Depression. Not feeling a little down. Not feeling low or sad. Not even crying real tears. Depression. Real and true depression. One of the most insidious, destructive of disorders. So little understood even by the professionals who claim to treat it.

Real depression is devastating. It lays waste to lives, to relationships, to hopes and dreams. Not just those of the depression sufferer. It destroys families, friendships, loves and relationships. It affects everyone it touches including the loved ones of those who suffer it’s destructive effects.

I can not describe what depression is to others but I can tell you what it is to me. First and foremost it is extremes. It is everything taken to extremes. It is sadness but sadness to the extreme, the bottom of the pit. It is hot burning tears rolling down your cheeks and you don’t know why. It is hopelessness taken to it’s extremes, to the point where even the hope of hope becomes an impossibility. It is crazy, insane thoughts, the urge to take your own life. It is worthlessness, despair taken to it’s limits, self hatred and self despite beyond anything I can even begin to describe. It is the black pit of hell come to suck you in, alive if necessary but all the better if dead. It is a total and complete loss of energy, of will power, of the will and drive to live. It is pain taken to a new level. It’s the inability to focus because the pain blinds all. It is heart wrenching, soul rending, mind blowing in it’s intensity. It is unreasoning, it needs no reason to be. It just is.

It is NOT something you can just get over. You can’t just snap out of it, keep yourself busy to keep your mind off it. It’s impossible to simply deal with it and continue to live. It’s not something that you can grab yourself by the bootstraps and drag yourself out of. Regardless of what some may think it’s not something you’ve talked yourself into. It’s not something you WANT to be. You’d move heaven and earth to make it stop. It’s not a state of mind that you’ve worked yourself into. While life events may serve as triggers they are not the root cause.

However, when you state, “viewed from the distance of history, it’s our current understanding of depression that looks odd” – could it be, because we have the tools to begin the of study of clinical depression in a more detailed and exacting way not available in previous times? You say odd, I say revolutionary.

When you say, “But we are unique in our belief that even a touch of melancholy is a sickness. We’re even unlikely to admit to shades of degree: depression to us is a binary proposition, something you either have or don’t, something that means illness and never anything else or more.” That is indeed a story or perhaps, more like advertising from the media, but as such, has very little to do with the physical disease model of depression, whose main importance imho, is the study and research into things we do not know – yet.

You talk about stories and historical perspectives about “depression”, which is really interesting, but then you make a statement that is just as naive as the drug companies “chemical-imbalance-take-a-pill-for-feeling-blue,” and that is, “depression is not a disease like diabetes.” Sure, neither is schizophrenia.

It’s the things you leave out in this essay, that point to a bias, and an inkling that this isn’t just about stories.

Finally, when you say, “Depression has had a tough thirty years of it” please understand that that may be a little too tongue-in-cheek for people who suffer from clinical depression.

As mentioned by others, there’s an abundance of studies showing physical changes in parts of the brain, differences in levels of neurological activity, genetic linkages, and rates of brain cell regeneration with depression.

It’s hard to imagine that anyone who has experienced profound depression could imagine it’s not an illness. Psychiatrically it’s classified as a “mood disorder” but in reality it’s a full-body experience, draining the sufferer of energy, blunting the senses, and producing a general and overwhelming physical malaise.

Maybe it’s not the actual level of serotonin or other neurotransmitters. Perhaps it’s a change in those levels, a deviation from what’s normal for that individual.

Yes, drugs are probably overprescribed for mild or misdiagnosed cases. Nonmedical factors are neglected in typical U.S. healthcare. Personal history, diet, exercise, social contact, talk therapy, exposure to sunlight, and good sleep hygiene all affect depression but, as noted, this is completely consistent with the medical model.

One point of caution not mentioned so far – in some individuals, SSRIs themselves can produce a sort of apathy that, while less painful than depression, can itself interfere with an individual’s ability to be productive and engaged in life.

Science is predicated on the assumption that there is such a thing as reality — it’s not all a matter of opinion, of how you look at things. Implying that any and all stories we tell ourselves are equally good is not helpful. I did find this article interesting and helpful though. The historical background gave a good overview of the roots of some our misunderstandings, and illustrated in many ways how far we haven’t come.

I feel you are adding some excellent and well-substantiated ideas to this discussion. To add more to your thoughts, I’d like to note that for many people who are afflicted (for lack of better word) with a mental illness in one form or another, there is an incredible amount of merit to the argument for strengthening the “disease” model of depression/mental illness, if for this reason alone: for employee rights in the workplace, for medical benefit rights, for civil rights, legal rights, and so on.

I, like many other people, I’m sure, sometimes face a difficult and cruel dilemma in our workplaces: that we very often can’t disclose the nature of our illness/condition to our employers because we will lose our jobs. Others can openly and, most importantly, safely disclose medical conditions that necessitate some accommodations on the part of the employer – such as reduced hours, etc., – including but not limited to conditions such as chronic fatigue syndrome, which is, like depression, also a nebulous and difficult to *prove* illness.

Nonetheless, someone with chronic fatigue syndrome, in my workplace, isn’t going to lose their job based on the criteria set forth in my workplace collective bargaining agreement; however, the language is just slippery enough, in the same worker’s contract, that someone with depression would be ill-advised to say anything about their illness, and ask for any type of accommodation for it.

I’d like to see a world where mental illness can come out of the closet, to be taken seriously enough to warrant social compassion and support, along with legal protection, rights and more resources for those who experience it. The idea is to build on treatment and support, so that people who experience it in its many different forms (whether the individual feels it’s an illness or chooses to identify it for oneself as a gift) can live lives that are as healthy and productive (even artistic!) as possible.

If I could, I’d run from depression as far as I could. I’ve tried. But the shadow, sometimes faint and sometimes dark, never really disappears entirely. I like to think I’ve tamed it, that it informs my work, and it does on many days. But it also sometimes catches me off guard and knocks me off my feet. It’s part of who I am, and I don’t feel ashamed, nor would I say that, 95% of the time, do I feel sick. I feel that the great majority of people who know me would be shocked if I said the words “me” and “depression” in the same sentence. Undoubtedly, depression has, for all of its anguishes, done me a lot of good, as well, because it’s informed so much of who I am, what I write, how I live. And I think I have a pretty cool life!

And so, I’d have to say that I am in favor of working with depression, and not against it. I am in favor of continued medical research that will hopefully develop new and better forms of treatment and insight into the biological and social causes of depression. This doesn’t mean that I vote for pathology, nor do I vote for brushing depression off as some kind of designer illness du jour. There’s a balance somewhere in all of this, and I’m holding out for that….

Thank you for clarifying some of the points from your original essay.

While I agree that science has yet to explain exactly how antidepressants work, it is also true that science cannot really explain how acetaminophen works to relieve pain and yet one would not say that the disease model of pain is oversold.

In addressing the idea of the disease model of depression, I agree that thinking one has only to prescribe an antidepressant to a person and have that person be magically healed is an oversimplification and not necessarily supported by the data. As is so often the case, the data are conflicting about which treatment is superior or if a combination of medication plus psychotherapy is the most effective. However, the fact that depression can respond to treatment other than medication does not imply that a disease model is wrong. There are other diseases that respond to treatments other than medication such as Type II diabetes, heart disease, and chronic migraines. These are all conditions that can benefit from so-called “lifestyle changes” as well as medications and I doubt that many people would hesitate to call them diseases.

In terms of the connection between serotonin and depression, I agree that while serotonin is not the whole answer (which is why there are antidepressants that target the dopamine and norepinephrine systems as well), it most certainly is part of the answer. A very basic search of pubmed (a database for biomedical articles) will point you to a large number of articles linking a gene associated with the serotonin system to depression. Many of these articles also look at environmental causes of depression, but that does not negate the fact that serotonin is involved somehow.

For these reasons (and many others), I disagree with your argument that the physical disease model of depression is oversold. I feel the problem is a bit more complicated than that and stems from the idea that as a society we seem to think that treatment of a disease (any disease) can and should be accomplished by taking a pill. This is seen in other areas of medicine, too, such as the demand for antibiotics in situations where the disease would resolve on its own or when the disease is clearly viral and therefore not affected by antibiotics. However, we would not say that because a virus such as a cold cannot be cured by a pill or that treatment with decongestants isn’t making you feel better or that behavioral changes can make the duration of the cold shorter a cold is not a disease. And, perhaps, a having a slight cold cannot be described as being a real burden or can actually be beneficial because it makes you realize that maybe you’ve been overdoing things and should take a little break, but, again, that doesn’t mean a cold is not a disease.

Finally, as you have pointed out, the disease model of depression can be both empowering and problematic. Instead of having “laziness” or “no ambition” or any number of other character flaws, you can say, hey, I have an actual disease. You wouldn’t say to a person with cancer, “Hey, you can stop the growth of the tumor anytime you wanted to,” and neither can you say to a person with major depression, “Hey, you could get out of bed anytime you wanted to.” And for many people I know, just knowing that they have something specific, that they can point to a cause of their problems makes them feel significantly better. However, one often trades the stigma of having a bad character with the stigma of having a disease. And, laziness does not get you denied life insurance, but having major depression can (ask me how I know). So, no, being able to say that depression is a disease doesn’t necessarily make a person’s life easier. But, unlike thinking that depression is “all in your head” I think the disease model does more good than harm.

I’d also like to say here is that you have done a commendable job in bringing forward a great entry into appears to be a very important topic. Just look at all of the comments your story has generated just here on Rumpus!

I’ve been perusing various sources to learn more about depression, in the past few days….looking at dictionary definitions, doing google searches on keywords associated with depression, medication, psychiatry, etc., and realize that more than anything, there is much work to be done in the field of depression of understanding, educating, living with, medicating, and most of all, articulating. It’s inevitable that different people will have different ideas, approaches, and discussions in what I hope to see as an evolving, and widening, and necessary discourse. Something as slippery yet tenacious as the evasive nature of depression itself merits, more than almost anything else I can think of, the skills of our finest writers, along with the availability of evolving medical research.

Here’s to a continuing and lively discussion….and thank you for your work.