Explaining Depression

Mental ill health has not always been identified in our society; it is only in the 20th century that illness' like schizophrenia and depression have been recognised. Before this time, anyone presenting behaviour that did not fit in with the social norm was seen to be 'possessed' by an evil spirit. It has been suggested that the accused in the Salem witch trials may have been mentally ill people, a theory which would make sense.

The idea that people with psychological problems were possessed was very much a belief held by most of society however, the idea that these abnormalities came from our biology was not revolutionary. Hippocrates believed that 'psychopathology resulted from bodily disturbances' (Hippocrates, n.d., cited in Joseph. S, 2001, 33) He believed that the body consisted of 4 chemicals named the 4 humours, (black bile, yellow bile, blood and phlegm) if these 4 chemicals became unbalanced then we became ill either physically or mentally and the treatment would be to try and balance the chemicals by- for example- blood letting.

These ideas were the beginnings of what is now known as the medical model in mental health. The medical model now assumes that biology and neurochemistry are the causes of mental illness and 'A person's behaviour and experience may change if there are chemical changes in the brain.' (Joseph. S, 2001, 31) The medical model is widely used today in psychiatry and aids scientific research into the causes of many psychiatric problems. As a result of this research scientist are able to develop treatment for psychiatric disorders and improve the quality of life for many people. However there are many criticisms of the medical model and on of the main critic is Thomas Szasz.

In oppose to the medical model Thomas Szasz developed his own theory for explaining psychological problems. His theory was based on the idea that mental illness did not exist and the abnormal behaviour presenting in 'mentally ill' people were just ways of coping with the stress of their world and that the 'concept of a distinctively normal well-functioning personality is rooted within psychosocial and ethical criteria. (Szasz. T, 1974, 209) In other words people with psychological problems can't interact properly with society and its values and the abnormal behaviour they produce is a way of coping with life.

Szasz is in oppose to almost every aspect of the medical model including the way in which classification systems are used to diagnose people with certain disorders. Smail who takes on board a similar view to that of Szasz criticises 'Psychiatry's obsession with cataloguing the phenomena of distress into diagnostic syndromes of illness is rendered ultimately futile precisely because the supposed victims of such illness are not carriers of clear- cut cultures of disease, but in essence ordinary beings struggling to cope in a disordered world' (Smail, 1996a, pp. 49-50 cited in Joseph. S, 2001, 150)

The medical model would argue that Kraeplin's (1856-1926) discovery that certain symptoms occurred together suggests that types of disorder do exist., and that classification systems such as the DSM IV and ICD 10 have useful in the diagnosis and treatment of many disorders since 1952. One of these illnesses is depression. The DSM IV states the criteria for diagnosing depression as:

After the diagnosis of an illness such as depression, a treatment plan is needed, however before treatment can be administered it is essential that the right treatment is given. In order to give the right treatment, the cause of the disorder must be identified and this is why there is much research into the mental illness of depression.

In the 1960's Joseph J. Schildkraut suggested that a deficiency of norepinephrine caused depression however a deficiency of this chemical does not affect mood in everyone and it was discovered at a later time that the cause of depression also involves the depletion of serotonin at the synapse. A new suggestion is that dopamine plays the final part in the role of depression however dopamine has only been found to be a cause in a small sample of sufferers. (Schimelpfening, 2004) Another suggestion comes from (Duman et al., 1997 cited in Satcher, D et al, 1999) who say that depression may derive from reductions in neurotrophic factors needed for certain neurons to survive. These causes are all biological and are what the medical model assumes causes depression.

In contrast Thomas Szasz believes that most psychological disorders are just alterations or an exaggeration of normal behaviour his view on depression is that it is one of many 'manifestations of disturbances in the social structure' (Joseph. S, 2001, 142) Szasz suggests that "The mental illness of depression is a dramatisation of the proposition 'I am unhappy'" (Szasz. T, 1961/1972 p.202) Schildkraut and Duman provide evidence for the fact that there is a biological basis for depression.

The view taken by Thomas Szasz also has some research to back up theory. Brown and Harris (1978) interviewed women living in London and found that there were four social factors contributing to depression: Women from lower social classes are more vulnerable to depression than middle class women, absence of a confiding relationship, 3+ children at home under 14 yrs, Loss of own mother at age 11 or under (Brown and Harris, 1978, cited in Harry Brignull, 2000) The fact that social class appears in the above list, indicates that not only our day to day experiences have an influence, but also as Szasz suggested, society as a whole.

After the process of diagnosis, it is only logical that treatment will follow, and both models possess very different ideas on treatment. Persons suffering from depression who are perceived to be neglected themselves can be sectioned under the Mental Health Act (SEE APPENDIX 2 FOR CRITERIA) this is supported by the medical model. However Thomas Szasz believes that mental illness is something that a person does and that a sufferer is responsible for there own actions and should have a right to freedom. If the person decides they do not want to seek help then they should be left to get on with their lives and should they harm anyone, be punished in the same way as a person of stable mind.

Should they choose to be treated, Szasz believes that self knowledge is the key to treatment, and that a psychiatrist's job ought to be to help the person realise what they are doing. The client should define when the therapeutic relationship should end. Ultimately this would happen when the person believes their problem has been solved and they are happy with the changes made to their lives.

It could be said that cognitive behavioural therapy may be similar to Szasz's idea of how someone should be treated. In cognitive behavioural therapy the therapists job is to help the client realise how absurd their thoughts actually are and then help them to change their behaviour. However Szasz, depending on how the therapist goes about helping, may dispute the fact that the therapist is to help change the client's behaviour as his view is that no coercion should be involved. (ed. Cutting. P, Hardy. S & Thomas. B, 2002, 25) The treatment he suggests is the same for every disorder including depression, as Szasz does not believe in the classification of mental illness

This view of treatment heavily contrasts with the medical model's view of treatment (SEE APPENDIX 3 FOR A CAREPLAN FOR DEPRESSION) There are three types of treatment suggested for depression; drug therapy, electroconvulsive therapy and psychosurgery. Drug therapy is the most widely used it is used on moderate to mild depression and the patient is prescribed either monamine oxidase inhibitors, tricyclic antidepressants or selective serotonin reuptake inhibitors. The job of these types of drug is to influence activity at the synapses in the brain and make the neuron more likely to fire and release neurotransmitters like serotonin however the MOI's and the TCA's also influence other neurotransmitters and side effects are a problem.

Another problem with TCA's are that they cannot be given to: people with ideas of suicide, the elderly and people with heart disease or narrow glaucoma. SSRI's are the most effective of the antidepressants and the side effects are kept to a minimum as they only affect the neurotransmitters involved in depression. However SSRI's do not work for all people suffering depression. Also all of the above drugs take up to two weeks to begin to work, if a patient is suicidal or all possible drug therapy has been exhausted then treatment would move on to electro convulsive therapy. (Moore B, Moore P & Wilkinson G, 1999 59-69)

ECT is where the brain (either one or both sides) is stimulated by an electric pulse causing a shock, it has immediate affects and the reason for this is unknown. However when ECT was first introduced it did cause damage to many people and now everyone having ECT must have a muscle relaxant to prevent and muscular damage and it has been shown to cause short term memory loss (ed. Brewin C R, 1997, 134-136)

A new treatment similar to ECT has just been introduced Transcranial Magnetic Stimulation, this is where a hand held electromagnetic coil is placed at specific parts of the head causing magnetic stimulation without inducing a seizure like ECT. It has been tested successfully in treating severe depression however it is still being researched and developed and like ECT is not free of side effects. (Citrome L, 1999) The final treatment used is that of psychosurgery however it is very rarely used as it involves a serious operation in which parts of the brain concerned with depression are altered. ECT, TMS and psychosurgery can all be described as inhumane and unnecessary however they have been proved successful as a last resort.

In summary the medical model assumes 'psychopathology is the result of physical imbalances, and that psychological problems represent some underlying cause' (Joseph S, 2001, 56) Biological treatments for depression have been proved a success however they do not tackle the underlying cause of the depression and we cannot take on board the deterministic view that 'anatomy is destiny' (Joseph S, 2001, 57) On the otherhand Thomas Szasz believes that the society we live in, the people around us and all their morals and beliefs are what shape personality and that psychiatrists deal with 'personal, social and ethical problems in living' (Szasz T, 1974, 262) However his views about treatment and a persons right to freedom of choice are not without flaw as many mentally ill people are danger to themselves and some a danger to others and we cannot ignore the fact that biological research has shown the links between neurotransmitters and depression.

To conclude it is felt that a more eclectic approach is needed for the diagnosis treatment and care of people with depression and the bio-psychosocial-spiritual model used in mental health practice today, is indeed the best option. It gives people a chance to be treated biologically, deal with the underlying cause of depression and keeps in mind their morals, beliefs and to some extent allows freedom of choice.