Key Moment: What We Get Wrong About Depression (and Anti-Depressants)

This is an excerpt from E178 of the Thinking Mind Podcast. In this clip, Alex speaks with neuroscientist and author Dr Dean Burnett about whether depression should really be understood as a disease.

They discuss the disease model of mental health, why depression is more complicated than a simple biological fault, and why mental health problems cannot always be treated in the same way as physical illnesses. Dean explains why calling depression a disease can sometimes help people take it seriously, but can also be misleading if it makes us think there is always one clear biological cause and one simple cure.

The conversation also explores the relationship between mental health and physical health, the brain-body connection, how stress and depression affect the immune system, and why the line between illness, adaptation and normal human suffering is often blurry.

They also discuss antidepressants, SSRIs, how often they help, why they are commonly prescribed, possible side effects, withdrawal effects, and why antidepressants should be understood as one tool among many rather than a perfect solution or something to dismiss entirely.

Dr Dean Burnett is the author of The Idiot Brain, The Happy Brain and several other books exploring neuroscience, psychology and the weird ways our brains shape our lives.

They discuss why the brain is not the perfect machine we often imagine it to be, why intrusive thoughts don’t define who you are, why anxiety and self-sabotage are often normal features of the mind, and why happiness is not something we are designed to feel all the time.

Dean also explains what we do and don’t know about depression, antidepressants, SSRIs, brain chemistry, neuroplasticity, withdrawal effects, and why mental health is far more complicated than simple slogans like “chemical imbalance” or “just think positive”.

Interviewed by Dr. Alex Curmi. Dr. Alex is a consultant psychiatrist and a UKCP registered psychotherapist.

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Transcript

SPEAKER_00 0:00

I'm gonna ask you something, and I personally have my own conflicting feelings about it, so I don't have a clear necessarily position one way or the other. But do you think the word disease is a useful word to apply to depression as a disease?

SPEAKER_01 0:14

It's a tricky one because you know there was for years people adopted the disease model of mental health or mental illness when diagnosing people. And I know you can I think that was necessary because before then you know mental health problems weren't even recognized as a medical thing. So you have to sort of integrate them to the medical system. And I do think that's what happened. Like if sort of you have a medical way of treating people with usually physical ailments, and you incorporate mental health problems into that, you still use the same system to deal with those. But yeah, there's a lot of problems with that because obviously a disease suggests that there is a root biological problem which can hopefully be fixed, and then the person will be cured. And you know, that's the sort of default assumption when you're treating something as a disease, and mental health problems typically don't work like that, and the medical ways of treating them don't work for mental health problems. So if someone came in with a disease, so let's say COVID, for example, uh so let's say we had an antiviral which cured it. So someone comes in and says, I've got this, these various symptoms. Ah, yes, you've got the this disease, you've got COVID. Okay, so here's the pills we take to cure COVID. Take these, come back and see me in two months or two weeks, whatever it is, and then we'll see if you've cured. If not, we'll try a different approach. And yes, no, that's a fairly logical system, but the patient is very passive in that. They turn up and say, Here's my problems. Doctor says, I know what your problems are, here's how you deal with it, do as you're told, see you soon. And you can't really do that with mental health problems because you know the person, the individual, the patient is the one, is the only one who can experience them. Their contribution is far more important. You can't put someone in like an X-ray machine, is up, there's your anxiety, and we'll just take that out. That's that's not you know, it's it's far more uh you know uh intertwined with your very self, your very being. So you need to have far more of a discussant, uh discursive, discursive-based approach. You need to have a sort of a two-e dynamic, which uh it's better now, but for a long time, that wasn't really taught in medicine. You have to be aloof, you have to be disengaged from your patient, ifn unless you need to talk to them. But you know, it these are you know old-fashioned ideas, but they were around for quite some time and you still get them occasionally. So yeah, I can see if the if the intention is to get people to take mental health problems seriously, like depression, and they don't, then saying it's like a disease, yes, that can be helpful. Same with like the usual thing of it's like a broken leg. Okay, you've got to treat it like it's a genuinely debilitating condition, which it is. But if you are trying to get people sort of trying to explain or work on how to treat mental health problems effectively in a way which benefits patient and medical community and those around them, saying it's like a disease can be unhelpful because that's not the approach you should be taking because they don't work like that. So, yeah, there are pros and cons to it. But I think if we're talking about you know pure scientific accuracy, it's not helpful to call it a disease. That would would be my stance on the matter.

SPEAKER_00 3:19

It can be quite complicated. One one thing that I think can be helpful to understand is not always, but I think often a mental health condition originates with some phenomena that's trying to help the person in some way. So, for example, one might experience a lot of social rejection, and that can cause sadness and retreat socially. And you can see how that be could be advantageous. There's a reason we feel sad. So, sadness is an emotion that compels us to stop doing what we're doing, retreat, protect ourselves, ruminate, and maybe think what's going wrong, what am I losing out on in this situation, and potentially eventually how things could how could things be better? And sadness in small doses like that can be very useful. But then if it goes too far, maybe you spend too much time alone, too much time disconnected from others, then sadness can become depression. And so, in that sense, maybe a disease way of thinking isn't super useful. However, if you then think about some other physical health conditions, they also operate in a diamond dynamic like that. Take liver cirrhosis as a response to alcoholism, the the cirrhotic process that's the liver laying down scar tissue because of the alcohol exposure. So the liver is trying to protect itself, but if there's too much scar tissue, then you get cirrhosis, which is the scar tissue becomes the poison, the scar tissue becomes the thing that stops the liver from functioning. So is cirrhosis a disease or is it liver failure to adapt to alcohol syndrome? You could say the same thing about type 2 diabetes, where the pancreas pumps out insulin at a very rapid volume to try and deal with the huge amount of sugar someone can consume in a modern society, and eventually it fails. So this line between disease and non- and adaptation is actually maybe a lot more complex, even in the physical health realm.

SPEAKER_01 5:16

Oh, absolutely. There's no sort of clear divide between these things. It's like as a like neuroscience, like person, the something that keeps up a lot is the whole physical health versus mental health, as if they're two distinct concepts, and they're not. Obviously, there's significant overlap, and the idea also you can argue it comes down to the whole brain and body, as if like those are two different things. They're not. Your brain is very much part of your body, and your body has significant impact on how your brain works, and although I think it does, it's very much a two-way street. It's not like the body is the horse and the brain is the jockey, you know, it's just that's the only thing that's in charge. There, it's no, it's a far, far stronger overlapping system. Things like depression, it confuses some people, but they do have it does have like physical symptoms. You know, you get people in a suppressed immune system because when you're in a fight or flight state, your immune system is response, response is suppressed because you have to, if you're inflamed, you're like it hurts, you're incapacitated, so you can't afford to have that whilst you're dealing with a problem. So therefore, the evolutionary response to stress is to suppress the immune system, so you don't get a debilitated immune reaction. But then, if stress doesn't go away, then that obviously endures for long periods, and you're more prone to sickness, or you know, you gain weight more because you know your body thinks I'm going to be fighting something any moment. I need to retain as many calories as I can, and you could be, or you resort to stress eating because it's you know, I need some sort of comfort to offset this constant low-level anxiety, stress, depression. So, yeah, there's there's so much overlap between where one part of it ends and one begins. And I think you can tell how um sort of nebulous these things are. Uh, because I wanna write one of my previous books. I I looked up like, oh, I need to sort of find um a definition of illness, because I was talking about this. I said, okay, look at the illness, the dictionary said um illness, a period of sickness. It's all right, fine. I went I went to I went to sickness. Yeah, sickness. The experience of being ill. All right. So just keep going back and forth. All right, so life sucks for a period of time. It's already helpful. Thanks for that. Yes. Yeah, so um, yeah, yeah. So you can sort of tell how like these things are far more uh blurry than you know the it would be much more helpful and people respond well to a clear set of systems, a little clear set of parameters. But you know, biology and nature just it hasn't been ever been like that. We are you know it's very messy down there when you get down to the nuts and bolts level of it all.

SPEAKER_00 7:39

In terms of antidepressants themselves, can you comment on what proportion of the time do they work? So, for example, if someone finds themselves depressed and they try an antidepressants for the first time, how likely is it that that antidepressant is going to help them significantly with their symptoms?

SPEAKER_01 7:57

From what I can tell, it's is a good chance uh because usually if you're first time presenting with depression symptoms, you go to the GP and they prescribe antidepressants, it will be an SSRI, but one of those those are the go-tos. One thing which people I don't think realize is they're not the go-to's because they are the best, most effective antidepressants. If anything, on paper, in terms of the their ability to treat depression, they're one of the worst. But that's because they also have the lowest likelihood of side effects. And that's obviously a huge consideration when it comes to taking a psychoactive substance which is meant to alter your mood. Like a lot of the more powerful antidepressants, the MIs and TCAs and stuff, they they can have more significant effects on your depression, but you know, we are actually altering the chemical levels of something in your brain which affects countless other systems too, and leads to anomalous activity in other parts of the body and brain, and therefore you get unpleasant consequences, like you know, digestive or like uh hypertension and physical problems, and like your moods go in a weird direction, so on and so on. So it's really hard to say for certain, but I think it's something like two out of three uh people who take an uh an SSRI will experience some benefit from it. Perhaps it might be a bit higher than that, I think. But it's also like they'll much less likely experience any side effects, too, which is like the main goal at first. So if you take it and after a few weeks it doesn't seem to be doing anything, okay, then you sort of okay, well, let's try one of the more powerful ones. And because obviously you you've shown that the you the you can tolerate this one at least, but it's not having the therapeutic effect, so let's step it up again. So yeah, I think uh the ratios really depend on how you know what sort of data you're looking at. Just not forget that you know depression, antidepressants are prescribed to a lot of non-depression cases. You know, they use off-label for things like anxiety disorders or people like with a lot of people with ADHD gets misdiagnosed as the having depression, and therefore when they get antidepressants, it doesn't really do what they should should be doing because it's treating the wrong thing. Yeah, so it's it's murky data, but they tend to be quite reliable, hence, they've become like the default approach to depression. So yeah.

SPEAKER_00 10:11

Do you share the concerns that are starting to emerge quite a lot, especially in the past couple of years, in terms of antidepressants withdrawal effects and particularly delayed withdrawal effects that you know people can be coming off antidepressants and have quite severe side effects as a result? And sometimes those withdrawal effects can persist for months or even years.

SPEAKER_01 10:34

Yeah, well, obviously that's um something we really should be um be aware of, keep an eye on. It's um I think it's sort of like uh you can sort of see that being um a sort of uh a stick to use to for the and the anti-pill arguments or the anti-medication arguments, which are still quite rife. Um but you know it's a valid concern because you know if you have been taking a substance or a drug for many, many years, it alters the chemical levels of your brain, your brain will adapt to that. Your brain will learn to expect it, it'll become dependent on it, like works any any other sort of drug. You know, your brain chemistry, your brain structure alters around the increased presence of an existing uh substance or an external substance if it's present often enough. That's what you get, like drug tolerance or alcohol tolerance or things like that. And you know, it's it's not not not necessarily a bad thing. So obviously, if you are taking a lot of antipressants, your brain's been stimulated to to fix or like adjust the depression regulation system, then that's good. You know, that's what you want to happen. But yeah, but these things have lasting effects, like people who have become addicted to something, you know, they say addiction is a lifelong thing, you just have to be vigilant forever now, because those those changes that happen in your brain, they don't necessarily go away, they might be suppressed or reduced, but they're still there, so they can be reactivated relatively easily. And you can see how that might happen, or probably does happen with antidepressants and things like that. So yeah, it's definitely something to uh which obviously needs to be looked at, looks to be worked on, needs to be monitored. And I I can imagine it's obviously become an increasing problem because of the prevalence of antidepressant use, which like I say, yeah, is a very much the go-to, almost default intervention for any sort of mood problem or mood disorder. And you again, people don't think that's good, and I agree that's not necessarily a good thing, but I do think it's um no, people will shout conspiracy like it's all the drug companies trying to freeze you or people trying to keep you quiet. No, I do think it's just what you get when you have a chronically underfunded, under-resourced health system. So when people come to you, say you're GP, you've got 10 minutes, so I've got I think I've got depression. You can say, Well, you put you on the waiting list for a counselor, those be like 18 months, and you it might work, or you can have a pack of pills now, and that's you know, it's a it's an option we have which fills a lot of gaps, but not necessarily the best option. That was the right option. But you know, if I think an ideal world we'd have a a a range of choices, but oftentimes we don't, and that's where we end up with using a lot more antipressions than we otherwise should. But you know, it's um that's a structural problem, I think, not so much a conspirating one.