THE TELEPHONE rang at the office one morning, while I was busy sorting out my paperwork. “It’s Munir, calling from Boston,” he said, clearly distraught. His voice was cracking, his speaking interrupted by quiet sobbing.
“What’s up?” I asked, playing innocent “You were doing so well last time I saw you in Montreal. Did anything happen?”
“Wel-1-1 …” I could sense there was something he didn’t want to tell me, but I pushed ahead.
“You can say it Munir, I won’t judge you or scoldyou,”Isaid.
“Well, my friends convinced me I didn’t need the pills. They said I was a smart guy and I could talk myself out of my negative state and get myself together with positive thinking and the right attitude. And, well I listened to them. I just wanted to see if I could do without the meds.”
He was clearly feeling remorseful. “If you give me another prescription, I promise I won’t do it again…”
We had talked about this many times in our sessions. Munir had a chemical imbalance and he needed his medication. I had explained to him about neurotransmitters and given him the analogy of diabetes and insulin. He seemed to be convinced when we had talked about it but wanted to prove it to himself one more time. And now he was in “meltdown” mode.
Munir represented every immigrant Muslim family’s dream. He was studying at Harvard Law School and he was near the top of his class. He had a brilliant analytic mind and he captured ideas very quickly. But he also had depression major depression – with a strong family history of mood disorders. He had tried many forms of non-chemical therapy from psycho-dynamic psychotherapy to cognitive therapy. In his more radical period he had even tried cathartic group therapy. But nothing worked effectively, except serotonergic anti-depressant medication, known as SSBIs. This was the only treatment that had brought long term relief – as long as he took it. Reluctantly over many years, he had come to accept this reality.
This brief anecdote opens the door to discussing current approaches to psychiatric problems and depression in particular. The term “bio-psycho-social” was coined by Dr George Engel, an internist and psychiatrist in the 1970s. He based his ideas on the work of Adolph Meyer who talked about “psychobiology” and Franz Alexander, the founder of the Chicago school of psychosomatics. Dr Engel developed his ideas working in the area of psychosomatics and more specifically what is now called Consultation-Liason Psychiatry i.e. psychiatrists working in medical and surgical departments to help other physicians understand the psychological concomitants of physical diseases.
Engel’s paradigm concluded that psychological factors interact dynamically with biological and social elements in both health and disease. The model goes further in stating that the cause and effect relationships are not usually linear but rather interacuve and reciprocal. This model is proposed as an antidote to two other theoretical approaches common at the time and still today – that is “dualism” (the mind/body dichotomy ) and “reductionism” – an ever-present danger in medicine, whether it be biological reductionism common in today’s high-tech environment or psychological reductionism, common in the Freudian era.
All of this may seem very abstract and inconsequential. In fact h has very practical relevance in the everyday practice of psychiatry and medicine as well as in everyday decision-making, outside the context of illness. We can, for example, think of our human needs in each of these spheres: the biological needs for food and shelter; the psychological needs for harmony and understanding ;the soda/needs for community and relatedness; and the spiritual needs for a meaningful relationship with the Absolute. 1 find it personally useful to consider these various dimensions in my own attempts at living a balanced life. A similar paradigm would be to think in terms of the needs of our bodies, minds, hearts and souls. We can begin to reflect in this manner so as not to become too one-sided in our approach to life. The superficial social context in which we live would bias everything towards the physical, the mind being a distant second. Heart and soul remain for the exceptional ones in this materialistic context.
Coming back to the case of Munir, he was unable to accept the biochemical underpinnings of his illness. Nor could his friends. We could say they were suffering from psychological reductionism. The “get a handle on it” or “pick yourself up by your bootstraps” mentality implies a strength of will-power and initiative that is not always present in people. In fact the nature of depressive disorder is such that this is the very capacity that is undermined by the illness itself. This is difficult for anyone who has not experienced serious depression themselves to understand.
THE CASE OF BARBARA
Barbara’s story was quite different from that of Munir. She was raised as a Catholic by practicing Christians. They took her to mass every Sunday but were not very concerned about religious matters for the rest of the week. She had decided to pursue her spiritual interests by practicing Christian meditation with a local group founded by a Benedictine monk. He had attempted to introduce Orthodox meditation techniques into his Catholic practice. But this approach was not working for her and she was hitting a wall.
The main stumbling block for her was Christian theology. She could not accept the Divinity of Christ nor the doctrine of “Vicarious Redemption” – that Jesus died on the cross for the sins of others. It just didn’t make sense to her. Most Christians accept these beliefs as part of the credo and pass over any logical contradictions therein. They believe that these concepts are mysteries that the human mind cannot possibly comprehend, and they accept them.
For Barbara this was not possible. And so she entered into a spiritual crisis. This was certainly not the only factor in her depression. She had also broken-up with her live-in partner a year previously and there was as well a modest family history of depression in the mother and grandmother.
When Barbara entered treatment she had all the hallmarks of a major depression. She had lost all motivation for work and even recreational activities. An active walker and mountain climber, she now stayed at home and watched TV. She was barely able to keep up with her job at an accounting firm. Soon after her treatment began I had to put her on sick leave at least until the effects of the medication kicked in.
Normally Barbara was a very dynamic woman. Once the medication started working, in about a month’s time, she was back at her spiritual quest. She knew the problem wasn’t solved simply because she was feeling somewhat better. She began studying other religions and philosophies and asked me about Islam. I explained to her that 1 was her doctor, not her spiritual mentor (although in the modern context one wonders at times if the mental health professionals have not taken over many priestly functions). In my practice, in fact, 1 have people from all of the major faiths. In a way, 1 have developed a certain specialty: a professional niche, with respect to people interested in the spiritual path as well as the psychological one. Most of the people who come to see me are content with their faith and happy to be treated by another person of faith, even if different from their own. 1 try to avoid theological debates whenever possible but especially in my practice.
Barbara’s case was different, however. There was a burning desire to know and she would not let me adopt the usual stance of neutrality. So I did suggest certain books she could read and organizations that could give her more information about Islam. She went about these pursuits with more and more energy. She visited Buddhist monasteries and Yoga Centres and mosques and eventually chose to become a Muslim.
But that was not the end of her story, unfortunately. After a while Barbara married a Pakistani man and went to live in Saudia Arabia where her husband had a contract as an engineer. Having been raised as a “liberated” Western woman, she was now confined to a foreigners’ compound, unable to drive and found herself uncomfortable with both the Saudi approach to religion stodgy and dry and formalistic – and with the Westerner’s liberal and often decadent lifestyle. She became socially isolated and then relapsed into depression; a serious one.
By the time she came back to Montreal, she was in a lamentable state. Her gaze was fixed and blank, she was constantly fearful of others and she was non-functional at home. We were back to square one – or worse.
We began slowly with both antidepressant and antipsychotic medications. Gradually we withdrew the antipsychotics and left her on the anti-depressants. She began her recovery by doing a little housework and gradually started taking classes in her field, accounting, in order to renew her skills. Fortunately, her husband was patient and understanding and with his help and support within a few months she was back on her feet. Her faith remained strong throughout this period, a somewhat surprising occurrence as 1 have seen many people wavering in their faith during an intense depressive assault
There was only one more obstacle to her complete recovery and that was her employer. After two previous depressions, the insurance company was reluctant to insure her for future disability. I had to have long talks with the insurance company psychiatrist to convince him that she was a good risk. He in fact had good evidence to the contrary. After two major depressive episodes the risk of a third one is very high. I argued that we had got through several major risk factors – a spiritual crisis and a social crisis and that my client was very collaborative in treatment and now understood the precipitating factors causing her depressions.
The employer relented and decided to give her a chance. Slowly she returned to work – at first for one day, then two and eventually back to fulltime employment for 3 years without a single missed day on account of illness.
I bring up this case not to congratulate myself or modern psychiatry. Our results are notalways as decisive or rewarding as they were in this case. Rather, I think the unfolding of events helps us to be aware of both the social and spiritual elements involved in psychiatric illness.
For this reason, I have argued for a long time that the Engelian Model of bio-psycho-social should be expanded to include the spiritual. I had even proposed a presentation at the Canadian Psychiatric Association on this subject 20 years ago but it had been refused. Unfortunately there is still a reticence to include the spiritual in the psychiatric paradigm because it is viewed as dubious, unmeasurable and thus scientifically “soft”. There are voices in the community, however, mostly from the Christian sector, arguing for the importance of faith and of prayer in the psychological sphere – but they are still voices in the wilderness.
The issue of using the bio-psycho-socio-spiritual model in psychiatry and in life, for that matter, is not purely theoretical but eminently practical. One of the major sources of error in medicine – as in life – is what I like to refer to as “dimensional confusions”. We can see this in the case of Munir where his friends reformulated his inherently biological problem into a psychological one – with potentially disastrous results.
We see this as well when patients refuse to take “chemical treatments” and want “natural ones” – as if our own bodies were not functioning on the basis of chemical and bio-chemical reactions already. And as if “natural treatments” were necessarily benign. They could profitably reexamine the assumption of the innocuousness of natural products – take tobacco and arsenic for starters, let alone snake venom – all very natural indeed.
Another frequent “dimensional confusion” is referring essentially medical and other specialized matters to religious authorities. Although we have Islamic precedents to warn us of this kind of error (see the story of the Medina date farmers requesting advice about grafting date palms from the Prophet may Allah Bless him and grant him Peace) many people continue to bring their ear infections and diabetes questions to the shuyukh. For du’a and baraka that is fine. For medical advice, beware. I have personally witnessed numerous near-tragedies and several actual ones due to this misunderstanding. We must seek out the appropriate asbab (causes) and understand the limitations of the human condition, even in highly evolved spiritual beings.
In the case of Munir, spirituality seemed to play a minor role. He was a believer but his practice was modest at best like many modern Muslims. Yet he was comfortable with his lukewarm faith and the sense of identity it gave him. In the case of Barbara the spiritual dimension was much more acute. Her himma (desire to know the truth) was strong and she could not be satisfied with half-measures. Her faith was strong and as in the case of many believers it maintained her through the turbulence and anguish of her depressive periods.
As a psychiatrist frequently confronted with people who have suicidal ideas and fantasies, it is a relief to work with people who consider suicide an act forbidden by God. Not wanting and not able to impose our beliefs on others, we have to deal with people on a regular basis who see suicide as an exit strategy. And, of course, this is stressful for everyone in their surroundings – both the physicians treating them and their family members. In this era of judicializing every untoward event in our lives, the threat of lawsuits and professional complaints hang over our heads constantly.
Returning to our main topic, let us return to a basic definition. What is depression? In some ways it is difficult to talk about. Depression as a term is very vast indeed. It can include anything from a mild feeling of “the blues” to a state of such excruciating psychic pain that death seems like the only way out or yet again to a state of catatonic mutism that looks like a severe form of schizophrenia.
That being said, according to the DSM-IV (Diagnostic Manual of the American Psychiatric association, 4th edition), there are three major categories: 1) Major Depressive Disorder; 2) Dysthymia; and 3) Adjustment Disorder with Depressed Mood. This does not include the various forms of Bipolar Disorder – formerly known as Manic-Depressive Illness.
In former times, psychiatrists talked of endogenous (biological) versus reactive depression (environmental) and psychotic versus neurotic depression; a vocabulary from the psychoanalytic era. There were also terms such as “melancholic depression”, a particularly severe form with psychomotor retardation or agitation and total loss of pleasure and “atypical depression” which included increased rather than decreased appetite and sleep in addition to interpersonal problems. All of these terms have now been excluded as independent entities and appended to the three major categories.
CRITERIA FOR MAJOR DEPRESSIVE EPISODES
Five or more of the following symptoms have been present for a two week period and represent a change from previous functioning. At least one of the symptoms is either, (a) depressed mood, or (b) loss of interest or pleasure:
1. Depressed mood most of the day as indicated either by subjective report (feeling sad or empty) or observation made by others (e.g. appears tearful).
2. Markedly diminished interest or pleasure in all or almost all activities most of the day.
3. Significant weight loss when not dieting or weight gain (e.g. change of more than 5% in body weight in a month).
4. Insomnia or hypersomnia.
5. Psychomotor agitation or retardation.
6. Fatigue or loss of energy nearly every day.
7. Feelings of worthlessness or excessive guilt nearly every day.
8. Diminished ability to think or concentrate; or indecisiveness.
9. Recurrent thoughts of death, recurrent suicidal ideation or a suicide attempt or a specific plan of suicide.
This is the basic depression paradigm. Modifiers of the general description may be “catatonic” (self-explanatory) “melancholic” (particularly profound or incapacitating) and “atypical” (having to do with characteristics like personality disorders and interpersonal dysfunction).
Dysthymic Disorder is a milder form of the disease and it includes: (a) depressed mood for most of the day indicated by subjective account and observation by others for at least two years, and (b) presence while depressed of two or more of the following:
1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or indecisiveness
6. Feelings of hopelessness.
Dysthymic patients may function for long periods of time without any noticeable impairment in their functioning. They may just appear negativistic and pessimistic or have chronically low energy and variable effectiveness at work and in family life. However, occasionally a Major Depressive Episode may occur within the background of Dysthymia and then we have “Double Depression”.
ADJUSTMENT DISORDER WITH DEPRESSIVE MOOD
Adjustment Disorder with Depressive Mood has the following criteria:
a) The development of emotional or behavioral symptoms in response to an identifiable stress or occurring within 3 months of the onset of the stressor.
b) These symptoms or behaviors are clinically significant as evidenced by either of the following:
1. Marked distress that is in excess of what would be expected from the stressor event;
2. Significant impairment in social or occupational functioning.
This disorder corresponds to the older idea of reactive depression. It is usually short-lived (by definition less than six months) and resolves on its own. It is caused by the ongoing ups and downs of daily living of which we see more and more in the modern world, causes such as job loss, financial difficulties, or marital breakup, for example. At times however what may appear to be an Adjustment Disorder turns out to be a Major depression and then we have a more serious situations on our hands.
In summary we have herein three forms:
1. acute incapacitating depression, or a Major depressive episode;
2. chronic smoldering depression, known as Dysthymia; and
3. depressive reaction to stressful events and life’s inevitable tests or Adjustment reaction depression.
So, what causes depression? Here we have to return to our bio-psycho-social spiritual model.
No other subject with the possible exception of schizophrenia has been as extensively researched as the biological concomitants of depression and yet we are still a long way from having any kind of definitive answers. Perhaps this is due to the heterogeneity of the disorder (depression is a vast category) or perhaps it is due to the complexity of human existence in general, as Allah has designed it.
Regardless of the reason, these are the facts. There is no specific biological test which can confirm depression as an EEG may confirm epilepsy or a Creatinine Clearance can confirm renal failure. We are unable to predict which patients will respond to which anti -depressants on the basis of their biochemical profile. And we have no genetic test thai can tell us which children of which depressed or bipolar parents are more at risk for depressive episodes themselves. So we are far indeed from a definitive biological description of depression.
There are some interesting biological and genetic findings, however, that point in the direction of certain parameters. Twin studies, for example, have shown that the concordance rate [or mood disorders in monozygotic twins is 2-4 times that of dizygotic twins. This means that an identical twin (monozygotic) is 2-4 times more likely to have the disorder than a fraternal twin (dizygotic) – when the other twin is affected. Since monozygotic twins have identical genetic make-up and dizygotic twins have 50% of their genes in common, the comparison between the two is very useful in determining the geneticity of a disorder. However the concordance rate of identical twins is not 100% even though they are genetically equal. Depending on the study, the rate may vary between 60-90%. Environment factors then have some impact – in some cases a determining one.
As to the familial tendency of depression, the rates in first-degree relatives of affected individuals is 2-3X that of the general population, In bipolar disorder (formerly manic-depressive disorder) the rates are even higher: 3-8X that of the general population. In addition there is significant crossover between the two disorders so that people who have a bipolar relative in the family are much more likely to have depression themselves than the rest of the population. All in all, we are talking of a strongly inherited trait.
Within the context of an article such as this we cannot attempt to cover all the other biological factors involved in the genesis of depression. This is a vast field of research. However, we will attempt to look at a few of the more interesting findings.
One of the more consistent findings in the field of depression is the disturbance of cortical secretion. Increased Cortisol secretion is apparent in 20-40% of depressed patients and 40-60% of depressed inpatients. In this way we have a window on the cortico-hypothalamic-pituitaryadrenal (HPA) axis or the stress-response, since elevated glucocorticord activity is the hallmark for mammalian stress response. Cortisol can be tested via urine or blood levels or then again through its feedback loop via something called the Dexamethasone Suppression Test. The sensitivity and specificity of these tests is not sufficient however for clinical use and Cortisol hypersecretion is observed in many other psychiatric disorders.
The link between the stress response and depression is an intriguing one. Is depression simply an effect of an overly stressed organism – a form of burn-out to use a popular term. Or are depressives simply people unable to manage stress because of some inherent deficiency in the HPA axis? At this point we are still in the realm of speculation.
Much of the discussion with regards to the biological origin of depression in recent history has been about the neuronal synapse and neurotransmission across the synapse – i.e., the passing of information along neuronal circuits via neurotransmitters. The three neurotransmitters that have been referred to most often are serotonin, norepinephrine or noradrenaline, and dopamine.
The serotonergic system is an important regulator of sleep, appetite and libido. It is also important in goal-directed behavior and certainly plays a role in mood. Reduced serotonin levels have been implicated in impulsive and aggressive behavior and especially in suicidality.
Serotonin’s claim to fame however was the discovery of fluoxetine or Prozac – the first SSRI. From there we see the development of the most commonly used family of antidepressants in clinical practice; which now includes Paxil, Zoloft and Celexa amongst others. Although these anti-depressant agents have been the subject of recent controversy due to a reported increase in suicidality in the early days of treatment their place in psychiatric practice is wellestablished. I certainly have seen many lives transformed in a positive way through their use. Some patients have even claimed to feel “normal” for the first time in their lives and this kind of result although by no means universal, is frequent enough to be highly encouraging.
The SSRIs do have their downside however. They often disturb the sleep-wake cycle and tiredness during the mid-afternoon is a frequent accompaniment. They also inhibit sexuality and for young couples beginning their relationship and even for those further into their marriages, this inhibition can be upsetting and disruptive. So they are by no means a perfect solution.
The norepinephrine (the second neurotransmitter) system is largely responsible for initiating and maintaining limbic and cortical arousal as well as modulating the function of other neurotransmitters. It is involved in stimulating goal-directed and reward-seeking behavior. Some nor-epinephrine specific antidepressants have been developed but generally they have not proved as effective as the SSRIs. One of the most recent ones was Reboxetine, which was eventually refused by the American FDA because it was not clearly superior to a placebo. However anti-depressants that work on serotonergic and norepineprine systems at the same time (the so called dual-action antidepressants) have proved to be highly effective and in some studies more effective than SSRI’s. Examples of such medications are Venlafaxene (Effexor) and Mirtrazapine (Remeron).
The other neurotransmitter that has been studied with respect to depression is dopamine, although its relation to schizophrenia and other psychotic disorders is more clear-cut. Dopamine is probably best known for the controversial and at times illegal substances that stimulate it. Thus both Ritalin (Methylphenidate) and Amphetamines used in the treatment of children with Attention Deficit Disorder and Cocaine, a drug of abuse, are dopaminergic substances. Dopamine is naturally responsible for the regulation of emotional expression, learning, concentration and complex executive and cognitive tasks. Its role in depression is less clear than serotonin but some of our current antidepressants such as Buproprion also known as Wellbutrin act on the dopaminergic system, while Ritalin (Methyphenidate) has been used as an augmenting agent in treatment-resistant depression.
The neuro-transmitter question has become more complicated over the last decade. For one thing, we now realize that all the activity does not occur only at the post-synaptic receptor sites. Important functions occur at the presynaptic sites through auto-receptors and heteroreceptors. And there is an increasing realization of the role of secondary messenger systems as well as genetic transcription and translation factors. Added to this are other neurotransmitters systems such as the glutamate and glycene neurotransmitters which are excitatory and continue to assume increased importance over time. So, the biological picture becomes more and more complex. (Subhanallah for the subUety and complexity of created beings!) Our treatments, however, remain based on more simplistic notions.
Another fascinating part of the evolving biological dimension is the use of cerebral imaging techniques – at first the simple CAT scans and MRl (magnetic resonance imaging) techniques. Recently techniques have been developed not only to see the anatomic structures within the brain but also to image the physiology and metabolic activity of the brain. These methods include the PET scan (Positive Emission Tomography), functional MRl and Magnetic Resonance Spectroscopy.
The most widely replicated finding on PET scan in depression is decreased anterior brain metabolism, more pronounced on the Left side. This is also known as hypofrontality. This refers to a lower level of brain activity in the more highly evolved areas of the brain, where cognition takes place. Increased glucose metabolism has also been observed in several limbic regions (areas responsible for emotions and memory) in severe recurrent depression. Although many of these findings are intriguing and do make sense in terms of the phenomemology of depression, none have yet proved useful clinically.
As in many areas of psychiatry the first theories of depression came from the School of Psychoanalysis and specifically the ideas of Sigmund Freud. The psychoanalytic approach attempts to understand the inner workings of the mind and the processes of the unconscious. Much of the theorizing is based on the idea of defense mechanisms such as “introjection” and “projection” and “libidinal energy” and “cathexis”. Although the terms are at times arcane and hermetic they do provide a useful vocabulary for discussing inner mental processes once the terminology is mastered. What they do not provide is a reliably effective means of changing these processes. Freud was well aware of this problem and predicted, quite remarkably, that neurophysiology not psychoanalysis would provide the ultimate answers!
As to his psychological formulation, in his classic paper, “Mourning and Melancholia” Freud hypothesized that depression was a form of bereavement gone wrong. In this theory depression represents anger directed at the lost object (person) that becomes re-directed against the self.
This process involves the “introjection” of the lost object identification with it followed by a turning against it. This anger or hatred then takes the form of lost self-esteem and of selfreproach and self-loathing, often seen in the profoundly depressed. Abraham, one of Freud’s colleagues added in the dimension of disturbed “infant-mother relationship” which renders the child more vulnerable to depression at a later age.
Here we have the elements of the classical psychodynamic theory of depression: 1) early disturbance in the mother-child relationship; 2) real or imagined loss; 3) introjection of the lost object as defense mechanism; and 4) anger and hostility directed at the self.
Although some of the concepts, such as introjection, and turning against the self have proven to be useful and informative, the psychoanalytic formulation of depression has not proved to be very clinically useful and rare is the contemporary psychiatrist who would use it as his basic model for treating depressed patients. In fact psychoanalysis has proven to be particularly ineffective in treating serious depression.
Other theoreticians following Freud have elaborated other psychodynamic theories. TIi ey have included Melanie Klein (the arch-rival of Freud’s own daughter Anna), Edith Jacobsen, and Heinz Kohut, the pioneer of the empathie approach to psychoanalysis. Melanie Klein believed that the depressive stage was a normal stage of development and depression was simply a fixation at this stage. Edith Jacobsen saw depression as a state in which the ego (self) was persecuted by the superego (conscience) which had become a sadistic and powerful mother taking delight in torturing the child. And Heinz Kohut founder of Self-Psychology believed that children had an instinctive need for mirroring (recognition by adults) and idealization (looking up to the parents) and if these weren’t fulfilled, depression could be a later outcome.
Many other theoreticians have come along through the years to try their hands at formulating a theory of depression. Two of the more interesting recent ones were Margaret Mahler who studied mother-infant interactions in laboratory situations and John Bowlby who looked more closely at the issue of attachment and separation in children and its effect on later psychopathology.
Despite a plethora of theories many clinicians have become disenchanted with a purely psychodynamic approach to treating depression. Dr Peter Kramer in his ground-breaking work Talking to Prozac relates many cases of blindalley psychotherapy of depression that only unblocked when Prozac or other SSRIs were added to the mix. Almost every psychiatrist in practice has had numerous referrals from psychologists who had reached dead ends in their treatment of depressed patients by purely psychological means only to see the impasse unblocked once anti-depressant medications were prescribed.
The overall tendency in the field has been to look to more active forms of psychotherapy in dealing with depression. From this vantage point two newer therapies have emerged: Cognitive-Behavioral Therapy and Interpersonal Therapy. We will describe more of the underpinnings of cognitive therapy in the remaining part of this section and look at interpersonal therapy under the rubric of the social dimension.
Dr Aaron Beck, the founder of Cognitive Therapy, noted in his early writings that “the early promise of Psychoanalysis that I had observed in the early 1950s was not borne out – as my fellow psychoanalytic students and other colleagues entered their fifth and sixth years of psychoanalysis with no striking improvement in their behavior or feelings. Furthermore I noted that many of my depressed patients reacted adversely to therapeutic interventions based on the ‘refelected hostility’ hypothesis.” He then began an agonizing reappraisal of his own belief systems about depression. From this reflection emerged cognitive therapy.
Dr Beck eventually postulated the cognitive triad of depression. The first component of this triad concerns the patients negative view of himself. He sees himself as defective, inadequate and deprived. Secondly he has a negative interpretation of ongoing experiences – he is, in other words framing his current experiences as defeat and deprivation. In current parlance he has become the opposite of political “spin-doctors”. He is spinning everything in a self-condemnatory rather than a self-congratulatory way. The third component is a negative view of the future – believing his current difficulties will continue indefinitely and manifesting an overall pessimism in whatever he undertakes.
From a spiritual point of view, we can see that this is the opposite of how we ought to think. Instead of having a positive opinion of God and of man, the depressed person has developed a negative opinion. Instead of trusting in God’s plan (Tawakkulas it is called in Islam and Sufism) the depressed person thinks everything will work out badly. And instead of being grateful and thankful for what is occurring; the depressed person is grumbling and complaining.
This does not imply that it is easy to change one’s way of thinking. Aaron Beck and the cognitive therapists have been described by one of my psychiatric teachers as the equivalent of Marines landing on the shore of hostile mental terrain. In direct contradistinction to the passive, empathetic analysts they are active, willful and even pushy at times and they encourage their clients to work hard and energetically against their dysfunctional belief systems. They direct, structure, provoke and coach their clients out of their lethargy and into the realms of ‘rational thinking’. This is not a simple task.
Another of the important contributions of cognitive therapy has been identification and correction of “cognitive distortions” that lead to “automatic thoughts” of a self-defeating nature. I think these cognitive distortions are particularly interesting as they can be used by any of us – whether depressed or not Mental health and realistic-thinking can be developed in each of us by taking account of these cognitive distortions. We will look only at the most important ofthese:
1. All or none thinking … (black and white thinking). For example, after a poor performance in a tennis match the patient concludes “I suck at sports”.
2. Catastrophising. For example, after losing a job, one thinks “FIl never be able to find another well-paying job” or after having trouble understanding a particularly complex lecture he tells himself “I’m no good at chemistry… I’m going to fail this course and ruin my entire academic career”.
5. Discounting the positive. I have noticed this one often in depressive patients. I must not tell them when they are doing better or they will make it a point of honor to prove me wrong. This is a common phenomenon. 1 like to call it the “onesided” balance sheet of mental accounting – only the debits are registered; the credits are ignored.
4. Labelling- “Vm a loser”, “Fm a nerd”. This can also be applied to others and tarnishes any possibility of a fruitful relationship, “She’s a user”, “He’s a manipulator”. All of this falls into the zone of the unproductive.
5. Magnification/Minimization. Often depressive people will devalue themselves and overvalue others. “That teacher is so clever, I’ll never be able to express myself as well as him” he thinks to himself.
6. Tunnel vision or Mental Filter. “I had one critical comment on my evaluation concerning time utilization, so I’m a lousy worker” (when in fact the evaluation included comments about her creative problem-solving and her good relations with other employees but these were discounted).
7. Personalization. “My boss was curt with me today as he passed in the hallway so he must not like me” (Many other explanations – such as excess work stress, difficult home situation or a generally irritable personality could all be explanations for the same behavior).
This list could go on and on. Cognitive therapy attempts in an active way to transform these distortions into more rational/realistic thinking. We can all at times fall into these distortions and it is interesting to try for ourselves to identify and correct them when possible.
Research seems to validate this approach as highly effective in dealing with depression. In some studies, in fact, cognitive therapy is equally effective to medication although these studies are usually designed by cognitive therapists themselves. Part of the reason for its effectiveness may be its more active stance and its willingness to advise, coach and encourage – something psychoanalysts were taught not to do. Part of the reason also may be the commonsense approach it has adopted as opposed to the more elaborate abstractions of psychoanalytic thinking. The short-term format used is also an advantage both in terms of economics and in terms of time.
The Social Dimension
Depression is a major social problem. 10-25% of women and 5-12% of men will have Major Depressive Disorder in their lifetime. Another 3-6% will suffer from Dysthymic Disorder sometime during their lifetime and 25-33% of people with Major Depressive Disorder will have Dysthymic Disorder as well, this phenomenon being called Double Depression. This does not include Bipolar Disorder, Cyclothymia and Adjustment Disorder. So we are dealing with a significant segment of the population. Almost everyone has known someone in their circle of friends or family who has suffered from serious depression – often known by euphemisms such as “burn-out” or “nervous breakdown”.
All epidemiological studies have confirmed a higher prevalence of major depression in women than in men – generally about 2:1. It is possible however that this is an artifact of our current criteria for depression. Men may express the depressive affect in others ways – for example by alcohol abuse and violent behavior. They would then receive another diagnostic label.
Several social factors appear to contribute to depression as well:
1. Lower socio-economic status.
2. Separated and divorced people have a higher rate.
3. Family history of depression and bipolar disorder.
4. Parental loss before adolescence is a risk factor for adult-onset depression. A deprived, disrupted home environment also constitutes a risk factor.
5. Stressful life events, such as divorce or death of a spouse, loss of employment
6. Lack of social support and social disintegration.
7. Unemployment: the rate of depression is three times higher in those not working. Homemakers were also three times more likely to experience major depression. An interesting reflection of contemporary values.
Most of these factors are self-evident. However one may begin to see how modern societies with their lack of community, high divorce rates, unstable employment situations and consumer lifestyle may be particularly “depressogenic”.
Generally there is not much we can do to change the social context in which we live. However it is important to be aware of what is happening around us and to see it in a some kind of historical perspective. I am struck in my daily practice of psychiatry at how many of the problems that people have are social rather than individual. From lonely, aging women seeking desperately for companionship, to men having suffered recent job losses, to constant conflict over the multiple tasks and responsibilities facing couples dealing with rebellious teenage children, the majority of the problems seen in therapy have a social context And yet, one has to deal with them on an individual level in order to survive. Much of psychotherapy is about managing these dilemmas.
One of the more recent forms of psychotherapy called Interpersonal Therapy was developed by two research-orientated practitioners who were well aware of the problematic social context after long years researching the epidemiology of mental illness. They are Gerald Klerman and Myrna Weissman. Based on the earlier ideas of Adolph Meyer and Harry Stack Sullivan, the individualistic ideas of Freud were re-interpreted in an interpersonal context. The patient’s current interpersonal experiences and attempts to adapt to social change and intercurrent stressors are seen as critical factors.
Interpersonal therapy is much more active and interventionist than classical psychoanalysis. The therapists are willing to work on problem-solving and not reluctant to give advice-something taboo in the psychoanalytic process mentioned previously. Patients are encouraged to become more active and to socialize.
This is of course not a new idea. Mulay alDarqawi, a great Sufi saint from Morocco, in his Risalat explained how he himself- burdened with waswas (obsessions) – was only able to escape from his inner preoccupations by constant socializing and avoiding solitude for a certain period of time. One has to balance our social needs, however, with our needs for contemplation and quiet reflection – and thence the spiritual dimension.
The Spiritual Dimension
Of all the dimensions related to depression it is not surprising to find that the spiritual one is the least studied. Many scientific-minded people take it as point of honor to be atheistic or at least unconcerned about matters of ultimate meanings. They prefer to be highly specialized and quantitative in their approach.
There is a well-known discrepancy in the literature between psychoanalysts and their clients. While 90% of Americans believe in God. only 43% of psychiatrists (according to the APA) do. As a believing psychiatrist I can confirm that many patients regardless of their religious background are pleased to be treated by a person with faith. I suspect that some ofmy clients choose me as their physician for this reason.
One of the exceptions to the dearth of research on religious issues in psychiatric practice is the work of David Larson, a psychiatrist and president of the National Institute for Health Care Research. He has extensively reviewed the research in Health Sciences and found positive associations between religious involvement and measures of physical health such as high biood pressure, cancer, heart disease, stroke and suicide. In the review Health Psychology (May 2001) he presents a meta-analysis (a form of study combining the results of many others studies) of 142 independent samples showing a significant effect in lowering mortality due to religious involvement.
As to what the intervening variables might have been, Larson hypothesized such factors as reduced smoking, drug and alcohol abuse, unsafe sexual practices as well as improvements in social support and marital-family stability. To maintain his scientific credibility he doesn’t dare suggest that rewards from God for good actions may be an important factor as well!
Of course, religion and spirituality go well beyond providing health benefits and prolonging life. The real purpose of spiritual practice is to give meaning and direction to our lives and to solidify our relationship with the Absolute. None of this can be measured quantitively and scientifically.
I have attempted, outside of any quantitative research model, to look into the spiritual implications of various psychiatric disorders. And I have noticed certain things about depressive people. They tend to be both realistic about life in the world and sensitive about what is going on around them, especially in other people. And almost by definition they are not willing to buy into the hype of the marketers and “good-time Charlies” of the modern world, where everything is about enjoying oneself and having a good time.
On this basis, I have come to the conclusion that depression is about seeing the world (i.e. dunya – the earth-plane if you wish) as it is. If one only sees this lower world, of suffering and pain and testing, then depression is the only possible affect. The rest is illusion.
In order to get out of this depression, one has to get a sense of the other world – the Akhira (the after-life) and also a sense of the ghaib (the unseen worlds). From these latter points of view, life takes on new meaning, and the heaviness of the material world can be alleviated.
“So why is everyone not depressed?” you may ask. Many are, in fact, living in delusion – the delusion of arriving at some kind of paradise on earth – though money, or social acclaim or through intimate relationships or through retirement planning – through a whole host of false gods. These delusions break down, of course, when confronted with the realities of sickness, tragedy and death. Depression then becomes the inevitable consequence.
For the meantime, despite these reflections, I am not recommending a purely spiritual approach to treating depression. We still need modern medications and therapies and social supports. But the spiritual approach allows us to frame all experiences, including that of depression, in a positive manner and gives meaning to every aspect of existence.
May Allah help us to see our lives clearly and to use all phenomena, animate and inanimate, as ways to His Holy Presence.