This is the third of three posts based on the work of writer Johann Hari, whose search for answers about his own depression led to his book Lost Causes: Uncovering the Real Causes of Depression–and the Unexpected Solution. In the first part of this series, we looked at the problems with the serotonin model of depression. These problems include the six weeks it takes for SSRIs to start working, the effectiveness of non-pharmacological interventions like cognitive behavioral therapy, the selective publishing of positive results as SSRIs hit the market, and the fact that depression during bereavement, for example, is not attributed to low serotonin. In the second part, we looked at how unmet psychological needs may play a much bigger role in depression than previously thought and that effectively treating depression requires finding a way to meet those needs. In this part, we will look at some ways to address those needs as part of a comprehensive program to treat depression. First, we have to acknowledge the challenges inherent in taking a broader perspective on depression. For most of the twentieth century, from penicillin to Prozac, the ideal solution to every medical problem was to take a pill. The pill approach suits everyone. The patient doesn’t have to seriously disrupt her life in order to solve her depression problem, the doctor doesn’t have to get into the weeds with every patient who comes in feeling depressed, and the pharmaceutical companies can make a tidy profit from treating a common problem. However, as we’ve seen, a pill is often not a long-term solution. With the pill solution, we typically end up with higher doses and diminishing returns. This is why psychotherapy typically makes depression treatment much more effective and has in fact been shown to be more effective by itself than SSRIs alone. Cognitive behavioral therapy, or CBT can give a patient excellent tools for dealing with common life challenges, but CBT alone cannot make up for unmet psychological needs. While negative emotions are often caused by our own inaccurate interpretation of events, it is also possible to be distressed by an objective interpretation of events. If you’re chronically lonely or perpetually in danger of being laid off, for example, anxiety is a normal and healthy reaction to your situation. You can’t stay in that situation indefinitely and expect to feel psychologically well. The challenge for patients and therapists alike is to figure out exactly what needs aren’t being met and come up with a plan to improve the situation. This is more complex than learning cognitive behavioral tools, and certainly more complex than taking a pill. It requires flexibility and introspection, as well as willingness to change, which can be the most difficult part. Hari relates a story told by a South African psychologist who traveled to Cambodia and learned they had a very different notion of antidepressants. A rice farmer, who had lost his leg when he stepped on a landmine, was depressed because his prosthetic leg made his work painful and difficult. His doctors bought him a cow so he could become a dairy farmer instead of a rice farmer, which made his work much more tolerable and relieved his depression. As part of comprehensive approach to treating depression, therapists have to look for the cow that will change their patients’ lives in ways that allow them to meet their psychological needs. More broadly, we, as a society, need to think about how our decisions either leads to a world where more people feel psychologically fulfilled, or one where people feel increasingly anxious and alienated.
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