Is Depression a Brain Disorder?

There are many reasons why someone might become depressed. Here are a few: bereavement, loss of a job, financial difficulties, and disappointment in love. It may also happen because of childhood abuse or neglect, whether remembered or suppressed. In other words, there’s always a reason for it although this may not at first be recognized.

Normal human misery
When does normal human misery, as we might call it, become abnormal? If one accepts that a condition of abnormal unhappiness exists, whether it’s called clinical depression (whatever that means) or a depressive ‘disorder’, this would seem to be a matter of degree. But any criteria for deciding where to draw the line would be arbitrary.

For example, the America Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders stipulates the experience of five or more from a list of nine symptoms lasting at least two weeks. But what if someone has fewer than five symptoms, even though they may be suffering greatly from, say, a broken heart – then they don’t have a depressive disorder?

Furthermore, if an entity called a depressive disorder exists in nature, this implies there is something wrong with the person’s brain. Dictionary definitions of ‘disorder’ from the eighteenth century onwards make this clear:

Samuel Johnson’s Dictionary of the English Language, 1755
‘Breach of that regularity in the animal economy which causes health; sickness; distemper.’

Shorter Oxford English Dictionary, 2007
‘Disorder: a disturbance of the normal state of the body or mind.’

What is mental health?
What, then, is the normal state of the mind? This is very difficult if not impossible to define, and it would therefore follow that abnormal or disordered states of mind are likewise difficult or impossible to define.[1]

There are, of course, states of mind where someone appears conventionally ‘mad’, being in great distress, running around in public shouting and screaming, with no clothes on. In my career I have occasionally encountered patients like this. They may need custodial care and sedation until they’ve calmed down. But rather than being labelled with an incurable brain disorder requiring medication with a so-called antipsychotic for the rest of their lives, such behaviour could be seen an a meaningful, if misguided, reaction to real-life problems.[2]

In the case of someone who is extremely unhappy for one reason or another, mental suffering is evident or easily elicited on sympathetic questioning. But if we believe that this suffering causes an abnormality of brain chemistry, or that such abnormality is assumed to arise spontaneously where no obvious cause of the unhappiness is apparent, in both cases we have a hypothetical biological explanation for the person’s depression.

Sometimes a reason and sometimes not
This fits in with the pronouncement on the Royal College of Psychiatrists’ website: ‘There will sometimes be a clear reason for becoming depressed, sometimes not.’

Similarly, the WHO website on depression states (paraphrased):

Depression is a common mental disorder. It is different from regular mood changes and feelings about everyday life and can happen to anyone. People who have lived through abuse, severe losses, or other stressful events are more likely to develop depression.

Again, they seem to be saying that depression can happen for a reason or for no apparent reason. In either case, it’s implied that something goes wrong in the brain.

Now let’s turn to the NHS website on depression, where under the heading ‘How antidepressants work’ we find the following:

It’s not known exactly how antidepressants work.

Note the weasel word, ‘exactly’. This implies it’s known to some extent how antidepressants work, but this is untrue. If they appear to work, it’s empirical (trial-and-error) and likely a placebo effect or due to spontaneous recovery. How do we know which it is? We don’t, and can’t.

The NHS continues:

It’s thought antidepressants work by increasing levels of chemicals in the brain called neurotransmitters. Certain neurotransmitters, such as serotonin and noradrenaline, are linked to mood and emotion.

Again, this implies that depression is caused by or is associated with diminished levels of serotonin and noradrenaline, but no objective evidence for this idea exists; it’s presented merely as a ‘thought’. The number of neurotransmitters in the human brain so far recognised is said to be over 100, but it’s a gross oversimplification and merely guesswork to put depression down to a disorder of neurotransmitters. And such disorders, if they occur, could well be the result rather than the cause of depression. Furthermore:

While antidepressants can treat the symptoms of depression, they do not always address its causes.

Another weasel word, ‘always’. So sometimes they do ‘address’ the causes of depression? And how do they do that?

 A palpable click felt in the brain
The doughty British Medical Journal likewise persists with the biological approach to psychiatry in a recent article[3] titled, ‘Finding the right treatment for severe depression.’ This is presented, without comment, as an account by a patient who ‘found himself unprepared for the diagnosis of severe depression and the challenges of trying different treatments.’

The story is as follows (paraphrased):

Waking in the middle of a dream, I felt a palpable click in my brain. Suddenly I felt very unwell. It never crossed my mind this would be related to my mental health. I was prescribed medication by a psychiatrist but it didn’t make me feel any better. I then discovered electroconvulsive therapy on the internet and asked to try it. I had a full course of treatment. The depression went as quickly as it had come.

Curious. I didn’t know the brain has any moving parts, and I wonder what the dream was about. But now we come to the point:

Alongside my psychotherapy I have remained on medication for the past 20 years. I was not aware the dysregulation in my brain caused by the depression meant there would be the ever-present potential for relapse.

Here we have the hypothetical biology of psychiatry back to front. The ‘click’ that the patient felt apparently caused the depression which caused the dysregulation in his brain, and this resulted in the patient allegedly requiring decades of medication. Thus, whether the so-called disorder or dysregulation in the brain arises de novo, or as a result of depressing life events, or follows the occurrence of a palpable click in the brain, an incurable depressive disorder is the result.

This is where a multi-billion-dollar opportunity has opened up for Big Pharma: normal human misery can be called a disorder of brain chemistry, in particular, a deficiency of serotonin, but this is fixable by drugs claimed to raise the level of serotonin in the brain. Behold, the advent of antidepressant wonder drugs!

Treatment-resistant depression
Similar to the narrow-minded view of the psychiatrist involved with the above-mentioned patient who felt a click in his brain, is the orthodox approach to what is called treatment-resistant depression – an unfortunate expression since it sounds like blaming the patient for refusing to get better. The methods used in this situation all continue down the blind alley of biological psychiatry by pursuing physical methods of one sort or another, without having the slightest understanding of how such methods might work.

Treatment-resistant depression means that someone remains depressed in spite of having tried at least two so-called antidepressant drugs. Nonetheless, the implication is that the patient’s symptoms should or might be amenable to drug treatment – if only we could find the right one! But since the number of approved drugs for depression, although large (and that’s a story in itself), is limited, we need to try experimental ones such as the hallucinogenic, psilocybin; or the general anaesthetic, ketamine. Both are potentially addictive and the latter can cause severe inflammation of the bladder; many other harms can be caused by both drugs.

Then there are physical methods such as memory-destroying electro-convulsive therapy (ECT) which is still occasionally used. Applying a magnetic field to the brain through the skull, and using a technique called deep brain stimulation have also been tried. The latter involves surgically implanting an electrode into the brain to send a small signal to counteract brain ‘circuits’ believed to be associated with depressive symptoms – an heroic measure which nonetheless appears promising in preliminary studies.

Depression as a diagnosis refers to depressing thoughts and feelings. Of course, certain parts of the brain are active during any mental activity, but the assumption here is that there is a primary disturbance in the part or parts of the brain that cause or are involved in depression. Therefore, the thinking goes, depression might be treatable if we could intervene somehow to block or otherwise counteract these presumed dysfunctional brain activities. Such an idea, however, is purely speculative and it is hubristic to assume that the above crude manipulations can cure depression.

Psychiatric drugs as a last resort
Psychiatric drugs may have a place as a last resort for symptom relief. But it should be kept in mind by both doctors and patients that:

There is no state of the brain, nor even particular features of brain activity, that corresponds to depression or anxiety, or any other mental state…drugs produce drug-induced states; they do not correct underlying diseases.[4]

These effects, which typically include sedation and emotional blunting, although they may be regarded as preferable by patients or others to the undrugged state, are in no sense a cure.

If you can’t cure the patient, help her to die
The reality is that we don’t know what is going on in the brain when someone is depressed or otherwise suffering from mental symptoms. Inability to accept this fact is well illustrated in the tragic case of Shanti de Cortez, a 17-year-old woman who was walking through Brussels airport in 2016 when a terrorist bombing outrage occurred. Though physically unharmed she was mentally traumatised. She was treated by medications and is reported to have said:

I get a few medications for breakfast. And up to 11 antidepressants a day. I couldn’t live without it. With all the medications I take, I feel like a ghost that can’t feel anything anymore. Maybe there were other solutions than medications.

What was the rationale for treating her with antidepressants? There was none. It was empirical treatment prescribed in the hope of making her feel better. It didn’t, and as she indicated, seems to have made her feel worse. It’s shocking beyond words that six years later she died by medically assisted suicide.[5]

Text © Gabriel Symonds

[1] https:drsymonds.com/do-mental-illnesses-exist/
[2] Middleton H, Moncrieff J. Critical psychiatry: a brief overview. BJPsych Advances. 2019;25(1):47-54. doi:10.1192/bja.2018.38
[3] https://www.bmj.com/content/bmj/389/bmj.r478.full.pdf
[4] A Straight-Talking Introduction to Psychiatric Drugs by Joanna Moncrieff, PCCS Books, 2020.)
[5] https://www.arabnews.com/node/2177566/world