Studies confirm the effectiveness of antidepressants in treating severe or major depression but, if you’re struggling with life, perhaps as a result of recent stress or other lifestyle factors, or suffering mild to moderate depression, is medication really your best option? Plus, if you do pop a pill, will it actually make a difference?
The spectrum between elatedly happy and black-dog depressed is wide and full of variances. Depression and anxiety are states that have been written about, often by those suffering them, for hundreds of years. Poets, politicians and philosophers alike have explored the murky world of melancholia and its effects, professionally and personally.
Historically, the place of depression, or melancholia as it was then known, was accepted as perhaps an uncomfortable yet normal stage of life. Just as some people seem perennially happy, others seem perennially melancholy. Rather than rush to label this uncomfortable state a disease, unconsciously unleashing hope for a cure, each individual’s tendencies were respected. Similar still was the respect paid to those experiencing euphoric happiness, compared to those in deep melancholia, in the belief that these extremes of feeling, both high and low, while intense are often passing, relative to the length of life.
Happiness: a spectrum
Part of the challenge in treating depression today is that, while it’s promoted as a simple disease with structured treatment and medication, the reality is depression manifests with a variety of symptoms, often in unique ways, for each individual.
In a chapter titled “Gifts of Depression” in his work Care of the Soul Thomas Moore writes, “Care of the soul requires our appreciation of these ways it presents itself. Faced with depression, we might ask ourselves, ‘What is it doing here? Does it have some necessary role to play?’ Even further, we may have to develop a taste for the depressed mood, a positive respect for its place in the soul’s cycles.”
Revelations by those in the public eye who have suffered or are suffering depression, combined with increasing education and discovery about the real and debilitating effects of depression, have led to improved understanding of the serious nature of this type of mental illness. However, it has potentially created an undercurrent where even minor — what might be considered normal — levels of melancholia are quickly prescribed a pill so that a return to the idealised state of happy can soon be reached.
Appreciating that melancholia or depression represents a spectrum of emotions that vary greatly in their intensity and debility is key to avoiding a one-pill-fits-all approach. While drug companies may have been quick to promote the “depression is a disease — here’s your cure” mindset, a moment’s pause raises questions as to their true motives.
Mild to moderate depression, what was once historically accepted as melancholia and understood to be part of the many changing seasons of emotional life, has been shown to be best managed through a combination of lifestyle factors, including talk therapies and exercise. The 2010 Australian of the Year, Professor Pat McGorry, a mental health expert, commenting on treatments for more minor forms of depression, said, “You should not go straight to medications or reach for the prescription pad; you should try counselling first.”
Has greater understanding about the very real nature of depression created a subculture in which those suffering real but possibly manageable sadness or stress rush to gain a diagnosis of depression, perhaps under the mistaken belief that there’s a quick fix for their unhappy state? Sadly, in these cases, it’s all too easy to end up on a medical merry-go-round, popping pills for a disease you may not have as severely as you fear.
Rethinking depression
In Care of the Soul, Thomas Moore writes, “Melancholy gives the soul an opportunity to express a side of its nature that is as valued as any other but is hidden out of our distrust for its darkness and bitterness.” Moore continues, “Maybe we could appreciate the role of depression in the economy of the soul more if we could only take away the negative connotations of the world. What if ‘depression’ were simply a state of being, neither good nor bad, something the soul does on its own good time for its own good reasons?”
Quoting Freud, Moore also noted, “Freud pointed out that during bouts of melancholy the outer life may look empty but at the same time inner work may be taking place at full speed.” Perhaps, then, there is a necessary place in life for periods of solitude or time away from your usual routines. Moore comments, “Some Renaissance gardens had a bower dedicated to Saturn — a dark, shaded, remote place where a person could retire and enter the persona of depression without fear of being disturbed.” (Saturn is the ancient god linked to melancholia.) The purpose of depression, since it’s clearly not a modern malaise, may be to offer, at least in its milder forms, space and time out. Perhaps the larger fallacy is to think that, once life’s path is set, you’ll be able to continuously progress and produce without periods of quiet retreat.
Moore continues by suggesting there is a lot you can learn from depression, that its ultimate gift may include gaining a much stronger sense of identity. “This peculiar kind of education — learning our limits — may not be a conscious effort only; it may come upon us as a captivating mood of depression, at least momentarily wiping out our happiness and sending us off into fundamental appraisals of our knowledge, our assumptions and the very purpose of our existence.” The resulting personal re-evaluation from introspection borne out of depression can lead you to “know who you are because you have uncovered the stuff of which you are made. It has been sifted out by depressive thought, ‘reduced’ in the chemical sense, to essence.”
Drugs & depression
While references to melancholia and its symptoms date back to the Renaissance, medications to treat depression are relatively recent. Gary Greenberg, writing in Manufacturing Depression, notes, “The first drug touted as an antidepressant was amphetamine.” He describes an ad from a 1945 issue of the American Journal of Psychiatry, which said: “If the individual is depressed … you can change his attitude by physical means.” This may well have underpinned the entire drugs-to-treat-depression industry.
Amphetamines were initially marketed to those described as neurotic or reactive depressives, not the more serious psychotic manic-depressives, (who at the time were treated with shock therapy), however their addictive nature and unstable effects meant they soon lost favour.
By 1955, a new drug for depression — meprobamate, known as Miltown — was available. It was marketed as having “outstanding effectiveness” for relieving “anxious depression”. Valium first appeared in the early 1960s, and by 1972 was the most commonly prescribed drug in the world, a position it occupied until the end of the decade.
Greenberg outlines how the anti-depressant drug market owes its success in part to “the emergence of a whole new market: people whose suffering wasn’t bad enough to warrant a visit to a psychiatrist’s office but who would confess it to their family doctor and then gladly take either (Miltown or Valium)”.
In 1997 there was a shift in the way pharmaceutical companies connected with possible clients. Greenburg outlines how that year, Lilly, the makers of Prozac, hired the Leo Burnett agency to launch an ad campaign for Prozac. Since then, wherever you might fall on the spectrum of melancholia/depression, information about a drug you could take that was being promoted with tag lines like “Depression hurts”, “Prozac can help” has been available not just through the medical profession but also in mainstream media.
Symptoms often listed included trouble sleeping, low energy, lack of appetite or “trouble feeling pleasure”, all of which can be symptoms of depression but may also be considered normal, especially in response to stress or change, at some point in life. The message seems to be, don’t worry, normal or not, you now don’t have to deal with such a variety of feelings — drugs can help.
On the use of drugs to treat depression, Thomas Moore comments, “If we persist in our modern way of treating depression as an illness to be cured only mechanically and chemically, we may lose the gift of soul that only depression can provide.”
What is happy?
If more drugs are being produced to ease depression — and are selling like hotcakes — doesn’t that mean we have instant access to happiness?
Psychiatrist Dr Viktor Frankl, in his seminal work, Man’s Search for Meaning, which details his experiences in Nazi death camps and their effects on his subsequent therapeutic work, differentiates between the search for pleasure — often misinterpreted to mean happiness — and the search for meaning. Frankl’s work places supreme importance on the value of discovering a sense of meaning. Of his psychotherapeutic technique, logotherapy, Frankl writes, “It is one of the basic tenets of logotherapy that man’s main concern is not to gain pleasure or to avoid pain but rather to see a meaning in his life. That is why man is even ready to suffer, on the condition, to be sure, that his suffering has a meaning.”
More recently, Martin Seligman’s work on authentic happiness concurs. In a 2002 article, he says, “Successfully pursuing pleasure does not necessarily lead to life satisfaction, but successfully pursuing the good life and the meaningful life does lead to higher life satisfaction.” Happiness, then, is less about you being in a constant state of pleasure and more about you engaging in something that gives meaning to your life.
Frankl sees three possible sources for meaning: “in work (doing something significant), in love (caring for another person) and in courage during difficult times”. Frankl discusses how happiness is like success — not something you can strive for but something that occurs as a pleasant byproduct of your actions and attempts to create meaning through a personally relevant focus.
One of the challenges in treating depression with mind-altering drugs is that, while the actions of many antidepressants are designed to improve brain function to enhance mood, the way in which they go about this can have an inhibitory effect on brain chemicals that contribute to positive, happy and pleasurable mental states. It’s as if the happy mood spectrum is also blocked by antidepressants as they go about inhibiting melancholia. While this minimises the heavy “black dog” energy of depression, it also takes the edge off positive feelings as well. Drugs for depression appear to limit feeling on both ends of the emotional spectrum.
It’s long been known that one of the common side-effects of antidepressant medication is reduced sexual desire. Rutgers University anthropologist Helen Fisher is exploring whether or not the antidepressant epidemic is “blunting” the emotional responses involved in desire, attraction and falling in love. Researchers are questioning the emotional barriers created by drugs that have been shown to reduce libido and sexual desire. Fisher says, “I’m concerned about well-adjusted men and women who go through a crisis and start taking antidepressants. They continue taking them, not realising they may be suppressing these other systems.”
Under fire is a common group of antidepressant medications, SSRIs, which affect serotonin levels in the brain and inhibit production of dopamine. Dopamine is one of the main neurotransmitters involved in the biochemical response to love. SSRIs are also known to have side-effects that inhibit libido and sexual desire. Fisher’s collaborator, psychiatrist J Anderson Thomson from the University of Virginia in the US, has this to say on the subject of those taking antidepressants who then develop marital or romance problems, “Don’t immediately assume it’s you or the relationship, because it may be the drug.”
Treating depression
Research shows that antidepressants are most effective if you are suffering from moderate to severe depression. If your depression is considered mild to moderate, a 2010 study from the University of Pennsylvania (published in the Journal of the American Medical Association the same year), discovered there is “little or no added benefit from the medications”.
Dr DeRubeis, who co-headed the study, notes the healing impact of the “sustained attention” received by study participants from doctors involved, which he describes as something that can “itself help relieve symptoms, drug or no drug”, for suffers of mild to moderate depression. He states, “The message for patients with mild to moderate depression is, ‘Look, medications are always an option, but there’s little evidence that they add to other efforts to shake depression — whether it’s exercise, seeing the doctor, reading about the disorder or going for psychotherapy.’”
Social drugs
Martin Seligman defines authentic happiness as that which combines pleasure, engagement and meaning. If you’re consumed by the purely pleasurable definition of happiness, the kind promoted by mainstream media, whereby happiness is depicted as being in a constant state of pleasure, it can be easy to think the high of pleasure is the extent — and focus — of happiness.
With this mindset, falling for the “get high, relaxed or mellow fast” promise of social drugs such as alcohol, ecstasy or marijuana can be easy. However, a drug-induced high is at best temporary. A drink — or more — is a common initial solution to taking the edge off a stressful day. The depression.com.au website highlights “one or two standard drinks for this effect is quite normal behaviour”. Alcohol can create a temporary reduction in tension or anxiety, but not depression, and has a level of social acceptability. However there is a difference between a glass of wine with dinner and upwards of four drinks a night or drinking heavily in order to interact at social events.
Depression.com.au highlights the similarities between the symptoms of excessive alcohol intake or marijuana use and the symptoms of depression, noting, “They are really indistinguishable.” Common symptoms include feeling miserable, tense, irritable, being quick to anger, having low motivation, an inability to concentrate, low libido and trouble sleeping. They specifically suggest the gradual reduction to nil of alcohol or other social drugs for those concerned about the emotional impact, stating, “Many people, who are apparently severely depressed, recover dramatically from this simple intervention.”
The problem with attempting to manage uncomfortable feelings or stress by using drugs or alcohol is that the relief gained is often temporary and thus can contribute to a vicious cycle in which increasing amounts of drugs or alcohol are required to gain progressively smaller amounts of relief. Depression.com.au notes, “The problem with using alcohol (or indeed substances such as marijuana or other illicit drugs) to change a person’s emotions is that the change only lasts a few hours, and a rebound effect takes place. A useful comparison is that using alcohol or other substances to change the way you feel is like borrowing money on a credit card! You have to give back everything you get, and a little bit extra, so you actually end up worse off than when you started.” In fact, Beyond Blue, Australia’s National Depression Initiative, goes so far as to describe drinking more alcohol and smoking marijuana as “harmful strategies” for managing depression.
Alcohol and other social drugs can intensify or negatively contribute to feelings associated with depression. Your return to a more content, happier life may ask you to explore the journey down the road to abstinence regarding social drugs. This may lead to the surfacing of other emotions, and exploring talk therapies may then help you manage those feelings in a more sustainable way — one that supports rather than diminishes long-term physical health.
Alternative mood boosters
Combined results from two different surveys exploring effective treatments for depression (covering a sample of almost 3000 people) highlight the importance of exercise and talk therapies as a contributing factor to maintaining a positive mood. Graeme Cowan’s 2007 book, Back From The Brink: Australians tell their stories of overcoming depression, includes the results of two separate surveys.
The Ultrafeedback survey, conducted via the depressioNet website, was completed by 271 individuals. The top five rated tools for effectiveness in managing depression included exercise, family and friend support, counselling therapies, fulfilling work and relaxation/meditation. A second study, surveying more than 2500 people and run through the Black Dog Institute’s website, rated the following five tools as most effective for helping manage depression: venlafaxine (an SNRI antidepressant medication), exercise, cognitive behavioural therapy, “other psychotherapy”, and interpersonal therapy.
In summarising the results, Graeme Cowan noted, “Both antidepressant medications and psychological therapies were rated as having some benefit for depression. The top 10 treatments included four different types of antidepressant medications and four different types of psychological therapies.” Exercise appeared to be a common factor considered effective by both groups surveyed. Commenting on this, Cowan questions, “When you consider the epidemic of depression in the Western world and the general decline in physical activity, you can’t help thinking there may be a connection.”
Beyond Blue provides a number of useful fact sheets about managing and dealing with depression or anxiety. Fact Sheet 14 discusses alternative treatments to depression and anxiety. It suggests there is “good evidence” to support the potential effectiveness for alternative treatments such as St John’s wort, exercise, regular quality sleep, self-help books that explore cognitive behaviour therapy, and light therapy (for depression linked to winter or seasonal triggers). Fact Sheet 14 also indicates there is “some evidence” for the effectiveness of acupuncture, massage therapy, relaxation therapy, supplements including the amino acid SAMe and folate, and yoga breathing exercises in helping manage symptoms of depression.
There’s a number of lifestyle factors that can contribute positively to your mood. While your need for medication is something to explore based on your individual situation with your medical health professionals, there is good evidence to support the inclusion of small changes such as reducing alcohol, increasing exercise and talk therapy in your mental wellness program.
Kelly Surtees is an internationally published writer devoted to expanding her wellbeing through personal growth.
