https://youtubetranscript.com/?v=jVczK116eyo
Okay, so we can define depression first for everybody watching and listening. So, depression looks like a condition analogous to an excess of pain. It’s associated with grief and shame and guilt. It’s characterized by a decrease in positive motivation, so less enthusiasm, less curiosity, less hope, often hopelessness per se, and a proliferation of negative emotion. So, and those are separate biochemical systems to some degree. So, if you’re really depressed, you have no positive emotion, and you have way too much negative emotion, and then that manifests itself, well, it can manifest itself as a virtual inability to move even, no motivation, and often an overwhelming sense of doom and a proclivity even towards suicide. So, that’s the depressive realm. It’s a psychogenic pain condition, and it differs from anxiety even in its, although they overlap. Now, I had clients who were in that condition, but then imagine that those broke into two classes. I have the odd client who, by all appearances, by all standards of multi-dimensional assessment, had fine lives. So, these would be people who were reasonably healthy, apart from the depression, let’s say, who had a functioning marriage, who had friends that they liked, and a marriage that they liked, even though the depression might have been twisting their perception of that. So, for example, they may have thought that they were now so useless and contemptible that no one like their wife could possibly love them, and that they were, you know, a burden to their family. But they still had tight family relationships. They often had careers that were well developed and going fine. They were about as educated as you could expect. They didn’t necessarily have any substance use disorders. They did productive things outside of work, but they were profoundly depressed. Okay, so that’s one category. Now, the other category of person wasn’t like that at all. They had no relationships. They had no stable marriage. They had no friends. They had no job. Their educational history was fragmented at best. They had no plan for the future. They didn’t have a life. Now, both of them were miserable and maybe even in an equivalent manner. But the first group of people with a functional life was very much unlike the second group. Now, what I noticed, and I’ve never found any literature directly pertaining to this, maybe you know of some, I found in my practice that if I recommended to those clients, the ones who had a functional life, that they try an antidepressant, it was often likely to have relatively miraculous effects. Whereas the people in the second category, the antidepressant, could maybe help ameliorate the worst of their suicidal ideation and possibly tilt them a little bit more in the direction of positive motivation. But generally speaking, not a very effective treatment. Now, and logically, because if all those things were absent, the mere offering of a biochemical treatment wasn’t going to provide someone with no partner with a highly functional marriage. So, and I think in that differentiation, we can also see a distinction between the biological, and that would be what was hypothetically plaguing the people with functional lives, and the conceptual, because it was the absence of the ability to go about forming all those relationships, say, and pursue all those pathways in the latter case. So, the first thing I’d like to ask you is, for your general thoughts about that diagnostic approach to distinguishing between the biological and the so-called psychological, and then, well, and then how you go about doing that, because you already pointed out that you accept the distinction between biological mental illness, let’s say, and well, conceptual disarray, something like that, or lack of skills. Yeah, so I think you just did a great job of articulating that framework that I just outlined, that there are some people who have brain disorders, their brains are doing things that don’t make sense, they don’t make common sense. The first person that you described, or that first category of people you described, it doesn’t make sense that that person is depressed. They’ve got a good life. Everything’s going well for them, and they will often even say that. They will say, I don’t know what’s wrong with me, doctor. I don’t know what’s wrong with me. My wife loves me. My kids love me. I have a good job. We finally saved up enough money to get that vacation home that we wanted. I just got a promotion at work. By all intents and purposes, I should be happy, and I am miserable, and I feel like a burden, and I don’t know what’s wrong with me. Please help me. I would argue that person has, very likely, has a brain disorder. The pathways that are hardwired in the brain to trigger the depression response are malfunctioning. They are misfiring. They are causing the sensations and all of the experiences and perceptions of depression when they shouldn’t be. And here’s an easy analogy. So there’s, you know, all humans will experience pain. Pain is a normal human experience. If we injure ourselves, we will feel pain. If we get surgery, we may have prolonged and extensive pain. Those are not disorders. They cause suffering, and people often want help for that, and people often want treatment. They might even take pills for it, or they might need physical therapy or something else. So it’s not that we don’t treat pain. It’s that they don’t have a pain disorder. And then there are other people who have pain disorders. Their pain system is malfunctioning and causing the sensation of pain when there’s no clear good reason for pain. So that gives us a framework of, you know, normal and extreme. Like, if you get surgery, you may have extreme pain, but those aren’t disorders. And then somebody who’s got a pain disorder, where they have chronic unrelenting pain for no good reason, their pain system is malfunctioning. And so that first category of person, I would say their brain, the networks that cause all of the different experiences of depression, those networks are malfunctioning. That they are either overactive or underactive, depending on what symptoms we’re looking at. But they’ve got a malfunctioning brain that is causing the experience of depression. The second category that you mentioned, the person whose life is just a tragic mess. They have never had anything good going for them. They don’t know how to create a good life. They don’t know how to take care of themselves, how to have good, positive relationships. Maybe they have no purpose in life. Those people will in fact experience depression. And if they don’t experience depression, that in and of itself is a disorder. Anybody in that circumstance should, in fact, be depressed. The human brain is hardwired to make that person depressed because the human brain is trying to get that person to get a life, to integrate themselves into society so that their tribe, so that other humans actually accept them, integrate them into the culture or the tribe or whatever we want to think about it. And so that, and that creates safety. That we as humans are supposed to be connected with others. And that means that we are supposed to be connected not only in terms of loving relationships or work relationships, but we’ve got responsibilities. We’ve got responsibilities to ourselves and to others. And if we’re not participating in that culture, in that society, that means we are an outcast. We are being shunned. We aren’t integrating. There’s something wrong. And those people will- And that’s a danger. It’s a danger. Well, so one of the things I’ve- Let me ask you what you think about this. So one of the- So you know, there’s a relationship between the degree to which a given brain is likely to produce serotonin and the relative social status of that person. So higher- Okay, so- And this is germane biologically to the problem that you just described, because it turns out if serotonin modulates the magnitude of pain-like responses to negative circumstances, to stress, let’s say. And if you’re low status, which means if you’re low status, you’re more likely to have an exaggerated response to stress. And that can kill you across time. That’s very well documented. Very high relationship between relative social status and risk for mortality. But the reason for that, and you’re pointing to this because someone might think, well, you know, your claim that you need to be integrated within a social community is just an arbitrary claim. There’s nothing based in reality about that. That’s just a- It’s just a supposition of normality, and there’s no reason to assume that it’s related to mental health. But the reason that’s erroneous is because you are much more likely to have opportunity and to have security of the genuine sort. So that’s the kind of security that can save your life if you have a very well-developed and functional social network, and you’re very well regarded and respected and integrated within that. And as you intimated, we do have systems that perceive that and that causes pain in the absence of that. And that is definitely a contributing factor to depression. That’s not some arbitrary moral presupposition. It’s hardwired into the fact that we are incredibly interdependent and social creatures. And that’s so much so, this is something for everyone to think about too. We’re so wired to need that social harmony and interaction that we can even punish the most vicious and psychopathic antisocial criminals by putting them in solitary isolation. So even those guys can’t do it alone. Okay, so depression can be a valid marker of the inability to be integrated, right? And it can become counterproductive even under those circumstances, but the condition in itself, just like the condition of pain, isn’t an indication of pathology. So, okay, so let’s talk about differential diagnosis. So, okay, so we’ve already agreed, as far as I can see, that there’s a difference between a physiological disorder and a more abstract or mental disorder. Now, the other thing I tried to do in my practice was to rule out the physiological before proceeding with the psychological. Okay, now you pointed to a bunch of potential contributors to the physiological. So let me list those, and then maybe you can tell me if I missed any, if you dispute any, and how you go about that diagnosis. So here’s some things that can make you mentally ill, apart from the contents of your thought or perceptions. We know that depression is associated with, often associated with markers of excess immunological activity. So if you’re in a cytokine storm, you can get depressed. There’s all sorts of dietary reasons that we could delve into. There’s all sorts of illnesses that can produce depression as a side effect. There’s an issue of adverse response to medication. It might be that you’re in bad physical shape and need to exercise more, and some people are more prone to depression in the absence of exercise. There’s a huge potential complication of toxin exposure, environmental and otherwise, and then there’s the associated problem. One of the quick pathways to depression, especially if you’re biologically tilted in this direction, is to drink to relative excess three times a week, because then you’re always in alcohol withdrawal. Okay, so another thing that a good diagnostician should do is think, well, this person presents with depression, but maybe they’re ill, and here’s, you know, 10 things we should look at to rule that out. So tell me what you think about that, and how you go about doing that when you’re actually seeing your patients.