Depression: Disease or "Experience"?

In October, the British Psychological Society (BPS), the largest professional body for psychologists in the United Kingdom, published a new report, "Understanding Depression." Since its publication, much has been written about this report, mainly by psychiatrists (see, e.g., Pies, 2020; Aftab, 2020). I would like to add some general comments here.

Melancholia, by the Italian baroque painter Domenico Fetti (circa 1620).

Source: Public domain

The report begins, "Depression is best thought of as an experience, or set of experiences, rather than as a disease" (British Psychological Society, 2020, p. 16, emphasis in original). Much of what follows is critical of the modern psychiatric understanding and treatment of depression, including criticisms of pharmacotherapy and electroconvulsive therapy (ECT).

For instance, in the section on medication treatment of depression, the report contains multiple paragraphs on "problems with medication" (p. 43) but devotes little space to the abundance of research accumulated over the past 70 years demonstrating the efficacy of pharmacotherapy in the treatment of moderate and severe depression, and melancholia. (See psychiatrist Peter Kramer's book Ordinarily Well for an exhaustive review of the research on antidepressant treatment.) Similarly, the report takes a critical tone in discussing ECT without mention of its well-established efficacy in melancholia, malignant (or lethal) catatonia, and acute suicidality (see Fink, 2008).

While appearing to broach new territory in the discussion regarding the nature of depression (and mental illness more generally), the report is, instead, largely a repackaging of the long-refuted ideas of the critical psychiatrist Thomas Szasz, who made a name for himself in 1961 upon the publication of his book The Myth of Mental Illness. How do I know this? Because I was an admirer of Szasz early in my career and maintained contact with him in the years before his passing. Joanna Moncrieff, a British psychiatrist cited in the BPS report, identifies as a Szaszian.

In making the argument that depression is an "experience" and not a disease, the British Psychological Society neatly aligns itself with Szasz, who argued that because there are no objective tests for mental disorders, these entities are mere "myths" or "metaphors." I have written elsewhere with psychiatrist Ronald Pies on the conceptual errors in Szasz's work (see, e.g., Ruffalo & Pies, 2018; Ruffalo & Pies, 2020) and will not belabor those points here, but suffice it to say that mental disorders meet all historically-based and established criteria for classification as disease.

Traditionally, disease has been conceptualized as a problem or entity that causes prolonged or severe distress and impairment—or suffering and incapacity—in the individual, living human being, regardless of whether there is a known cause or etiology (see Pies, 1979). To claim that mental disorders do not count as disease because they have no known biological causation is to make a straw man argument. Plenty of medical diseases, readily accepted as such, have no known underlying pathophysiology, yet they remain diseases ("dis-eases") because they characteristically produce some combination of suffering and functional impairment. Depression, bipolar disease, and schizophrenia are no exceptions.

While psychiatric diagnoses often do describe the patient's subjective experience, many disorders—including depression—also have predictive validity, genetic risk factors, neurobiological correlates and psychometric characteristics that may be objectively demonstrated. Furthermore, as Pies (2020) has astutely pointed out, to say that depression is an "experience" adds nothing to our understanding of depression. Everything that occurs in our lives is an experience, and, of course, some experiences are also diseases.

Thus, it is clear that the BPS report rests on a mere linguistic argument, not a medical (or psychological) one. To call a disease by another name—to wish a disease into nonexistence and believe this to be true—is to engage in what psychoanalysts call denial. There is plenty of room for criticism of our current treatment of depression—and much of this criticism comes from within psychiatry, e.g., most antidepressants are prescribed by nonpsychiatrists, and many patients with mild depressions would be better off in psychotherapy as opposed to being treated with medication. But to deny the existence of depression as a disease is to throw the baby out with the bathwater.

Despite the obfuscations of British psychologists—many of whom have likely never treated inpatients with the most severe forms of psychiatric illness—depression is a complex biopsychosocial disorder amenable to a variety of treatments, depending on type and severity, including psychotherapy, pharmacotherapy, and ECT.