Transcriber: Young Lee Reviewer: mariana vergnano
Hello everyone.
I mostly live in an attic in Oxford,
so you'll forgive me for being completely outside my environment tonight.
I'm afraid I'm not going to be terribly
funny like the previous speakers.
That's partly because psychiatrists aren't very funny people.
Freud famously said that there's no such thing as a joke.
But, no, actually it's because that
my topic tonight doesn't lend itself very well to jokes
and my topic is actually a very serious topic.
It's depression.
Now, most people think of depression
as a mental disorder that is a biological illness of the brain.
Today, I'm going to argue that the concept of depression
as a mental disorder has been over extended,
has been unhelpfully over extended to
include all manner of human suffering.
And, more controversially,
that depression or "depression" as broadly understood,
can actually be good for us,
an idea that I explored, that I developed
in my recent book "The Meaning of Madness."
Now let us begin by thinking very broadly about depression.
There are important geographical variations
in the prevalence of depression.
And these can in large part be accounted for
by socio-cultural rather than biological factors.
In traditional societies, human distress is more likely to be seen
as an indicator of the need to address important life problems
than as a mental disorder requiring professional treatment.
For this reason, the diagnosis of depression is correspondingly
less common.
Some linguistic communities do not have a word,
or even a concept with which to talk or think about depression.
And many people in traditional societies
with what may be construed as depression
present instead with physical symptoms,
such as fatigue, or headache, or chest pain.
So, for example, Punjabi women,
who have recently emigrated to the United Kingdom
and given birth find it baffling
that a health visitor should pop around
to make sure that they haven't developed post-natal depression.
I mean, not only had they never
conceived of giving birth as anything but a joyous event
but they don't even have a word
with which to translate the concept of depression into Punjabi.
Now, in modern societies such as the UK and the USA,
people talk about depression very freely,
very readily, very openly.
As a result, they are far more likely to interpret
their distress in terms of depression
and also far more likely to seek out a diagnosis of the illness.
At the same time, groups with vested interests,
such as pharmaceutical companies
or indeed, so called mental health experts
promote the notion of "saccharin happiness" as a natural,
default state and of human misery, of human distress
as a mental disorder.
The concept of depression as a mental disorder can be useful
for some of the more severe intractible cases
that are treated by hospital psychiatrists.
But probably not for the vast majority of cases
which are relatively mild and short-lived
and easily understood in terms of life problems,
human nature or the human condition.
Another non-mutually exclusive explanation
for the important geographical variations
in the prevalence of depression
may lie in the nature of modern societies themselves
which have become increasingly individualistic
and divorced from traditional values.
For many people living in our society today,
life can seem both suffocating and far removed,
lonely even and especially amongst the multitudes.
And not only meaningless but absurd.
By encoding their distress in terms of a mental disorder
our society may be subtly implying
that the problem lies not with itself, but with them,
fragile and failing individuals that they are.
Now, of course, many people prefer to buy into this
reductionist, physicalist explanation
rather than, I suppose, confront their existential angst.
However, thinking of human distress in terms of
a mental disorder can be counterproductive
because it can prevent people from identifying
and addressing the important psychological
or life problems that are at the root of their distress.
Now, all of this is not to say that
the concept of depression
as a mental disorder is bogus,
not at all,
but only that the diagnosis of depression
has been overextended
to include far more than just depression,
the mental disorder.
If like the majority of medical conditions
depression could be diagnosed according to its etiology
or pathology, that is, according to its cause or effect,
then such a situation, such a problem
would never have arisen.
Unfortunately, depression cannot as yet be diagnosed
according ot its etiology or pathology
but only according to its clinical manifestations or symptoms.
Given this, a doctor cannot base a diagnosis
of depression on anything so objective as for example
a blood test as in malaria,
or a brain scan as in stroke
but only on his subjective interpretation
of the nature and severity of the patient's symptoms.
If some of these symptoms happen to tally with
a diagnostic criteria for depression,
then, you know, bingo, the doctor is justified
in making a diagnosis of depression.
Now, the problem here
is that the definition of depression is circular,
the concept of depression
is based on the symptoms of depression,
and the symptoms of depression, in turn,
are based on the concept of depression.
Thus, it is impossible to be certain
that the concept of depression
maps onto any distinct disease entity.
And, particularly since a diagnosis of depression
can apply to anything from mild depression to depressive psychosis,
and depressive stupor
and overlap with a number of other mental disorders,
including anxiety disorders, dysthymia,
and adjustment disorder.
One of the consequences of our many of symptoms approach
to diagnosing depression is that two people
with absolutely no symptoms in common,
not even depressed moods,
can both end up with the same diagnosis of depression.
For this reason especially
the concept of depression has been attacked
for being little more than a socially constructed dustbin
for all manner of human suffering.
Now, let us grant, as the orthodoxy has it
that every person inherits a certain
compliment of genes that make him or her
more or less vulnerable to developing depression
or a state that might be diagnosed as depression
during his or her lifetime.
And let us also begin to refer
to this state rather than depression
as the depressive position
to include both clinical depression
and milder forms of depressed moods.
A person enters the depressive position if the amount of stress
that he comes under is greater than
the amount of stress that he can tolerate
given the compliment of genes that he has inherited.
Now, genes for potentially debilitating disorders
such as depression tend to pass out of a population
over time, over a very, very long period of time -
we're talking hundreds of generations -
because affected people have fewer children
or fewer healthy children than non-affected people.
The fact that this has not happened for this - depression -
suggests that the genes are being selected for
despite their potentially debilitating effects
in a significant proportion of the population
and therefore that these genes
must be conferring some important adaptive advantage.
Now, before talking about what important adaptive advantage
these genes could be conferring
I think it's important to note that there are other instances of genes
that both predispose to an illness and confer
an important adaptive advantage
and the most quoted or most studied example is usually
I would say sickle cell disease.
In sickle cell disease, red blood cells assume a rigid sickle cell
that restricts their passage through narrow blood vessels.
This leads to a number of serious physical complications,
and in traditional or historical societies
to a radically curtailed life expectancy.
At the same time, however,
carrying just one allele of the sickle cell gene
prevents malarial parasites
from reproducing in red blood cells,
and thereby confers immunity to malaria.
The fact that the genes for sickle cell disease
are particularly common in populations from malarial regions suggests
that at least in evolutionary terms,
a debilitating illness in the few can be a price worth paying
for an important adaptive advantage in the many.
Now, what important adaptive advantage
could the depressive position be conferring?
Now if I've made you fall asleep, I hope I haven't,
but If I have made you fall asleep then please wake up now
because I think this is going to be the most interesting part of my talk.
So what important adaptive advantage
can the depressive position be conferring?
Just as physical pain has evolved to signal injury
and to prevent further injury,
so the depressive position may have evolved
to remove us from damaging, distressing, or futile situations.
The time and space and solitude
that the adoption of a depressive position affords
prevents us from making rash decisions,
enables us to see the bigger picture,
and in the context of being a social animal,
to reassess our social relationships.
Think about those who are meaningful to us
and relate to them more meaningfully
and with greater compassion.
In other words, the depressive position may have evolved
as a signal that something is seriously wrong
and needs working through and changing
or at least processing and understanding.
Sometimes we can become so immersed
in the humdrum of our everyday lives
that we no longer have time to think and feel about ourselves
and so lose sight of our bigger picture.
The adoption of the depressive position
can force us to cast off the Pollyannish optimism
and rose-tinted spectacles that shield us from reality;
to take a step back,
to reevaluate our priorities,
and to formulate a realistic or the modest plan for fulfilling them.
Now although the adoption of the depressive position
can fulfill what I would unfortunately call
such a mundane purpose,
it can also enable us to develop a more refined perspective
and deeper understanding of ourselves,
of our lives, and of life in general.
From an existential stand point,
the adoption of the depressive position
obliges us to become aware of our mortality and freedom
and challenges us to exercise the latter
within the framework of the former.
By meeting this difficult challenge,
we are able to break out of the mold
that has been imposed upon us,
discover who we truly are,
and in so doing, begin to give deep meaning to our lives.
Many of the most creative and insightful people in our society
suffer or suffered from depression
or a state that may or would have been diagnosed as depression.
They include the politicians Winston Churchill and Abraham Lincoln.
The poets, Charles Baudelaire, Elizabeth Bishop,
Hart Crane, Emily Dickinson, Sylvia Plath, and Rainer Maria Rilke.
The thinkers, Michel Foucault, William James,
John Stuart Mill, Isaac Newton,
Friedrich Nietzsche and Arthur Schopenhauer
and the writers, Charles Dickens, William Faulkner,
Graham Green, Leo Tolstoy, Evelyn Waugh
and Tennesee Williams
and the list just goes on and on and on.
To quote Marcel Proust,
who himself suffered from very severe depression,
"Happiness is good for the body,
but it is grief which develops the strength of the mind".
(Applause)
I take it that the clapping is for Marcel Proust.
Now you see, people in the depressive position
are often stigmatized as failures or losers.
Of course, nothing could be further from the truth.
If these people are in the depressive position,
it is just because they have tried too hard,
or taken on too much
so hard and so much
that they have made themselves ill with depression.
In other words, if these people are in the depressive position,
it is because their world was simply not good enough for them.
They wanted more, they wanted better
and they wanted different.
And not just for themselves, but for all those around them.
So if they are failures or losers,
this is only because they've set the bar far too high.
They could have swept everything under the carpet
and pretended, as so many people do,
that all is for the best in the best of possible worlds.
However, unlike most people, they had the strength
and the honesty to admit
that something was amiss,
to admit that something was not quite right.
So rather than being failures or losers,
they are all the opposite.
They are ambitious, they are truthful
and they are courageous
and that is precisely why they became ill.
To make them believe that they are suffering from some mental disorder
or some chemical imbalance in the brain
and that their recovery depends entirely
or even mostly on popping pills
is to do them and to do us an immense disfavour.
It is to deny them the opportunity
not only to identify and address important life problems,
but also to deny them the opportunity to develop
a more refined perspective and deeper
understanding of themselves
and of the world around them
and therefore, to deny them the opportunity
to develop their highest potential as human beings.
Thank you very much.
(Applause)