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04 cp44 (4) 571-580.qxd04 CP44 (4) 571-580.qxd 8/26/08 10:46 AM Page 571 Abstract: A multifaceted approach to treating depression may be optimal. Use ofantidepressant medication in the United States is very high. While medication hassaved lives, in some instances it paradoxically extends depression, if it leads pa-tients to avoid changing life situations and personality patterns that are destructive.
Involvement of the community in treating depression may be helpful, too, as in therituals of the Ndup and of “sitting Shiv’a.” The link between depression and a lackof social connectedness may have a specific neurological underpinning, as demon-strated dramatically by Mayberg. Changes in neurobiology can significantly alterexperience, but changes in experience can also significantly alter neurobiology.
Keywords: depression, Mayberg, deep brain stimulation, antidepressant, psychother-apy, Shiv’a Hope is the thing with feathersThat perches in the soul . . . And sore must be the stormThat could abash the little birdThat kept so many warm. WE ARE LIVING IN THE AGE OF PROZAC. An estimated 14 million Americans suffer from depression (Kessler et al., 1994); 11% of women and 5% of men in the noninstitutionalized population take antide-pressant medication (Stagnitti, 2005). These days, you do not need to consulta psychiatrist to get antidepressants; nonpsychiatrists issue approximatelytwo-thirds of anti-depressant prescriptions in the United States (Foote andEtheredge, 2000). If you tell your general practitioner that you are verysad, there is a good chance that he or she he will prescribe some Prozac,Effexor, or one of the newer antidepressants. It may work—you may feel Contemporary Psychoanalysis, Vol. 44, No. 4. ISSN 0010-7530 2008 William Alanson White Institute, New York, NY. All rights reserved.
04 CP44 (4) 571-580.qxd 8/26/08 10:46 AM Page 572 less sad; but will you be better? Or can the medication make your lifeworse in the long term? Solomon (this issue) describes his “incompetent psychoanalyst,” who encouraged him to avoid medication while he headed into a downwardspiral. Although it is certainly possible to harm some patients by discour-aging needed medication, it is also possible to make the reverse error: totell patients that their depression is purely biological and discourage themfrom getting much-needed psychotherapy.
Medications have saved the lives of some patients I have treated, but medications have damaged the lives of other patients. Some long-termusers of antidepressants want to become free of the medication. They findthat it dulls their emotions in general, and some wonder if it has anes-thetized them from feelings that might be useful. But they also find thatgetting off the medication is a tricky business. They suffer troublesomeside effects when they taper off the SSRIs. If the medication is an SNRI likeEffexor (venlaflaxine), which affects the levels of two neurotransmitters,the withdrawal effects can be especially severe and disorienting (Fava et al.,1997).
What is depression good for? All the human emotions evolved to serve useful purposes, as guideposts of our experience and motivators of ourbehavior. Sadness and anxiety are signals that there is something trou-bling that may require a change of behavior. Sadness can signal that wehave suffered a loss and will need to lay low for a while until we readjust.
Anxiety can signal that there is something dangerous that we must ad-dress. While there are some situations in which biological factors makeour emotions go awry, usually emotions have a purpose and should notbe ignored or suppressed. Modern psychiatrists tend to see sadness andanxiety as symptoms to be eliminated. The result is overprescription ofmedications that dampen unpleasant emotions without also helping peo-ple to use their emotions productively as signals of a life situation or apersonality pattern that is problematic.
As a psychoanalyst, I see more and more people in my practice who have been on antidepressants for decades. Some have a depression withno discernible cause, what used to be called “endogenous depression,”and are significantly helped by medication. Others, however, have experi-enced a traumatic event or a serious loss and were prescribed medicationto give them symptom relief, with no attempt to improve their psycholog-ical situation with effective psychotherapy. They came to believe that theycould not survive without medication. This conclusion was buttressed 04 CP44 (4) 571-580.qxd 8/26/08 10:46 AM Page 573 SOCIAL AND NEUROBIOLOGICAL FACTORS IN DEPRESSION when they tried to stop the medication and experienced serious with-drawal symptoms, which were identified by their psychiatrists as “a de-pressive relapse” that required continued medication.
Destructive Effects of Antidepressant Medication: A Case Study This is a case in which the destructive and limiting effects of antidepres-sants stood out. When I began psychotherapy with Lois, a 50-year-oldwoman, she had been taking antidepressant medication for 18 years. Inher 20s she felt extreme anxiety and began psychotherapy with a collegecounselor. Two years later, she started having sex with that therapist, whowas married. After years of assignations in motels and parked cars, hesuddenly dropped her. She became extremely depressed. Her physicianprescribed Prozac (fluoxetine), which she took for 16 years. When theProzac no longer seemed effective, she was switched to Effexor (ven-lafaxine), which she took for four years. She worried that the medicationwas dulling her emotions and might be otherwise interfering with her lifeexperiences. She had tried once to get off the medication by herself butexperienced severe withdrawal symptoms, including dizziness, rage, andsuicidal thoughts, and resumed taking the medication.
When Lois started psychotherapy with me, she was extremely anxious.
Her long-term relationship was falling apart, and she was at sea about hercareer. After two years of treatment, she stabilized her life and decided thatshe wanted to stop the medications. She tapered off the Effexor graduallybut nevertheless experienced extremes of rage and tearfulness. Althoughthese emotions were intense and may have been amplified by the medica-tion withdrawal, they were appropriate, in kind if not always in magni-tude, to the situation. Things were happening to her that should havemade her angry or sad.
She talked about getting on the subway in New York and getting furi- ous at a man who was taking up room on the bench with his bags whenthe car was full and many passengers were standing. She reprimandedhim, but then thought her anger was too strong and that she came acrossas crazy. This was one of those critical points in a psychotherapeutictreatment: should she be given medication to keep her emotions frombecoming too intense, or should she be helped to live with those intenseemotions, understand their source, and come to discriminate if and howto act on her emotions? She was suppressing anger in all areas of her life,even those more central to her well-being than subway etiquette, so it 04 CP44 (4) 571-580.qxd 8/26/08 10:46 AM Page 574 was not surprising to me that her anger, when she did release it, seemedexcessive.
She would come into session and go into a litany of things that had en- raged her. And they all were things that one could easily imagine makingone angry. Perhaps, I wondered, if she learned to use her anger as a signalthat something was really wrong, she might not feel so depressed. Shealso might not feel that her anger was crazy and out of control. Eventually,she started to tell me about things I did that infuriated her. Any time I com-mented on her appearance, she felt rage inside, but for a year she hid thatreaction. Finally, it “leaked” out, and I inquired about other things I didthat angered her. I told her I much preferred knowing about my effect onher than for her to try to contain her anger privately. We looked into thegenetic roots of why my actions brought out such rage in her, but it wasprobably more significant that she could learn that her anger was not sim-ply destructive but could also be used to better our relationship.
Lois tried to be a nice person. She often went too far, getting herself into abusive situations that would have made anyone angry. She lent moneyto friends and then discovered that they were living more luxuriously thanshe but took their time to repay the debt. She could barely allow herself tobecome aware of her anger, let alone express it. We found several suchsituations in which her anger was an important signal that she was beingabused. Once she was off the medications, she could no longer “manage”her anger as easily by suppressing it; instead, she learned to feel entitledto express her anger and curtail the abuse. The more we clarified these sit-uations and alleviated them, the less she seemed to get angry at thingsthat had little bearing on her well-being, like the rude people who puttheir bags on subway seats.
Lois came from a family in which the expression of any aggression was forbidden. She was raised to believe that ladies should not show theiranger, except to domestic help or other employees. When she first startedthe medication, she was enraged and bereft after her therapist ended theaffair with her abruptly. The medication softened those emotions. Was thatnecessarily for the best? How would her life have turned out if she had experienced the full depths of her anger and pain at the time, without med-ication but with competent psychotherapeutic help? I did not know herwhen she first started the medication, and there was no second-guessingthe past. I could deal only with the intensity of her emotion during thecurrent withdrawal from medication.
04 CP44 (4) 571-580.qxd 8/26/08 10:46 AM Page 575 SOCIAL AND NEUROBIOLOGICAL FACTORS IN DEPRESSION Are intense emotions a troublesome symptom that should be alleviated,or are they an important signal that should receive attention and lead tochanges in a person’s life? There is no simple formula for this determination,and good clinical judgment is essential—but judgment must be exercised.
Often, today, medications are quickly prescribed, and serious problems in aperson’s life are glossed over.
I have described a similar choice between medication and psychother- apy in the resolution of panic attacks (Blechner, 2007). There are patientswhose panic attacks are smoothed over by anxiolytic medications but donot fully disappear. An in-depth psychoanalytic interview frequently re-veals a situation in the person’s life which should make him or her afraid.
The problem is not an irrational fear, but a situation that should cause fearbut is being dissociated. When the fear-causing situation is brought fullyinto awareness, the erratic panic attacks that seem meaningless are re-placed with continuous, intense fear that has a clear cause. When the fear-causing situation is resolved in the person’s real life, the panic attackscease. While the predominant psychiatric approach to panic attacks is totreat the outburst of fear as the problem, in many cases, the lack of expe-rienced fear is the problem.
A similar pattern may operate in depression. A patient may be facing circumstances that would make most people depressed—loss, pain, hope-lessness, social isolation, and a sense of being ineffective. Medicationsmay change or mask these emotions, but they may paradoxically lead thepatient not to make the significant life changes that might head off suchpain in the long run.
The current trend in clinical work is to use psychotropic medications to lessen depressive symptoms. Medication requires less time of the clinicianthan does psychotherapy, at least initially. Over the long term, however,medications are not necessarily more cost effective than a psychodynamicresolution of a clinical problem. For Lois, the trade-off was obvious. Onceshe had identified and modified the character issues that were getting herinto rage-inducing, masochistic situations, she found herself less depressed.
Twenty years of medication had cost a lot of money, but the cost waseven greater when she considered the interpersonal losses she had sus-tained over those twenty years because she had suppressed rather thanused her emotions.
04 CP44 (4) 571-580.qxd 8/26/08 10:46 AM Page 576 Social Treatments for Mourning and Depression: Besides psychotherapy, would it be helpful for some depressed people tohave constructive community involvement in their treatment? Would itmake sense to have a family or community “intervention” for depression,as there often is in the treatment of substance use? There can be greathealing power in experiencing the concern of others about a troubled life.
There is a tradition of mourning in the Jewish religion called “Sitting Shiv’a.” After a close relative dies, you do not work; for seven days, youspend the entire day sitting at home. People come to visit and offer con-dolences. Although I no longer observe most Jewish rituals, after my par-ents died, I sat Shiv’a and was surprised by the ritual’s power. It allowedme to focus on my grief, but there was also enormous solace in having myfriends and relatives take time off work or their regular lives to be with meand offer comfort. It makes one aware of one’s social network and howsupportive it can be. While sitting Shiv’a, I kept thinking, “You care aboutme, too?” I realized how much this ritual works to resolve sadness andprevent it from becoming depression.
Andrew Solomon’s experience of the African Ndup ritual for depres- sion reminded me of sitting Shiv’a. Solomon writes: “There is a power inthe fact that these people who could ill afford a day away from the fields,had all taken all this time for me and devoted all this close attenton to mymental state.” There are important differences, of course, between theNdup and Shiv’a. In the Ndup, there is loud drumming and a celebratoryair, which are not the custom in Shiv’a. In this respect, the Ndup is morelike an Irish wake, which brings friends and relatives together in a morefestive atmosphere. Solomon, in the Ndup, was bathed in the blood of afreshly-killed ram. Whether that has any parallels in Western religiouspractice is debatable, although there are parallels at least symbolically. Af-ter all, there is the Christian hymn, “Are you washed in the blood of thelamb?” (Revelations 7:14) To be washed in the blood of the lamb is to bewashed of sin by virtue of the blood of Jesus.
In the various rituals for mourners, we see the elements of social treat- ment of grief and depression. If we have effective Western rituals formourning a death, why are they not adapted for depression triggered byother losses, such as divorce or financial crises? We can find one signifi-cant difference between attitudes toward widowhood and attitudes to-ward other losses. In Western culture, being widowed carries no shame.
04 CP44 (4) 571-580.qxd 8/26/08 10:46 AM Page 577 SOCIAL AND NEUROBIOLOGICAL FACTORS IN DEPRESSION No one will blame you for your husband’s death (unless you have killedhim). You are the object of total sympathy and support. But, unfortunately,many other kinds of losses carry the taint of shame—divorce, losing a jobor a lover, experiencing great financial loss—these all are perceived withmixed emotions, sometimes with pejorative judgments and blaming of thevictim. What did you do to cause your divorce? What mistakes caused suchenormous financial losses? There are no comparable rituals of communitysupport like Shiv’a or Ndup in Western culture for those losses, or even forunspecified losses that may show up as depression, but perhaps thereshould be.
It may be helpful to have a community of friends and relatives be in- volved in helping the depressed person, just as it is also healing to behelpful to others when they are in trouble. This proposal is related toO’Leary’s observation (this issue) that both involvement in a spiritualcommunity and being helpful to others with a community spirit can re-lieve depression. I noted something similar with my patient Lois: A friendof hers was dying of cancer and asked her friends to surround her hospi-tal bed and sing to her. Lois spent an entire day in this community singand found that her depression lifted during the experience.
Reciprocal Relation Between Neurobiology and Experience The brain changes experience, and experience changes the brain. De-pression is not only a disorder of neurotransmitters, it is an illness of lossof social support and the loss of hope that such support will ever be avail-able again (Watt and Panksepp, in press). Scientists studying depressionare beginning to understand the relationship between hope (“the thingwith feathers”) and brain changes. For example, we know that depressioncan be correlated with lower hippocampal volume (Vildebech andRavnkilde, 2004) and higher cortisol levels (Pruessner et al., 2003). Wealso know that high self-esteem and internal locus of control are bothpositively correlated with higher hippocampal volume (Pruessner et al.,2005) and negatively correlated with cortisol levels in stressful situations(Pruessner, Hellhammer, and Kirschbaum, 1999). The implication, whichis not conclusively proven, is that high self-esteem and a sense that youcontrol the events in your life may insulate you from depression and thatthere is a biological basis for this. However, to what degree the brain stateleads to the feeling or the feeling leads to the brain state is still open toquestion.
04 CP44 (4) 571-580.qxd 8/26/08 10:46 AM Page 578 There is also a correlation between an increased feeling of social con- nectedness and decreased depression, both of which may be influencedby the same area of the brain. This has been dramatically illustrated byHelen Mayberg, who is well known for her work with patients who donot respond to any of the traditional treatments for depression. Mayberginserts microelectrodes that inhibit Brodmann Area 25 in the brain andthus relieve depression in some people (Mayberg et al., 2005). One of themost surprising findings is that electrical stimulation, while relieving de-pression, can also dramatically enhance the patient’s sense of social con-nection. This was revealed during the operation, when, unbeknown tothe patient, Mayberg switched the stimulation on and off. She describedthe phenomenon vividly to journalist David Dobbs (2006): Mayberg had told her patient, Deanna, that if anything felt different, sheshould say so. Mayberg wasn’t going to tell her when the device was acti-vated. “Don’t try to decide what’s important,” Mayberg told her. “If yournose itches, I want to know.” . . . “So we turn it on,” Mayberg told me later,“And all of a sudden she says to me, ‘It’s very strange,’ she says, ‘I knowyou’ve been with me in the operating room this whole time. I know youcare about me. But it’s not that. I don’t know what you just did. But I’mlooking at you, and it’s like I just feel suddenly more connected to you.’”Mayberg, stunned, signaled with her hand to the others, out of Deanna’sview, to turn the stimulator off. “And they turn it off,” Mayberg said, “andshe goes: ‘God, it’s just so odd. You just went away again. I guess it wasn’treally anything’” [p. 54].
The patient did not know that the deep brain stimulation had been turnedon and off, but with the stimulation on (which would relieve the depres-sion), she also felt interpersonally connected to her doctor. With the stim-ulation off (which would have left her depressed), she felt distant fromher doctor. This observation demonstrates the link between the feelingsof depression and of interpersonal isolation, and suggests that this linkmay have a neurobiological basis.
Mayberg’s research shows how a change in the brain can drastically al- ter experience. However, the reverse is also true: intense experiences, likepsychotherapy, can change the biology of the brain.1 Such findings suggest 1 See Linden (2006) and Beutel and Huber (2008) for summaries of the data; also see Schnelland Herpertz (2007) and Doidge (2008).
04 CP44 (4) 571-580.qxd 8/26/08 10:46 AM Page 579 SOCIAL AND NEUROBIOLOGICAL FACTORS IN DEPRESSION a basic principle for researchers and clinicians: Changes in neurobiologycan significantly alter experience, but changes in experience can also sig-nificantly alter neurobiology. There is a bidirectional influence, and thedepressive system can be altered through neurobiological or experientialinterventions. While we can value the changes in affect that are achievedby medication and other biological interventions, we must also value theway psychotherapy, community intervention, and other intense interper-sonal experiences can change the brain. A multifaceted treatment ap-proach may offer the best hope for those who are depressed.
Beutel, M. & Huber, M. (2008), Functional neuroimaging—Can it contribute to our under- standing of processes of change? Neuro-Psychoanalysis, 10:5–16.
Blechner, M. (2007), Approaches to panic attacks. Neuro-Psychoanalysis, 9:93–102.
Dobbs, D. (2006), A depression switch? New York Times Magazine, April 2, pp. 50–55.
Doidge, N. (2008), The Brain That Changes Itself. New York: Penguin Books.
Fava, M., Mulroy, R., Alpert, J., Nierenberg, A. & Rosenbaum, J. (1997), Emergence of ad- verse events following discontinuation of treatment with extended-release venlafaxine.
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Foote, S. & Etheredge, L. (2000), Increasing use of new prescription drugs: A case study.
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Kessler, R., McGonagle, K, Zhao, S., Nelson, C., Hughes, M., Eshleman, S., Wittchen, H.-U. & Kendler, K. (1994), Lifetime and 12-month prevalence of DSM-III-R psychiatric disordersin the United States: Results from the National Comorbidity Survey. Archives of GeneralPsychiatry, 51:8–19.
Linden, D. (2006), How psychotherapy changes the brain—the contribution of functional neuroimaging. Molecular Psychiatry, 11:528–538.
Mayberg, H., Lozano, A., Voon, V., McNeely, H., Seminowicz, D., Hamani, C., Schwalb, J. & Kennedy, S. (2005), Deep brain stimulation for treatment-resistant depression. Neuron,45:651–660.
Pruessner, J., Baldwin, M., Dedovic, K., Renwick, R., Mahani, N., Lord, C., Meaney, M. & Lupien, S. (2005), Self-esteem, locus of control, hippocampal volume, and cortisol regula-tion in young and old adulthood. NeuroImage, 28:815–826.
Pruessner, J., Hellhammer, D. & Kirschbaum, C., (1999), Low self-esteem, induced failure and the adrenocortical stress response. Personality and Individual Differences, 27:477–489.
Pruessner, M., Hellhammer, D., Pruessner, J. & Lupien, S. (2003), Self-reported depressive symptoms and stress levels in healthy young men: Associations with the cortisol responseto awakening. Psychosomatic Medicine, 65:92–99.
Schnell, K. & Herpertz, S. (2007), Effects of dialectic-behavioral-therapy on the neural corre- lates of affective hyperarousal in borderline personality disorder. Journal of PsychiatricResearch, 41:837–847.
Stagnitti, M. (2005), Antidepressant use in the US civilian non-insitutionalized population, 2002. Statistical Brief #77. Rockville,MD: Medical Expenditure Panel, Agency for Health-care Research and Quality.
Videbech, P. & Ravnkilde, B. (2004), Hippocampal volume and depression: A meta-analysis of MRI studies. American Journal of Psychiatry, 161:1957–1966.
04 CP44 (4) 571-580.qxd 8/26/08 10:46 AM Page 580 Watt, D. & Panksepp, J. (in press), Depression: An evolutionarily conserved mechanism to terminate separation-distress? A review of aminergic, peptidergic, and neural network per-spectives. Neuro-Psychoanalysis.
Mark J. Blechner, Ph.D. is a Fellow, Training and Supervising Analyst,William Alanson White Institute; and Editor-in-Chief, ContemporaryPsychoanalysis. 145 Central Park WestNew York, NY [email protected]
Absorbable Stabilisation of the Bar inMinimally Invasive Repair of Pectus ExcavatumM. Torre1, V. Jasonni1, C. Asquasciati1, S. Costanzo1, M. V. Romanini2, P. Varela31 Pediatric Surgery, G. Gaslini Institute, Genova, Italy2 Plastic Surgery, IST, University of Genova, Genova, Italy3 Pediatric Surgery, Calvo Mackenna Hospital, Santiago, ChileResults: The surgical technique for the stabilisa-tion