We know what good depression treatment looks like.  You probably won’t get it.

Approximately half of people with post-traumatic stress disorder (PTSD) also suffer from Major Depressive Disorder (MDD) (Flory). That is my justification for treating depression in a blog primarily devoted to PTSD.  Depression usually follows some of the earliest symptoms, such as anxiety and flashback but there are no fixed rules (https://www.ptsd.va.gov/understand/related/depression_trauma.asp).

As I’ve posted recently, it has become almost commonplace today, at least among those impressed by the latest results of neuroscience, to say that Descartes got it backward.  Not “I think therefore I am,” but “I am therefore I think.” The mind is composed of body.  Brain makes mind possible.

Yet, this is not how we experience ourselves.  “I feel therefore I am” is probably the first and fundamental experience of self, or at least the experience that makes life worth living.  It is the feeling of being alive. Depression is the opposite.  It robs existence of vitality and pleasure.  That’s the cardinal symptom of major depression; it can make life not worth living. Depressed people are about twenty times more likely to commit suicide (Gotlib and Hammen).   

“Depression is the flaw in love”

A couple of recent books that take the neurological basis of depression seriously, also see love and its loss as central to the experience of depression.  Because the mechanism of depression takes place in the brain, and because medication and other treatments that work on the brain help, doesn’t mean that our experience of the world is unimportant.  Most important is loss, above all the loss of love: of being loved, of a loved one, as well as the loss of values crucial to one’s identity, such as the loss of religious belief.*

Depression is the flaw in love. To be creatures who love, we must be creatures who can despair at what we lose, and depression is the mechanism of that despair. When it comes, it degrades one’s self and ultimately eclipses the capacity to give or receive affection. It is the aloneness within us made manifest.

Love, though it is no prophylactic against depression, is what cushions the mind and protects it from itself. Medications and psychotherapy can renew that protection, making it easier to love and be loved, and that is why they work. (Solomon, p 15)

Medication and therapy make love possible.  For what is the good of a more balanced mind if one has nothing of value to do with it?  Generally, this love is of another person, but it can be love of one’s work, or faith. 

Stress causes depression among the vulnerable.  Surprisingly, humiliation is the greatest stressor, loss is the second. (Solomon, p 61).  But perhaps they are not so different.  Though we seldom think about it this way, loss is shaming.  After loss we are exposed to the world, naked and alone.  Once you experience a shaming loss, you will never be the same, for you will have learned something about your vulnerability that you may have sensed but never known.

Solomon’s depression seems to have lurked in the background for years, but his mother’s death, and subsequent break-up with his girlfriend instigated a major depression.  His account is the most horrifying depiction of depression that I have ever read (pp 39-100).  It is not artistic, just brutal and frightening, an account of an obliterating force that destroyed every aspect of his life.  It was far worse than what is called anhedonia, an inability to experience pleasure in anything.  Instead, he lived in a state of horror.  Imagine living for months within the experience rendered by Edvard Munch’s “The Scream.”

Medication and therapy

It is puzzling that experts are still debating whether medication or therapy is the best approach to treating depression, for obviously the best approach is both.  This silly dispute is rooted, I believe, in whether one thinks that the phenomenology of depression, that is, its experience, is central to understanding, or whether neuroscience is enough.  Ellen Frank  says that the dual approach is

“the treatment strategy for preventing the next episode of depression . . . It’s not clear to me how much room there’s going to be in the future of health care for an integrated view, and that’s scary.” (quoted in Solomon, p 104; see Frank and Reynolds, 1999)

Why wouldn’t drugs plus therapy be the obvious solution?  Because drugs are relatively cheap; therapy isn’t.  But it gets worse.  The therapies most recommended by so-called authoritative sources are cognitive behavior therapy (CBT) and interpersonal psychotherapy (IPT), which sounds good, but isn’t, for it is another short-term approach (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5709536/) Both are generally referred to as structured psychotherapy, and they really are.  CBT and IPT are readily manualized—that is, capable of being used by relatively unskilled technicians after a short period of training. 

CBT is often completed in as little as twelve sessions, IPT in 12 to 16 weeks.    Basically similar, IPT focuses on affects (feelings), CBT on cognitions (thoughts).  Instead of focusing on “distorted” thoughts, IPT focuses on “distorted” thinking about important people in one’s life.  In neither is there any opportunity to explore feelings and emotions that might lie behind these “distorted” (which can only mean socially unacceptable) thoughts and feelings.  More on what good therapy looks like shortly. 

            Progress in treatment, less in understanding

We have made but small advances in our understanding of depression at the same time that we have made enormous advances in our treatment of depression. (Solomon, p 171)

There are lots of drugs to treat depression.   Here is only a partial list of drugs by class.  Most classes have at least two drugs; there are at least seven SSRIs, and four SNRIs.  Prozac is the most well-known SSRI.    

Recently, ketamine (also known as the party drug “special K”), and psychedelics, have shown promise, especially since they act quickly, unlike many depression medications. 

In addition, there is ECT (electroconvulsive therapy, that is shock therapy); TMS (transcranial magnetic stimulation); and DBS (deep brain stimulation, electrodes implanted in the brain connected to a pacemaker-like device).  

The lesson I take from all these medications and treatments is that no one really understands depression very well, and the standard practice is to try lots of drugs, many originally developed to treat psychosis, such as aripiprazole (Abilify).  These drugs are almost always prescribed in combination with other drugs.  The good psychiatrist will keep mixing and matching drugs until some combination works, at least for a little while.   

The number of drugs used to treat depression runs into the hundreds when one considers each permutation or cocktail, often three or four drugs, as a different treatment.  Nothing quite like this exists for any other disorder.  It means that we simply don’t understand the disease, if that’s what it is.  If it’s an existential crisis, whatever that is exactly, then all the drugs in the world are going to help only a little bit.  Unlike schizophrenia, we have made little progress in the genetic mapping of depression (Duncan and Keller).

In any case, don’t imagine that increasing serotonin is the solution.  We still don’t know how it works, and increasing serotonin levels in the brain via SSRIs (selective serotonin reuptake inhibitors), still the largest class of antidepressant drugs is not magic. 

When you raise serotonin levels and cause certain serotonin receptors to close up shop, other things happen elsewhere in the brain, and those downstream things must correct the imbalance that caused you to feel bad in the first place. The mechanisms, however, are completely unknown. (p 113)

“This serotonin thing,” says David McDowell of Columbia University, “is part of modern neuromythology.”  It’s a potent set of stories. (p 22, communication with author)

What is to be done?  It depends on who you are.

When an expert in neuroscience and psychiatry suffers a major depressive episode, what does she do?  She develops a close relationship with a good therapist, sees him weekly or more often, and maintains the relationship over decades.

Over the next many years . . . I saw him at least once a week; when I was extremely depressed and suicidal I saw him more often.

He kept me alive a thousand times over. He saw me through madness, despair, wonderful and terrible love affairs, disillusionments and triumphs, recurrences of illness, an almost fatal suicide attempt, the death of a man I greatly loved, and the enormous pleasures and aggravations of my professional life — in short, he saw me through the beginnings and endings of virtually every aspect of my psychological and emotional life. (p 87)

He taught Kay Redfield Jamison, author of An Unquiet Mind, how brain and mind were beholden to each other. 

My temperament, moods, and illness clearly, and deeply, affected the relationships I had with others and the fabric of my work. But my moods were themselves powerfully shaped by the same relationships and work. (p 88)

A lifetime of pills and therapy

After stopping and starting medication several times, Jamison learned that she will need both drugs and therapy for the rest of her life.  The drugs control her depression and mania.  They keep her from ruining her career and relationships.  They keep her out of the hospital.  They keep her from becoming suicidally depressed.  And they make psychotherapy possible, and only psychotherapy heals. 

Pills cannot, do not, ease one back into reality; they only bring one back headlong, careening, and faster than can be endured at times. Psychotherapy is a sanctuary.  (p 89) 

The problem with therapy

Jamison received a type, level, and degree of psychotherapy unavailable to 99.9% of the population, a point she never mentions.  What she mentions is how therapy saved her life, and how much therapy she had.  During one particularly difficult time, “I was seeing my psychiatrist two or three times a week.” (p 111)    

The debt I owe my psychiatrist is beyond description. I remember sitting in his office a hundred times during those grim months. (p 118)

Her debt was not just emotional.  Hardly anyone can afford the quality, intensity, and duration (essentially her entire adult life) of psychotherapy Jamison received.  Most don’t need it, but most need far more than they get.  If they’re lucky and are able to work the health insurance system (and severely depressed people can’t do that), their insurance will authorize CBT or IPT for a few weeks.  They may be adequately medicated.  Medication is cheap compared to therapy.  But they will never receive the quality and quantity of care Jamison received. 

Few will.  That is reserved not merely for the wealthy, who can pay $350 an hour (actually about 45 minutes) to talk with a psychiatrist who listens, and doesn’t just medicate.  Jamison was known in the field, giving her access  to the best psychotherapists in the United States.  She could instead have worked with a medicating psychiatrist and a skilled and experienced psychotherapist without a medical degree.**  It makes little difference, as long as the psychotherapist is patient, skilled, experienced, and utterly reliable. 

            Depression is the leading cause of disability

Depression is the leading cause of disability for people in the United States between the ages of 14 and 44 (https://www.cdc.gov/genomics/resources/diseases/mental.htm). Worldwide, including the developing world, depression accounts for more of the disease burden, as calculated by premature death plus healthy life-years lost to disability than anything else but heart disease (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8134814/).

Neither in An Unquiet Mind, nor in Fires in the Dark, does Jamison say one word about the availability of care for the average, or even not-so-average person.  Of course, her books are basically memoirs, but if she wants to write “A Love Song to Psychotherapy,” as she puts it in a New York Times interview, then should not the question of whether her beloved therapy is available to others be raised, if not answered? ***

Most insurance plans cover only short-term structured therapies, such as CBT or IPT. What’s the point of establishing an impossibly high and unavailable standard of superior care? Even if they are able to seek help for a major depressive disorder, almost all will receive far less help than they need.  Anything else is too expensive. 

Of course, most depressed people don’t need the level of care Jamison did, but almost all need more than they get.  And Jamison’s books serve an unstated purpose, the purpose served by all utopian speculation.  The impossible and unavailable is a measure of how far short we fall, and how far we have to go. 

It’s not difficult to imagine a psychological support system that, without providing a lifetime of psychiatric care, would recognize how much support the severely depressed need, and care enough to provide it.  However, as Frank suggests, we seem to be going in the other direction.  A medication-only solution is driven not only by cost pressures but by a neurological way of thinking that has transformed the depressed person into a depressed brain.  Many sufferers now refer to their depression as a “chemical imbalance.”  It’s true, but it’s not the whole truth, and the whole truth seems to be drifting further and further away. 


A Canadian study estimated that providing CBT to every person in Ontario with a major depressive disorder would cost the provincial government about $68 million Canadian dollars in 2021.  The CBT would be limited to 8 or 16 sessions. This is the least effective therapy available.  On the other hand, $68 million is cheap, and combined with medication it’s likely to help some, measured by what the study calls QALY (quality-adjusted life years), whatever that means in real life (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5709536/).  I conclude that providing high-quality care (which CBT is not) for large numbers of people suffering from major depressive disorder is not impossibly expensive, though it would not be cheap.  It’s all a question of values. 



* In “Mourning and Melancholia,” the classic work on the subject, Sigmund Freud draws an important distinction.  Mourning is normal, and grieves for the lost object.  Melancholia (depression) treats the lost object as part of itself, turning against the self for its loss.

** A professor of psychiatry, Jamison lacks a medical degree. 

*** Jamison’s more recent Fires in the Dark (2023)  adds little to her argument.  It reads more like an extended postscript.  In an interview with The New York Times, she said “If I could have subtitled it ‘A Love Song to Psychotherapy,’ I would have.”  https://www.nytimes.com/2023/05/22/books/fires-in-the-dark-kay-redfield-jamison.html  


Laramie E. Duncan and Matthew C. Keller, “A critical review of the first 10 years of candidate gene-by-environment interaction research in psychiatry.”  American Journal of Psychiatry.  Published online: https://doi.org/10.1176/appi.ajp.2011.11020191.  October, 2011.

Janine Flory, Comorbidity between post-traumatic stress disorder and major depressive disorder.  Dialogues in Clinical Neuroscience, vol. 17 (June 2015), 141-150.   https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4518698/

Ellen Frank and Charles Reynolds, “Nortriptyline and interpersonal psychotherapy as maintenance therapies for recurrent major depression,” Journal of the American Medical Association 281, no. 1 (1999). 

Freud, “Mourning and Melancholia.” Standard Edition 14: 243-258. (original 1917).

Ian Gotlib and Constance Hammen, Handbook of Depression, 3’d edition.  Guilford Press, 2015.

Kay Redfield Jamison, An Unquiet Mind.  Vintage, 1996.

Kay Redfield Jamison, Fires in the Dark: Healing the Unquiet Mind.  Knopf, 2023.

Andrew Solomon, The Noonday Demon: An Atlas of Depression, with new material.  Scribner (2015)

drawing of Kay Redfield Jamison


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