A cure for darkness

This being, following reference 1, notice of the book at reference 3.

A book which, despite being written twenty years later, tells a similar story to that from Solomon. Like Solomon, Riley is a sufferer from depression himself. Like Solomon, he has written a successful book about the subject generally. By profession, a science writer and this is his first book. That is to say, a Penguin paperback with round 400 pages of text and 50 pages of stuff at the end. 35 chapters organised into 4 parts.

Very much the same sort of thing as the Solomon book, covering a lot of the same ground, with lots of short pieces about treatments, about the people involved, patients, therapists and scientists – and rather longer pieces about his own encounter with depression. But somehow, a bit more chaotic and I found it hard to keep track of all the treatments, all the chemicals and all the people. The book would have been improved by some clearer structuring and some graphics, graphics which one might think a science writer would have been well able to provide.

Riley also comes across as being a bit more inclusive than Solomon, including treatments and chemicals which are not mainstream, maybe not even legal in this country. For example, the Santo Daime church of reference 7, with its use of the vegan psychedelic ayahuasca, from South America. Known to our chemists for its dimethyltryptamine (DMT), to be found at reference 8. A close relative of various other psycho-active substances.

The sort of pull-out that I would have found helpful.

Some commonly prescribed drugs for depression, in England, in 2016. Vortioxetine may have become a big thing. In 2016, paroxetine hydrochloride was the only one in the top ten the consumption of which was falling.

As Solomon pointed out in his book, depression is a big problem, it is not yet solved and there is always the next big thing. There is always hope, just around the corner.

Oddments

While it seems clear that in some western countries, say the US and the UK, the number of people housed in mental hospitals increased massively through the nineteenth century and only started to fall in the middle of the twentieth century, it is not clear at all whether the incidence of mental illness is changing, whether the incidence of depression is changing. Noting here that the stresses arising from hunger, disease and discomfort have decreased. There is, for example, probably less death by starvation than there has ever been.

Short questionnaires are an important part of managing mental health. One example of such being the 9-question Patient Health Questionnaire (PHQ-9), a diagnostic tool introduced in 2001 to screen adult patients in a primary care setting for the presence and severity of depression.

Depression does seem to run in families. If one or both of your parents were depressives, it does not follow that you will be, but it does make it more likely.

There seem to be links between depression and the immune system, between depression and the flora of the gut. Which last takes me back to reference 6, a book from which I have been diverted and the index to which contains several entries for depression.

Scanners have opened up new possibilities. Do the brains of depressed people look different from those who are not? Is the pattern of activation different in some way? Are some circuits more or less active?

Nomenclature

A one point in all this, I got confused about the difference between a psychologist and a psychiatrist. Consulting Webster’s, I find that a psychiatrist is a term with a medical, a hospital flavour. A physician who specialises in psychiatry, to be distinguished from one who specialises in neurology. While psychiatry is the branch of medicine which deals with mental disorders.

While a psychologist is a student of mind or behaviour, normal or otherwise, not necessarily and not usually a doctor. Or a practitioner of clinical psychology. And psychology is the study of mind or of behaviour.

So while the drift seems to be that psychology is about minds in general, while psychiatry is about disordered minds. In which neat arrangement, clinical psychology does not fit.

Psychoanalysts, the followers of Freud, dominated psychiatry in the 1950s and 1960s, certainly in the US. But by the 1980s they has become an endangered species. In the beginning, psychoanalysts were generally medically qualified. But they also allowed lay analysts, that is to say psychoanalysts who were not medically qualified. An advantage being not having to spend lots of time and energy on something of peripheral interest, a disadvantage being that a lay analyst has very limited authority to prescribe pills. Perhaps not so limited as it used to be.

To give one example, cognitive therapy (CT) is a psychotherapy practiced mainly by  psychologists, health workers and social workers. And Aaron Beck, the inventor of cognitive behaviour therapy (CBT), got his MD and did time as a psychiatrist, before he trained as a psychoanalyst. After all of which he moved onto CBT.

And then we have psychiatric social workers. Who, according to Bing are: ‘mental health professionals that can assist patients and their family members in coping with both mental health issues and various economic or social problems caused by mental illness or addiction’.

I suppose there is no avoiding these difficulties with names in a field which is so much on the move.

Melancholia

I have now read Freud on melancholia, that is to say reference 4, now a little more than 100 years old. With the branch of depression he describes being rooted in object loss – often but not necessarily a person – but a loss which is unconscious and the task of the analyst is to bring it out. Conscious object loss is usually dealt with by a normal process of mourning, which might take a while, but which leaves the subject free to move on. At least I think that this is the idea.

Apart from being reminded what a good writer Freud was, and how well he was served by his translator, I still think there is something here for today. Maybe Freud, while getting a lot wrong, has pitched his analysis at the right place, in terms of the right sort of entities. Something I hope to come back to in due course.

And given that fights over status, at least among males, quite possibly pre-date (in evolutionary time) getting attached to other people, maybe there will be room for the theories of John Scott Price, alluded to at reference 1. From where I associate to the various stories I have read over the years about the speed with which animals get over the loss of those they are close to. Also to the various stories I have read of people expelled from their communities just pining away - which does not seem to fit building one’s theory of depression on attachments to particular others either - even if one allows the generalisation of other people to more abstract objects.

Other matters

One of the arguments against Price is that the male status fights do not account for women getting more depressed than men. It now strikes me that it might be possible for a trait which is adaptive for, say males, will often be passed onto females as well, where it might be less adaptive. But on balance, the product is fitter and so thrives. Something to be looked into.

I have also been pondering about mind over matter. It seems reasonably clear that you can mitigate depression with talking therapy, with life style changes or with pills. All three treatments are making helpful changes to the electro-chemical scene in the brain. To this extent mind is in control over matter. In this case over the neurons, the chemical soup in which they reside and the junctions which connect one neuron to another. Perhaps over the neurons themselves, perhaps promoting their birth and growth. It seems unlikely that one is going to make gross changes to the brain in this way, but, nevertheless, over time it is not clear either whether or where this control has to stop.

Conclusions

The conclusions of the earlier post at reference 1 stand, and there is not much to add.

Depression is a very common complaint, is found all over the world and is often associated with stress, trauma or serious physical disorder – but a complaint which can be treated. Untreated, it can often result in suicide. Usually best treated with a combination of talking and chemical treatments. With ECT – now a very safe procedure – available for those not greatly helped by talking or chemicals. Should probably be used more than it is.

Chemical treatments usually take time and usually come with more or less unpleasant side effects. One needs to persist to get the benefits. One needs, at some level, to want enough to get well.

Depression is not given the resources that it should be. It accounts for a great deal of human misery and should be given a bigger slice of the health and welfare pie than it has been given hitherto. We can do better than just throw pills at it, effective though they can be.

In sum, Riley was a useful supplement to Solomon. The general story might have been the same, but the books do not cover the same ground.

PS: the next day: I talk above of hope around the corner.  So I read this morning in Medscape of a new-to-me treatment for depression called vagus nerve stimulation (VNS), which started life in Germany as a treatment for epilepsy and which has been available, if not well known, in the EU and in the US for more than twenty years. Maybe it will catch on here in the UK.

References

Reference 1: https://psmv5.blogspot.com/2022/05/the-noonday-demon.html.

Reference 2: The noonday demon: an anatomy of depression – Andrew Solomon – 2001. The prompt for reference 1.

Reference 3: A cure for darkness: the story of depression and how we treat it – Alex Riley – 2021.

Reference 4: Mourning and melancholia – Sigmund Freud – 1917. Inter alia, the source of the snap above.

Reference 5: https://psmv5.blogspot.com/2022/05/medical-vocabulary.html. A post about humours, an ancient model which did include depression, once called melancholia.

Reference 6: Gut Feelings: The Microbiome and Our Health - Alessio Fasano and Susie Flaherty – 2021.

Reference 7: https://en.wikipedia.org/wiki/Santo_Daime. 

Reference 8: https://en.wikipedia.org/wiki/N,N-Dimethyltryptamine.