or just CRPD: UN Convention on the Rights of Persons with Disabilities.

WHO: World Health Organisation.

****

This material is copyright but can be copied or quoted on condition the author is acknowledged.