Allow me, if you will, to engage in some inexpert speculation. If you read the following, please keep in mind that I am just some idiot on the internet and not in any way qualified to give advice.
It seems to me that depression is not a disorder, disease, or abnormality, but a necessary and purposeful reaction of the mind and brain to certain stimuli. Of course this is not always the case, and the same symptoms can be triggered by other factors that affect our neurochemistry or mental function, but in a normally functioning mind and brain I think this is true. When examined in this context, what do we find?
Depression makes us apathetic, reluctant to act, and unconfident. A while back there was an article on HN spitballing that depression and mania were related to our mind's assessment of its own ability to predict outcomes. Overconfidence in its own predictive ability manifests as mania, and low confidence manifests as depression. This makes some sense. If you are confident in your predictions you are more likely to act on them, and if you are not you are less likely to. Given this, I submit that it's possible that what depression really is, much of the time, is a philosophical problem.
Philosophy is our model of reality, and we use that model to make predictions and decide how to act in the world to affect change. When that model is known to be broken, we lower our confidence in it and act less. Over time, as more and more of our model is revealed as flawed and our confidence in it continues to plummet, we enter a state of learned helplessness. Finding ourselves unable to predict the results of our actions, we are unable to determine how to effect the changes we desire in our lives, leading to interesting contradictions like being bored and at the same time unmotivated to do things we used to enjoy. We don't want to be in this state, but we lack the ability to see a path out of it, so we become frustrated, angry, and/or sad. It can eventually reach a point where the only path out of the suffering that we're confident in, is death.
In fact, this model-breaking occurs many times in our minds' development. As we grow up we form several different models of reality, all of which are inevitably revealed to be flawed. This is the reason you find children who believe they are hidden just because they can't see you (their model of reality doesn't include the concept of different perspectives), and why the terrible twos are so terrible (the young mind is dealing with its model of reality failing), for instance. With children, however, there are plenty of people around them operating with better models of reality to help them work out a new one. Societies can also be modeled this way, and if we look at the past we find that human cultures also go through a similar pattern of forming a stable model of reality, eventually finding it flawed, suffering through process of dealing with that, and ultimately resolving the crisis. I say resolving because, in actuality, there are two solutions to the problem of realizing your model is broken: forming a new, more accurate, one; or ignoring the information that contradicts it.
This is the important point, I think: When an individual's model of reality is broken, and society cannot guide them towards a more accurate one because society itself is still operating on the model that individual has determined to be flawed, then chronic depression is a likely result. Our current societal philosophy, the one our health care system is also based on, see's this individual's suffering not as a transition period in which they form a new model, but a severe disorder. To them, the rejection of the model is a form of insanity, and unclear thinking. This is why you sometimes see people tell a depressed person an obvious platitude in an attempt to cheer them up, only for it to further frustrate the depressed individual: they are aware that the platitude is part of a flawed model.
Further, the health care system is, like most of current western society, firmly implanted in empiricism. Science and measurement are the hammer, and everything else is a nail. Society as a whole forms its model of depression on measurements and manipulation of the neurochemical and behavioral aspects of depression, the social side effects, etc, but without regard for its greater reason for being. They are witchdoctors, sacrificing chickens to drive out the demons and bloodletting to balance the humors. Sometimes it works, because even a broken clock is right twice a day, but a lot of times it doesn't.
If one were to assume that this assessment is accurate, then reason we get depressed is so that our mind is motivated to take a step back and build a more accurate model of reality. The thing to do, then, is to help the sufferer realize why they are suffering. There's nothing wrong with them, they don't have a chemical imbalance of the humors, they aren't bad people for feeling the way they do or for not having faith in what society tells them is true. They have in fact taken a step toward growth, and nearly all growth comes at the cost of suffering. They need to look hard at where reality has shone the light on their flawed conception of it, reason through the problems, and build a more accurate replacement, and we may not be equipped to help them.
There was also an excellent thread and discussion a while back suggesting depression is more of an evolutionary mechanism: https://news.ycombinator.com/item?id=16216647.
I also wonder how much of depression is attributed by improper biochemistry in the brain, low serotonin etc. even though your environment/situation is actually fine.
Depression is an illness that is defined by its symptoms. The causes are diverse and can be deeply personal. This is unlike most other illnesses, where there is a much smaller set of possible causes for a given set of symptoms. For some illnesses the causes are unavoidable, I can't do anything to prevent the catching a cold, I have to step outside and interact with the world where the virus lives. For others causes can be addressed, for example, I experience stomach pains after drinking milk so I stop drinking it.
The current state of mental health care is in terrible shape. Doctors do not have the time to provide psychiatric advice but they do have just about enough time to sign off SSRI prescriptions. Your pills may help you get through the day a bit easier but if you do not address the cause of your illness your symptoms will eventually surface again. There are cases where perhaps the cause is completely due to a chemical imbalance but from all I've read about depression, this seems rare. Most of the time the suffer needs help addressing the root cause of their depression. Sometimes it's learned helpnessness which needs a change in our mental model, sometimes its about quitting destructive habits/addictions or sometimes we understand reality completely and just need to change our behaviors to become satisfied with life.
You make some really great observations in your post. I found them very enlightening, eye-openers. However, I have to disagree on the fact that depression is usually/mostly a change of your perceptual model.
As you mentioned, depression is the state during which your prediction of the future (correctly or incorrectly) is that any action you take will result in a highly unpredictable, and mostly dangerous/damaging/negative feedback.
Bad enough feedback for the best action plan to be doing nothing at all.
There are two main, and very important types of depression branching off here.
One is the type where your prediction is wrong.
The other is the type that your prediction is right.
There are many cases where your modeling of reality is now flowed or outdated. Maybe you grew up with negative or mentally ill people, and you know no better. Maybe your school teachers were assholes. Etc. In this case someone needs to show you, possibly through demonstrations, that your perception of reality is actually flawed. Off the top of my head, most psychotherapy, like cognitive behavioral therapy, offers just that. Your therapist will try to prove your model of reality to be wrong (even if it's not, but that's another discussion), and convince you that things are better, to look at things positively etc. Some times, for some people, that works. Other might refuse to update their model and choose to ignore reality. Others find dysfunctional ways to cope with life. Others will get a terrible therapist with a worse model than theirs. Many things are possible.
The other main category of depression is the type where your model of reality and your prediction is correct. Like a dog or lab rat that gets zapped with 50% probability no matter what it does. At first it will try really hard to figure out what's going on, and in the end it will figure that trying isn't worth it and it will stop. You can give that animal all the ketamine in the world, and it still won't be happy, because their environment is flawed, not their perception or learning abilities.
In real life, examples include dealing with unstable people (bipolar, narcissistic etc), being stuck at an actual dead-end situation with near-zero chances of recovery (homelessness, bad chronic illnesses), etc
In this case, someone needs to fix your environment (if possible, ie homeless or dealing with unstable people) and not your perception.
Another source of depression is the realization that your life cannot work unless the world at large radically changes. Maybe you know what needs to change, but not how to make it change. Maybe you know what and how, but you also see the high cost involved where becoming the revolutionary leading the charge just lands you in prison or other drama and fails to get you the happy life you desire. Even if it benefits people who come after you, it won't benefit you. There is nearly zero hope of achieving a fulfilling life.
Death becomes the only relief you can imagine. Depression is the only alternative to hurling oneself into the path of potentially violent revolution.
This sounds like the unhelpful "it's just a phase, it will pass"
Just like a wound or a bruise, depression lasting weeks is ok, if it last years is a severe disorder.
> the health care system is, like most of current western society, firmly implanted in empiricism. Science and measurement are the hammer
That would be nice: science has been doing very well in the last 200 years.
If anything, psychology and psychiatry are often accused of not being rigorous enough.
> They are witchdoctors, sacrificing chickens
You just wrote that medicine is firmly implanted in empiricism.
> we get depressed is so that our mind is motivated to take a step back and build a more accurate model of reality. The thing to do, then, is to help the sufferer realize why they are suffering.
Psychology "talk" therapy has been focusing on introspection since Freud. It's often not effective enough.
In the same way that cough syrup will never cure a cold, antidepressants alone will never cure depression.
Could you cure a cough with couch syrup? Could you cure a sore throat with pain killers?
Antidepressants makes the basis for a depression diagnosis go away for some of those who are treated. Having no measurable level of depression is probably the closest we will ever get to a cure of depression at large.
If the depression is caused by something specific, say a vitamin deficiency, that underlying issue would of course not be treated by SSRI. But we don't know enough to say that there always is something specific causing the symptoms. What if the issue is actually a serotonin deficiency? Just like some people naturally produce to little vitamin D and have to take supplements.
What if not all DNA sequences lead to a happy life? There's nothing in evolution that enforces that all offspring has to be happy for survival to happen.
As the example of learned helplessness illustrates, depression can be induced in a predictable way. Even on an intuitive level, a stance of submissive apathy could increase chances of survival, if one is a captive.
My (lay person’s) view is that what we see as clinical depression is a symptom of a “bias” or miscalibration issue, where the feedback circuits in the brain responsible for maintaining homeostasis have been forced to work outside of their functional ranges. The brain has a lot of redundancy and compensating routines, but they have their limits.
One of the most obvious causes would be having a weakened part of the brain, whether through injury, genetic, or environmental causes. The brain becomes miscalibrated, and can’t maintain equilibrium because some essential component is operating “out of spec.”
If you look at other human attributes and biological systems, they are all prone to disorder. Or perhaps, to having characteristics that fall on the outer edges of the distribution of the characteristic. As a simple example, when an individual is under a certain height, we call that a “disorder” or “syndrome.”
So there is an element of arbitrariness and imprecision as to where these definitional borders are drawn. They are fuzzy. But, looking at a larger population, you can start to see patterns where you can definitely place an individual into a sub population of people who have a disorder.
Mania, for example, has enough common symptoms, that I am confident it is an actual, physiologically based, “disorder. Even though the symptoms of mania are all behaviors and states experienced by “healthy” people, all the time.
I also have a theory that by the time a mental health problem starts to become perceptible by others, it is actually a pretty severe condition. The individual’s internal state is probably far more disordered than it appears to be. Because our brain is so flexible, and powerful, it can compensate even extremely disorder functioning, for the purpose of hiding the illness from others.
My ideas are largely consonant with yours. You’ve outlined a “model”of depression, which uses the concept of depression being a response to having ones mental construct of reality broken. That would be the functional aspect of depression.
My view is that “depression” the disease occurs when the brain can no longer maintain homeostasis. So if someone is being tortured, for example, depression would be a an expected response. If the torture is severe enough to push past the ability of the brain to maintain order, which is the point of torture, that’s a situation where calling the state a “disease” or an “expected response” is simply a matter of semantics.
Because depression is a normal state, part of a stress response, it’s symptoms can look, and be, very similar, even though the causes can be myriad. I think this is why the blunt instruments of psych drugs are used to treat these symptoms across so many different scenarios. They don’t work great, but they do work.
Thank you for taking the time to share your thoughts and insights on this, and articulating them so well.