Will my depression still be taken seriously?

If you have ever been prescribed antidepressants, your GP may have explained that they work by rebalancing chemicals in your brain. For many people, this medical definition is helpful in validating the very real distress they are experiencing. So how might it affect us, as someone with depression, that recent research refutes this theory?[i] Can we still feel as if our psychological pain is taken seriously when we seek help?

The chemical imbalance theory proposes that anxiety and depression occur when we have low levels of certain neurotransmitters in our brain. As such, SSRI antidepressants inhibit reuptake of the neurotransmitter serotonin. And SNRIs inhibit reuptake of both serotonin and norepinephrine. This leaves more of these neurotransmitters available for use in our brain. It had been believed that low levels of serotonin and norepinephrine contribute to depression, but when deliberately reducing these neurotransmitters in test subjects, researchers found that non-depressed candidates did not become depressed. Moreover, depressed subjects did not become more depressed.[ii] So it seems we are currently missing something from this picture.

However, medical practitioners consider much more than our brain chemistry when diagnosing anxiety and depression. They use a biopsychosocial model to consider the various factors both contributing to and likely to alleviate our emotional state. This is why a GP may prescribe counselling instead of or in addition to antidepressants. So what is the biopsychosocial model?

Biological

Although we use the term ‘mental illness’, very few mental disorders currently have a proven biological cause. Those that do, such as Alzheimer’s and epilepsy, are known as organic disorders[iii]. Like most other mental illnesses, depression and anxiety are not organic disorders in current diagnostic manuals. At the moment, they are diagnosed based on the number and duration of specific symptoms that our GP assesses.

Alongside the chemical imbalance theory, another biological theory of depression being researched is that of genetic inheritance. Some studies suggest that inheriting short versions of a gene that transports serotonin makes us more vulnerable to depression than if we inherit two long versions of this same gene. But this is not to say that, if our parent has depression, we will necessarily have it too. It depends on which combination of genes we inherit as well as the amount and degree of life stressors we are exposed to[iv].

Outside of biological theories, there are other biological factors that might be taken into account when diagnosing anxiety and depression, such as changes in our sex hormones. For example, during menopause, levels of oestrogen, progesterone and testosterone drop. As these hormones are connected with decision-making and memory, a menopausal person might have increased feelings of uncertainty. Menopausal individuals are also less protected from their naturally occurring stress hormone cortisol, which can increase their anxiety. Depending on a patient’s previous experiences with anxiety and depression, a GP may discuss HRT rather than antidepressants to address these biological symptoms.

Psychological

Shakespeare writes ‘what’s past is prologue’[v]. Counsellors will often be interested in a client’s unique interpretations of past experiences, and the way that influences their reactions to their present world.

The human mind is always looking to optimise our chances of survival. When we think we have noticed a pattern in our environment, we programme a survival response to it into our autonomic nervous system. Our autonomic nervous system is part of our unconscious and reacts quicker than conscious thought. However, it can be harder to update when our environment changes. It often has a ‘better safe than sorry’ approach to change and prioritises survival over happiness.

An example of this might be someone growing up in an emotionally unstable environment who uses hypervigilance and self-reliance in order to survive. Later, when they find themselves in a stable, loving environment, the anxiety and disconnection that once kept them safe, can now feel confusing and a block to finding connection and happiness.

There does not need to have been malicious or neglectful intent in our formative environments for us to develop self-protective unconscious strategies. Intrusive medical treatments, the death of a loved one, being at boarding school, and plenty of other situations may similarly cause us to develop self-preserving unconscious strategies that once served us, but which perhaps no longer do.

Social

What is considered a mental illness in one time period or culture, is not necessarily considered so in another. Homosexuality appeared in a key diagnostic manual for mental disorders until 1973. And, whilst burying a deceased relative under the kitchen, or sitting them outside the front door would seem abnormal in many cultures, it is normal in others.[vi] There are shifts in what societies consider normal and consequently there are changes in their concepts of behavioural abnormality.

The expectations of the society we live in create stressors that provide motivation to conform and feel acceptable. In the age of social media, we recognise the pressures on us to look good and appear popular. But there are many other everyday conditions of worth in our society that might be putting pressure on us: being a good student, a devoted parent, a committed employee, a high earner, sensitive to others’ needs, and environmentally responsible... When we feel we are coping with these, our self-esteem is good.

But when we are struggling to fulfil these conditions of worth, we can become anxious, self-critical, and fearful of others’ criticism. When we feel it has become impossible to fulfil them, we can become depressed. And this is not necessarily because we are insufficient or not up-to-par. Sometimes it may be because the social expectations themselves are unreasonable or actually no longer serve us. Sometimes our moral or biological imperatives change, even if it takes us a while to realise that.

Even the schedules of the society we live in can affect our well-being. For example, a teenager’s circadian rhythm is such that they are still in their natural sleep cycle until mid-morning. So when they are obliged to be up at 7:30am for morning classes, their healthy, restorative sleep cycle gets interrupted. Inadequate sleep reduces our capacity for emotional regulation and increases our anxiety.[vii]

Biopsychosocial and holistic models

As we can see above, there is crossover in these models and they are not always clear-cut. The combined biopsychosocial model supports an overall picture of what might be causing anxiety or depression, and what might help relieve it. Prescribed drugs may help us, and so might counselling or changes in lifestyle.

Biopsychosocial models of emotional well-being sometimes extend to incorporate spiritual or existential contributing aspects. For example, a holistic counsellor may be exploring concepts of justice and the afterlife with a bereaved client; or reconsidering self-identity and existential purpose with a career-driven professional who has unexpectedly been made redundant.

The biological model can view distressed states as maladaptive. Biopsychosocial and holistic approaches, whilst fully acknowledging the distress of conditions such as anxiety and depression, also consider how they have come about within our unique experiences of life.

Perhaps we are a survivor of childhood adversity where hypervigilance kept us safe in our past but is redundant and misplaced now. Perhaps we have burnt out from social and financial pressures to take on more than is reasonable for us to do, and depression has been the body’s last resort at withdrawing our energies from an insurmountable task. Perhaps we have got caught in an anxiety feedback loop where our mind anticipates stress, so our body releases cortisol to prepare for it, and our system interprets that cortisol as evidence there is stress.

Benefits of refuted theories?

Despite criticism of the chemical imbalance theory, it has arguably played a role in having decreased the stigma around acknowledging our psychological pain and has increased our acceptance of professional support. Feeling validated by a biological explanation has arguably helped people feel less judged and self-critical. This has in turn made people more willing to attend counselling, challenge unconscious patterns, and manage present triggers.

The biological explanation has perhaps been the gateway to accessing biopsychosocial and holistic therapeutics which recognise the wide range of potential factors contributing to anxiety and depression, and the varied and individual means to address and alleviate them. These alleviations sometimes lie in the changes within ourselves, and sometimes in the changes we make in the relationships we have with the environments in which we live.

Sources:

[i] Davey, C., 3rd August 2022, The chemical imbalance theory of depression is dead – but that doesn’t mean antidepressants don’t work, The Guardian
[ii] Ibid p125
[iii] Davies, J., 2013, Cracked, Icon
[iv] Bionews 348, 9th June 2009
[v] Shakespeare, 2014, The Tempest, Cambridge School Shakespeare
[vi] Death is not the end: Fascinating funeral traditions from around the globe | (ted.com)
[vii] Understanding the Teenage Circadian Shift or Sleep Wake Cycle | Actforlibraries.org