Depression is the most common mental disorder in the developed world. It particularly affects adults of working age and so the consequences extend beyond the problems associated with the clinical symptoms and impairments in day-to-day functioning experienced by the individual, to broader economic and societal costs. Yet, despite evidence of the real impact of depression on individuals and society, the whole subject of depression is mired in controversy. This is partly because the concept means different things to different people. Many acknowledge that states of depression are authentic but struggle to differentiate between depression as an emotion or mood state (such as dejection or sadness), depression as part of someone’s (pessimistic) personality makeup, and depression as a mental disorder (sadness accompanied by symptoms such as sleep, concentration, appetite, and energy disturbances). Others accept the idea of ‘clinical depression’, but see it as a problem of the mind, which is regarded as the element of a person that enables them to be aware of the world and their experiences, to think, and to feel. People who focus on the mind often reject the notion of biological causes. Others still see depression as an understandable reaction to life circumstances that should therefore either be allowed to heal naturally or should only be treated with psychological and social interventions. Whilst there are some observers who claim that depression is an invention of the modern world, blame the rise of ‘medicalization’, and see those who promote treatments, especially the use of antidepressants, as entering some sort of conspiracy with certain factions or organizations such as the pharmaceutical industry.
To try to make sense of some of these different perspectives we have decided to use this text to discuss the evolution of the concept of depression and its treatment and also to examine some of the controversies and future directions for research. To understand the path we have taken it is helpful to offer a few observations at the outset. For example, it is useful to know that the term depression comes from the Latin de (down from) and premere (to press) and so deprimere translates as ‘to press down’. This word gained widespread acceptance in the 19th and 20th centuries, and was increasingly used to describe mental conditions experienced by individuals who were treated in the community. However, before the word depression came into common parlance, the word melancholia had been employed. Technically, the term melancholia refers to a mental condition that is characterized by more extreme levels of depression, accompanied by physical symptoms, and sometimes by hallucinations and delusions. In the 19th century, the use of the term melancholia was more restricted, being mainly applied to individuals with severe depression that required treatment in the old asylums.
We use this evolution to help readers to understand that these different views of depression have influenced theories of the causes of depression and the nature of the treatments that may be offered. We also want to alert readers to how depression was understood by the so-called Fathers of Modern Psychiatry such as Emil Kraepelin and Sigmund Freud, whose ideas have been viewed as not only influential but also controversial.
We hope that the approach we have taken allows people to understand the context in which international approaches to classifying mental disorders were developed. The background information we provide attempts to shed light on the efforts made to distinguish clinical depression from the normal human experience of sadness on the one hand and from other severe mental disorders such as manic depression (also called bipolar disorders) or schizophrenia (also called psychotic disorders) on the other. It also highlights that drawing boundaries and developing categories for diagnosis, an approach which is widely accepted in medicine, is often derided in psychiatry. We discuss some of the reasons for these double standards and then move on to discuss theories about the causes of depression and how old-fashioned treatments for melancholia evolved into modern treatments for depression and manic depression.
Other chapters examine some of the current controversies about what treatments and therapies may work for depression and then some indications about future research are given. We finish by examining depression in society from the perspective of its global burden and economics, as well as issues such as stigma and whether people who experience mood disorders are more likely to be creative than other members of society.
We want to highlight that condensing information about the most common mental health problem on the planet into 35,000 words has been a challenge. So, this Very Short Introduction includes a selection of topics that we find are interesting or challenging (does depression exist?), issues that cannot be ignored (how can suicide be prevented?), and some of the themes that we think will become more talked about in the next few years (does psychotherapy change brain functioning?). It is difficult to do justice to some of these topics in a few thousand words and we have excluded many issues that you may want to know more about. It is likely that many of these topics were considered or indeed were included in the earlier drafts of the manuscript. We can only apologize if issues that are particularly important to you have ended up on the cutting-room floor.
If you are thinking of buying this VSI volume then it is probably sensible for us to be also clear about what this book does not include. We have not written a patient guide—you are unlikely to be able to decide from reading this book whether you have depression or a certain type of mood disorder. If you have or previously have had an episode of depression, this book is unlikely to help you determine if your experiences have been caused by a chemical imbalance in your brain or by life events or some other combination of factors. This is not the goal of what we have written about. Nor is this book a treatment manual; we do not begin to discuss what treatment best suits which person. Even more importantly, this is not a self-help book; we do not describe techniques to deal with the symptoms of depression. Lastly, a VSI book is not a substitute for a textbook; we are not trying to cover every theory, every type of treatment available, and every aspect of depression. Indeed, as the title suggests this is a very (very) short introduction and selective review of a complex and challenging topic.