Growing from Depression: A Practical and Philosophical Self-Help Guide

By Neel Burton

What if depression were a blessing as well as a curse? This is a book about how depression can have benefits as well as costs, and how to reap those benefits while making yourself feel better—better, in fact, than ever before.

 

Semi-finalist, the BookLife Prize

 

You have, in some sense, embarked on the hero's journey. Despite being ill-fated, despite starting out as a victim and underdog, the hero is able to rise up to life and experience it in its horror and fullness, rather than merely suffer or survive it and occasionally drink its dregs like so many of us do.

 

In myth, the aspirant has to travel through hell, or deep into the forest or labyrinth, before slaying the monster and re-emerging as a hero.

 

If your depression is the journey through the Inferno, then let this book be your guiding Virgil.

 

If your depression is the descent into the Cretan labyrinth, then let this book be Ariadne's ball of red thread.

 

A comprehensive, sympathetic, and thought-provoking guide for those who want to explore their depression in more depth.
—The British Journal of Psychiatry

 

Neel is an incredibly insightful and elegant writer, with a deep knowledge of all he surveys.
—Dr James Davies, psychotherapist, author of Cracked

 

I've read many Neel Burton books. He's a wonderful writer and able to immerse you lightly in pretty heavy stuff.
—Adrian Bailey, Vine Voice

 

About the author

 

Dr Neel Burton FRSA is a psychiatrist, philosopher, and wine-lover who lives and teaches in Oxford, England. He is a Fellow of Green-Templeton College in the University of Oxford, and the winner of several book prizes. His work features regularly in the likes of Aeon and Psychology Today and has been translated into several languages. When he is not reading or writing, or imbibing, he enjoys cooking, gardening, skiing, learning languages, visiting museums and gardens, and travelling, especially to sunny wine regions.

 

◆ Grab your copy now for a new and powerful way of looking at depression.

• Language: English
• Publisher: Neel Burton
• Release date: May 28, 2023
• ISBN: 9781913260477

Book preview

PART I

UNDERSTANDING DEPRESSION

Bud burst

Bud burst, the vine in my garden.

1

WHAT IS DEPRESSION?

There is, I’m afraid, no clear answer to this question.

Many people use the word ‘depression’ to refer to normal disappointment or sadness, and there can be little doubt that the concept of depression as a mental disorder, that is, a biological illness of the brain, has been overextended to include all manner of human suffering.

The concept of depression as a mental disorder may be helpful for the severest cases treated by hospital psychiatrists (medical doctors such as myself who specialize in the diagnosis and treatment of mental disorders), but probably not for the majority of cases, which, by and large, are mild and short-lived, and readily interpreted in terms of life circumstances, human nature, or the human condition.

Figures for the lifetime prevalence of depression (the chance of any one person developing depression in the course of his or her lifetime) vary according to the criteria used to define ‘depression’, that is, according to where we decide to draw the line between normality and illness.

Going by the criteria in the influential American classification of mental disorders, the DSM-5, the lifetime prevalence of depression is about 20 per cent, and the 12-month prevalence (the chance of any one person having suffered from depression in the past 12 months) is about 10 per cent—which still seems very high for a biological illness of the brain.

Depression, as defined by DSM-5, is now so common that the costs of treating it exceed the costs of treating hypertension and diabetes combined. Sales of antidepressant drugs continue to rise, and, in England, have more than doubled since 2008. According to NHS Digital, an estimated 8.32 million identified patients received an antidepressant drug item in 2021/22. For perspective, that’s around 18 per cent of the adult population.

Why is it so difficult to define ‘depression’?

If someone is suspected of having malaria, a blood sample can be taken to look for malarial parasites; and if someone appears to have suffered a stroke, a brain scan can be taken to look for an arterial obstruction.

But unlike stroke, malaria, and most other medical conditions, depression, in common with other mental disorders, cannot be defined and diagnosed according to its physical cause (etiology) or effect (pathology), but only according to its symptoms or manifestations.

In practice, this means that a doctor cannot draw a diagnosis of depression on any objective criterion such as a blood test or brain scan, but only on his or her subjective interpretation of the nature and severity of the patient’s reported symptoms. If some of these symptoms appear to tally with the diagnostic criteria for depression, which are very loose, then the doctor is able to justify a diagnosis of depression.

The philosophical problem here is that the definition of ‘depression’ is circular: the concept of depression is defined according to the symptoms of depression, which are, in turn, defined according to the concept of depression.

For this reason, we cannot be certain that the concept of depression maps onto a distinct disease entity, particularly since a diagnosis of depression can apply to anything from mild depression to depressive psychosis and stupor (Chapters 3 and 4), and overlap with several other concepts and constructs including adjustment disorder and anxiety disorders (Chapter 7).

An awkward consequence of our ‘menu of symptoms’ approach to diagnosing depression is that two people with absolutely no symptoms in common can both end up with the same, unitary diagnosis of depression. Indeed, a recent paper in the Lancet suggested that there are up 10,377 unique ways to qualify for a diagnosis of depression! For this reason especially, ‘depression’ has been charged with being little more than a socially constructed dustbin for all manner of human suffering—which can then be labelled as a mental disorder and treated in under five minutes with a simple prescription.

We often speak of normal disappointment or sadness as ‘depression’, as in, Jack failed his driving test and is feeling pretty depressed and about it—when, years ago, we would simply have said that Jack was feeling ‘upset’. We even apply the term to undesirable outcomes or states of affairs, as in, The plastic pollution in the Pacific Ocean is deeply depressing. So when things in our life get out of control, it can be all too easy to conclude that we are suffering from what is, in the end, a mental disorder.

But by pushing us towards doctors and drugs, this belief can prevent us from identifying and addressing the important real-life problems or psychological issues that are at the root of our distress, and so prevent us from making a more complete and durable recovery. If our knee is hurting, we might take the painkillers, or we might do the exercises: the painkillers are easy, the exercises are difficult, but I would rather have my knee back and stronger than ever before. And, of course, the one need not preclude the other.

The advice between these covers will benefit anyone with low mood, whether or not they meet the diagnostic criteria for depression. In fact, it will benefit anyone at all, including those who have never suffered from depression.

We are all, in some sense, on the same journey.

References

Prescribed Medicines Report: Summary. Public Health England, updated 3 December 2020.

Hasin DS et al (2018): Epidemiology of Adult DSM-5 Major Depressive Disorder and Its Specifiers in the United States. JAMA Psychiatry 75(4):336-346.

Fried EI et al. (2020): The 341 737 ways of qualifying for the melancholic specifier. Lancet 7(6):479-480.

2

WHAT DOES DEPRESSION FEEL LIKE?

The symptoms of clinical depression, as defined by DSM-5, fall into three groups, as per Table 2.1.

Table 2.1. Symptoms of depression.

Table 2.1. Symptoms of depression.

The core symptoms of depression are low mood and loss of interest or pleasure. Although these symptoms are present in the vast majority of cases, some people with depression never complain of low mood but present instead with symptoms such as headache or tiredness, or simply an inability to function, that is, to do the things that they normally do.

The psychological symptoms of depression include poor concentration, poor self-esteem, guilt, and recurring thoughts of death or suicide. Poor concentration is the norm, and the person may struggle to focus on everyday activities such as reading a book, watching the news, or following a conversation. As a result, she may struggle to remember or recall things, and come to the conclusion that she is losing her memory. But while depression can, and often does, affect concentration, it does not directly affect memory.

The physical symptoms of depression often affect the areas of sleep, appetite, and the libido. The person may find it difficult to fall asleep, or wake up feeling unrefreshed. In some cases, she may wake up unusually early, a phenomenon referred to as ‘early morning waking’. She may eat considerably less than usual, not only because she no longer feels like eating (loss of appetite) but also because she no longer enjoys her food, or no longer has the motivation, energy, or wherewithal to prepare or eat it. She may have no desire for friendship or romance, or even for simple conversation, which, in the long run, can undermine her relationships and the often vital support that they provide.

If you are in a relationship with someone with depression, remember that your partner still has feelings for you, even if she is not currently able to express them. Looking ahead, your presence and patience and understanding and support in a time of need is very likely to strengthen your bond.

Many people with depression also suffer from anxiety, either as part and parcel of the depression or in the form of a separate, diagnosable anxiety disorder. There is much more on anxiety in depression, or anxiety and depression, in Chapter 16.

In contrast to normal sadness or stress, the symptoms of depression vary little from day to day and barely respond to changing circumstances. For example, a depressed person who normally loves dogs will not lighten up even if presented with a bright-eyed pup.

According to DSM-5, for a diagnosis of depression to be made, five or more symptoms from a list similar to the one in Table 2.1 must have been present for a period of two weeks or more.

At least one of the symptoms must be either depressed mood or loss of interest or pleasure (a core symptom), and the symptoms must be associated with significant distress or impairment.

The diagnostician must also have considered and excluded other conditions that can masquerade as depression, such as thinning of the blood (anæmia) or an underactive thyroid gland (hypothyroidism).

If you were after a precise and technical answer to the question posed in Chapter 1—what is depression?—then this would be it.

The advice in this book applies to you whether or not you meet the formal criteria for depression—which, as I explained in Chapter 1, are somewhat arbitrary. Even if you do meet the criteria, this need not mean that the problem is with your brain rather than your life circumstances. For instance, it may be that you are overworked, or in a bad or underpaid job, or simply in an ill-suited one.

The problem need not be with your brain, and it need not be with you.

3

HOW BAD CAN THINGS GET?

Depression is usually classed as mild, moderate, or severe.

Mild depression is by far the commonest form of depression—if it can even be counted as depression. People with mild depression may complain of feeling low, tired, and/or stressed or anxious, but some frame it more in terms of how it’s affecting their everyday life. For instance, they might say that they are no longer able to concentrate on their job, or no longer able to enjoy the company of their loved ones.

People with mild depression might harbour suicidal thoughts, but these are usually fleeting and fragmentary, and acts of self- harm are unusual.

Moderate depression is the ‘textbook form’ of depression. Many if not most of the symptoms of depression, including the physical ones, are present to such a degree that the person finds it difficult if not impossible to fulfil her professional, marital, parental, and other social