Depression is simultaneously the most common and the most disabling mental illness we treat. It can be life altering: it can damage relationships and careers, and often leaves people feeling without hope. When I began at CAMH 10 years ago, I had many questions about this mental illness, which affects a striking 1 in 10 Canadians. What causes depression? What treatments work best? How can we improve our services to make our patients’ lives better?
Over the years, both in my clinical practice and research, I have worked through these questions with my patients, colleagues and community. And, although I continue to study the nature of depression and how best to treat it, I’ve drawn some conclusions, which I’d love to share in light of Psychology Month.
The original cause of depression may not be what is causing or maintaining it now
It is not uncommon or unreasonable to want to know why you are experiencing depression. I think this reflects the real power of understanding – if we know why something happened, then surely we are in a better position to fix things, aren’t we?
Reflecting in this way and coming to appreciate the complexities of your own story is the basis of numerous effective treatments. But present-focused treatments such as cognitive behavioural therapy (CBT) have a limited focus on the historical events that may have contributed to current difficulties, and many of these treatments have the strongest evidence for long-lasting benefits (so far!).
In my research, I have seen that the effects of early life experiences and long-standing dispositions influence depression through their impacts on thinking styles. For example, a personality trait like being highly emotional is linked to negative thinking patterns (e.g., jumping to conclusions), which in turn is linked to how much patients improve in treatment.
These kinds of research results suggest that making changes to those thinking styles is a useful place to intervene, and that doing so does not negate the importance of the earlier links in the causal chain.
Depression may reflect a “chemical imbalance” – but that doesn’t mean that only chemicals can help
Depression is experienced differently by everyone, but many experience it in a very physical way. The absence of appetite and fatigue, for example, can hit you as hard as any flu. Many also experience depression in the absence of any triggering event, which can increase their depressive thoughts (“Others have it so much worse than me; I have no right to feel this way”). These experiences of depression can decrease patients’ sense of their options and contribute to beliefs that if there are no clear internal or external precipitating events, then the source of these symptoms must be chemical – and thus only impacted by chemical means.
Medications are in fact useful for a substantial proportion of patients, and the best choice for many. Yet, research has shown that both medications and psychotherapy result in neurochemical changes in the brain – just via different mechanisms. Still other treatments recognize that our brain is actually an electrochemical organ that we can impact electrically as well as chemically, and these neurostimulation treatments can have excellent results particularly for those who have not found success with medications or psychotherapy.
It’s time to ask not “what works” but “what works best for whom”
There are many treatments available for depression, with almost as many types of psychotherapy as there are types of medication. Overall, there are few differences between antidepressant medications or between psychotherapies, and the majority of studies have confirmed that groups of patients who receive antidepressant medication seem to improve to the same degree as groups of patients who receive psychotherapy. These research results might suggest that these treatments work equally well, and for all intents and purposes they do – when you are talking about groups of patients. Do those same treatments work equally well for an individual patient? Not necessarily! There is increasing research to suggest that some patients may do better with medications and others with psychotherapy, for example. Finding ways to match patients to the treatments that are most likely to benefit them specifically is a central preoccupation of mine, and a large number of researchers across Canada.
Final thoughts
This Psychology Month I am reflecting on my professional journey, particularly in the treatment of depression. The conclusions I’ve come to spark even more questions, and it’s a gift to join forces with my colleagues in psychology and other disciplines, and with the patients and community we serve, to lessen the hold this disease has on our society.
It is a systematic campaign to understand the “why” of depression. It is heartening to know, then, that there are multitudes of treatment options, and that these treatments work for many different reasons – providing numerous potential roads to recovery. We may in fact not need to know exactly how our patients came to develop their difficulties with depression to help them to find another path.