Does depression have an upside? It's complicated.


Jonah Lehrer's story on "Depression's Upside" has created quite a kerfuffle. The idea he explores â that depression creates an analytic, ruminative focus that generates useful insight â sits badly with quite a few people. It's not a brand-new idea, by any means; as Jonah notes, it goes back at least to Aristotle. But Jonah (who â disclosure department â is a friend; plus I write for the Times Magazine, where the piece was published) has stirred the pot with an update drawing from (among other things) a very long review paper published last year by psychiatric researchers Paul Andrews and J. Anderson Thomson.

The story and the flap it raised has made me examine my own thinking about this notion.
I've now read the piece and much of the reaction several times and have, ah... ruminated on it quite a bit. The subject hits close in several ways. I've written quite a bit about depression and have suffered its teeth a few times.And this analytic-ruminative theory â which I'm going to call ART here, for the sake of efficiency and fun â relates strongly to many of the issues I explored in my Atlantic article, "The Orchid Child," and will explore further in The Orchid and the Dandelion.

The article struck many commenters and readers as on-target. Evolutionary types seemed to like it. People who had experienced depression seemed roughly split, some agreeing that it generates light and others saying it just throws you down a black hole. Some commenters raised sharp objections . The most thoughtful critiques came from Neurocritic (another favorite of mine, though I don't know him) and Tufts University psychiatrist Ronald Pies. Lehrer responded with grace, poise, and intelligence, both at other people's blogs and in multiple posts at his own.

Yet that hardly resolved the tension, much less the question.I've always viewed the ART model skeptically myself, at least as wielded broadly. It doesn't fully jibe with my own experience, with the experience of some depressed people I know well, or with what I've seen in depression studies. Yet I think it has some merit and legitimate insight. Examining it can shed light on what depression really is (and isn't).

It's complexicated. I'll take it in sections.

Muddy Ground

The term depression is so messy, muddy, and imprecise that almost any talk about the nature of depression will encounter sloppy ground. Atop that, psychiatry itself is similarly messy and confused.

By chance and rich luck, Louis Menand published a fine article pointing out this muck and confusion the same week that Lehrer's piece appeared. Menand opens by describing a hypothetical case of "situational depression" (You've been laid off and are feeling bleak and increasingly withdrawn...), then asking you to consider whether you should follow your doctor's suggestion that you start a course of antidepressants. That's just the setup, of course, for a knockdown:

However you go about making this decision [i.e., whether to take the meds], do not read the psychiatric literature. Everything in it, from the science (do the meds really work?) to the metaphysics (is depression really a disease?), will confuse you. There is little agreement about what causes depression and no consensus about what cures it. Virtually no scientist subscribes to the man-in-the-waiting-room theory, which is that depression is caused by a lack of serotonin, but many people report that they feel better when they take drugs that affect serotonin and other brain chemicals.

Then he muses:

Is depression--insomnia, irritability, lack of energy, loss of libido, and so on--like a fever or like a disease? Do patients complain of these symptoms because they have contracted the neurological equivalent of an infection? Or do the accompanying mental states (thoughts that my existence is pointless, nobody loves me, etc.) have real meaning? If people feel depressed because they have a disease in their brains, then there is no reason to pay much attention to their tales of woe, and medication is the most sensible way to cure them. Peter Kramer, in "Against Depression" (2005), describes a patient who, after she recovered from depression, accused him of taking what she had said in therapy too seriously. It was the depression talking, she told him, not her.

This provides valuable context for considering the ART model. The history Menand covers reminds us that psychiatry and its terminology are sloppy â and that you court difficulty and danger when you discuss science (perhaps especially the science of the mind) without some historical perspective. Every time you zoom out your view of psychiatry and its diagnostic categories, for instance, you see terrain stretching at a scale and in corrugations that the previous, more tightly framed perspective never suggested.

This applies especially to "depression" â a term I air-quote because it's enormously imprecise abouit not just degree and duration of symptoms -- that is, whether you're sad for a few days or in couchbound despair for years -- but also about the biological and neural dynamics involved.

Lehrer notes, for instance, that some studies show that depression generates increased activity in the ruminative, problem-solving areas of the prefrontal cortex, or PFC. Ries counters that other studies show a decrease in PFC activity. Indeed, researchers have found both things.

They've found similar 180-degree differences in how recovery from depression affects PFC activity. A few years back, Emory neurologist Helen Mayberg and colleagues looked at the neural activity of depressed patients as they responded successfully to treatment â drugs in some cases, cognitive behavioral therapy in others. In both cases, PFC activity changed. But it ramped up in people who got better while on medication, and down in people who get better while undergoing cognitive behavioral therapy or CBT. (I discussed this study and its implications in a profile of Mayberg I wrote a while back. My Times Magazine article on Mayberg's experimental brain surgery trial also sheds some light on depression's nature.)

How so? It took a while for Mayberg to figure it out:

âOh man,â says Mayberg. âI was stumped. For a while I had to just set it aside.â Why did the CBT patientsâ frontal activity go from high to low as they got better, rather than vice-versa?

She finally realized that the successful CBT patients were almost by definition going to show this pattern. In CBT, patients learn to recognize and change thought patterns that help depress them. An active frontal area, then, was virtually required to make CBT work. The patients who responded to CBT did so either because they were busier thinkers by nature (and therefore more amenable to CBT) or were, when scanned at the beginning of the study, in an earlier stage of depression in which their frontal areas could still rise to the task. The CBT responders entered the study already trying to think their way out of their depression. The scans showing these initial high levels of frontal activity, then, âwere pictures,â as Mayberg put it, âof the tug-of-war between the depression and their attempt to self-correct.â When their attempt succeeded, the frontal areas could relax, and the scans showed the reduced activity.

This is a major point: It's not just depression that varies tremendously; people's reactions to it, and their possible paths out of it (and, doubtless, into it), also vary tremendously. This adds to the difficulty of offering any sweeping statements or theories about depression's nature. Yet sometimes we need sweeping statements to force a broader view.

Back to ART

Which returns us to the analytic-ruminative model. As I noted, I think the ART model has limits. Yet unlike some of Jonah's critics, I think (and I regret to report that I speak from experience as well as study) that even nasty, long, potentially lethal depressive episodes can (but don't always) inspire crucial insight. Why would some episodes do so and others not? Well, the factors I can suggest include a) the nature of the depression (particularly whether it's due to situations you have the power to change) and b) whether you possess at the time the combination of cognitive chops, inclination, and social and/or professional support to generate some insight. In other words, if you're down, maybe even really down, because a particular situation is defeating you, and ... (here you can add a bunch of ifs having to do with your willingness and ability to work the problem, the quality of your therapist, the people around you, etc.) ... then you might solve a key problem or gain a key insight.

The insight might even turn an unsatisfying life into one deeply rewarding. A psychiatrist once told m, and I think he's right about this, that most people don't face a whole bunch of different problems during their lives; instead, you tend to face the same problem presenting itself in different forms. Learn to recognize and better handle the core problem (which you are always, of course, part of), and you'll cut a smoother path. And this recognition can happen even amidst of intense depression; in fact, the depression may the only thing capable of driving you to do the needed work.

In this sense, the ART model offers a crucial truth. Yet it's part of the muddle of this thing that many depressions â perhaps most but not all deadly serious depressions â destroy rather than create. Thus the depressed PFC activity; thus the anemic powers of thought, memory, and will; thus the frozen emotions, the seized cognitive powers, the sense that every road is fogged over. These depressions just smother you.

Despite all the complexity, it's that simple: Sometimes, for some people, depression ramps up constructive thinking; for other people (or at other times for the same people for whom depression sometimes brings insight), it smothers it. Did Virginia Woolf's bipolar depression bring her insight and creativity? Quite possibly. Yet in the end it drowned her.

The Orchid Angle

The question of depression generating insight leads inevitably to the much-discussed (and sometimes disputed) association between depression and creativity. Does depression, either unipolar or bipolar, generate creativity? There's some evidence it does. There are links. But what's the source of the link?

Well, depression might, as above, sometimes directly inspires introspection and insights contributing to creativity. That's a direct causal relation.

But I think that some attributing creativity to depression may, in some cases and perhaps in general, mistake association for cause â that depression is not the thing that generates creativity and insight but a byproduct of another trait that does. And that this other trait is sensitivity â and particularly the sensitivity that comes from the "sensitivity" genes I recently wrote about in the Atlantic.

The sensitivity hypothesis asserts that some gene variants presently considered "risk genes" for mental health problems in people with stressful lives are actually "sensitivity genes" that make you more sensitive to all experience. One of the genes in question is the serotonin transporter gene, or SERT gene, which helps regulate the neurotransmitter serotonin. Two of the three variants of this gene (the "short-short" or s/s version and the "short-long" or s/l versions) have been shown to put people with stressful life histories at greater risk for depression. The sensitivity or orchid hypothesis asserts that these short SERT variants don't make people more sensitive to bad experience but to all experience, bad or good. It's not a "depression gene" but a sensitivity gene. What you make of that sensitivity naturally depends on other assets or experiences you have.

If this is so, then it's possible that this sensitivity hypothesis may account (wholly or in part) for findings that "depressed people" have more insights or creativity -- only it's not necessarily the depression that generates the insight, it's the heightened sensitivity.

This comes close to being the sort of "spandrel" that Ron Pies discusses in his critique of Lehrer's article. As Pies explains, a spandel, in evo talk, is a neutral or disadvantageous trait that comes along as a byproduct (or one expression) of some larger, broader trait that is adaptive:

In architecture, a spandrel is simply the space between two arches. Molecular evolutionist Richard Lewontin and paleontologist Steven Jay Gould argued that many traits in nature are nonadaptive, and--like spandrels--are simply byproducts of other, presumably adaptive traits. For example, Gould notes that bones are made of calcite and apatite for adaptive reasons, but they are white simply because that's the color dictated by those minerals--not because "whiteness" confers an adaptive advantage.

In her upcoming book, The Pocket Therapist, Therese J. Borchard candidly observes that, "...the sensitivity that produces so much of my [emotional] pain is precisely what makes me the compassionate person I am." ... I believe that Borchard may be gesturing toward one possible mechanism by which depression is genetically conserved: not by virtue of its adaptive value, but by virtue of depression's ability to "hitchhike" along -- as a spandrel -- with a sensitive, altruistic, and compassionate nature: traits that are indeed adaptive, in many social contexts.

As Borchard wisely counsels, we should not renounce or disown the part of us that produces depression -- it is a piece of our messy, complex, and wondrous humanity. And, to be sure: ordinary sadness or grief may indeed be a good teacher. We should not rush to suppress or "medicate" what Thomas à Kempis called "the proper sorrows of the soul." At the same time, we should be under no illusion that severe clinical depression is a "clarifying force" that helps us navigate life's complex problems. That, in my view, is a well-intentioned but destructive myth.

I differ with Pies here. I think â I think I know â that severe clinical depression can sometimes, in some cases, serve as "'a clarifying force' that helps us navigate life's complex problems." At other times, in other cases and other people, serious depression is indeed but a dangerous byproduct â a spandrel âthat comes from a heightened sensitivity. And that sensitivity may rise, as described in my article, from gene variants such as the S/S and S/L SERT alleles.

Doubtless the tremendous variability in depression, and the wiggy variations in its association with insight, creativity, and other upsides, depends too on other variables about which we're clueless. Much murk remains

So does this get us anywhere? I think so. Some of Lehrer's critics said he'd contributed but a "sloppy and insensitive article" that insulted the depressed and did the discussion harm. I say otherwise. Given depression's immense complexity, not to mention the muddle that is psychiatry, I think we will always, as Menand put it, "lurch" about rather clumsily in our attempts to understand it.Yet even when people articulate fairly stark positions, as Jonah did in his article and Pies in his critiques (actually, because they take stark positions), these dust-ups can, if people engage them with a willingness to look deeper, think a bit, modify their positions, perhaps even ruminate a bit, produce some useful insights. The muddle can produce clarity, the noise an upside.


More like this

I was following this on Jonah's blog and find the concept rather interesting. Overall, I can't say I agree with it, but I'm sure it is true for some.

As for the creativity/sensitivity issue: I've always been creative. I haven't always put this toward any actual physical goals such as painting, songwriting, writing, etc.; but when overcome by MDD (which later "blossomed" into bipolar I), I was no more creative than I ever was, yet I was producing many more works of art. What drove me to create was tied in with sensitivity in a way. Before the onset of the MDD, I had the average burdens of an average kid. When the depression began, and thereby the burdens increased, there was so much emotional turmoil, hate, disgust, hopelessness, etc, that it was impossible to keep it all in. I needed an outlet to purge the nastiness I dealt with on a daily basis. This gave me a lot more drive to physically create, rather my usual more cerebral creativity.

Another plus to creating my written works is that I can now go back and look at them with a more or less sober mind (thanks, counselors and meds!), and see how truly messed up I was. And I can recognize patterns in thought and reasoning that only made things worse. It's something to reflect upon; it helps to recognize how far I have come. In that respect, I have more hope for the future. I'm more likely to take chances in the name of success.

While this isn't what the paper addressed, and wasn't quite as much detail as I originally intended to post, the concept of the positive spin could perhaps be tenuously related...maybe...

Dear Mr. Dobbs:

As the author of the critical rejoinder to Jonah Lehrer's article, I appreciate your nuanced and thoughtful analysis. Thanks, also, for citing my article on the Psychcentral website.

I think our respective positions are not terribly far apart. Depression, as you well explain, is an extraordinarily "heterogeneous" condition, which, in turn, affects extraordinarily different "types" of individuals. I do not doubt that for some very resourceful, intrepid, and
frankly, lucky, individuals, even a severe bout of depression could serve as a "clarifying force". It would be equally true, though, to say that for a few individuals with these qualities, a massive head injury could also serve, eventually, to "clarify" certain issues for them; e.g., "I am a vulnerable, mortal creature; my life and mind are subject to misfortunes I can't control; I had better re-orient my values in life, so that I spend my remaining time doing things I really want to do..." etc.

This, of course, is a far cry from saying that major depression--more than other severe disorders--is either specifically or uniquely "adaptive." I would need to see the controlled, randomized studies showing me such a specific advantage to major depression (versus, say, dealing with Lou Gehrig's Disease, Parkinson's Disease, stroke, etc.).

I also believe there is a very practical, clinical reason why we should resist an enthusiastic embrace of the "ART" or analytical-rumination hypothesis. For severely depressed patients who, more likely than not, have significant cognitive impairment, it may do more harm than good to tell them that, in fact, they have been given a great gift that will allow them to solve their problems more efficiently. For every such patient who is perked up by such a "teaching", I believe there will be ten who will experience it as "counter-empathic"; i.e., alien to the felt experience of their suffering. Most would likely think,
"Am I doing something wrong? My brain feels like chewed bubble gum. Why am I not solving problems like the doctor said? What's wrong with me?"

Finally, in Psychiatric Times, evolutionary biology professor Jerry Coyne PhD will be presenting his own critique of the "ART", sometime within the next few weeks. I hope you will "stay tuned"!

Best regards,
Ronald Pies MD
Editor in Chief, Psychiatric Times
Professor of Psychiatry, SUNY Upstate Medical U.
and Tufts USM, Boston

By Ronald Pies MD (not verified) on 10 Mar 2010 #permalink

Thanks, Anodyne, for writing in, and Ronald Pies, for your note as well. I think you're right: That you and I are not terribly far apart; and neither am I terribly far from where Jonah stands on this.

A couple responses to yours:

1. Your parallel (offered half tongue-in-cheek, I think, but still... ) between depression and a head injury I find prolemmatic. I think there's an elemental difference in the sort of attention sometimes brought to bear by depression and the sense of mortality and vulnerability created by a head injury. The former implicates one's own thinking, and invites one's own agency, in a way the latter does not. This isn't always so, of course, and applies to those cases that can produce useful insight, as described. But to say the focus and clarifying impetus this produces is the same as that of a person who suffers a head or other injury seems to me well off the mark. I see what you're saying; but I don't agree with it.

As to the practical reasons one should or might resist embracing the ART model: I certainly see what you mean there, and I see why therapists and psychiatrists would resist it. Yet it seems to me that to reject it altogether, and to not be open to the possibility that some patients could turn their depression into opportunities for insight, is to miss some highly valuable therapeutic possibilities. That's not to say you should encourage immersion in depression. But the pressure created by the depression can â even as you try to relieve it â be turned against core problems that cause or aggravate the sense of helplessness. Again: Not always; but sometimes, and then, sometimes crucially.

Sounds easy from here, of course, and I fully credit, believe me, the difficulty of dealing with these issues with real patients in despair and possible or even very clear danger. It may be that the most sensible response for a healthcare provider â the 'do no harm' track â is to not embrace the depression in any way but to push back hard at every front. But that's a practice and a practical decision meant to do the right thing most of the time and avoid grievous mistakes. It's a decision to make (I'm overgeneralizing) a monolithic response to a multifaceted, mysterious condition. But that a monolithic response is the most practical (if it indeed is) doesn't make the condition any less mysterious or variegated or homogeneous; it doesn't mean that sometimes you're missing something, or that depression never behaves in a different way.

Thanks again for writing, and for your thoughtful and good-spririted discussion throughout.

Thanks, David--I appreciate your rejoinder, and I'd like to clarify and sharpen the points I was trying to make. Then, I will refrain from further comment, as I'm sure I've said more than enough!

1. I was not making an ontological claim that a head injury (or Parkinson's, etc.) will produce the same "clarifying impetus" as might be the case in depression--merely that this is an empirical question to be settled by appropriate research, not resolved a priori by means of a particular ideology of "depression". Indeed, with all due respect to your particular experience, it begs the question (in the logical sense of presuming as true precisely what is in dispute) even to assert that major depression provides a "clarifying impetus" at all. (As I've acknowledged, however, it may indeed do so for a few lucky and "plucky" individuals).

2. From the clinical standpoint: Suppose a severely depressed patient were spontaneously to say to me, "You know what, Doc? I'm finding some real meaning in this depression. It's given me insight into a number of aspects of my own being, as well as helped me to work through some really complex problems that have stymied me for years."

Aside from the fact that I would wonder what on earth the patient had been smoking that day, I would certainly not try to "quash" this patient's hopeful and grateful attitude toward his or her depression.

I would probably say, "Well, I think it's absolutely terrific that you are able to find meaning and benefit in this very difficult condition you are struggling with. Are there any other ways in which your depression has helped you?"

That is the way I believe therapists can be "open" to the hypothesis put forward by Thomson and Andrews, and defended (in my view) by Mr. Lehrer. This, of course, is entirely different than "prepping" a patient, proactively, with the notion that cognitive "gifts" will soon descend upon him, as a result of a bout of major depression.

There may, nevertheless, be opportunities to help a patient explore possible "insights" gained in the course of depression, if he or she seems interested in doing so. Moreover, after a patient has recovered from a bout of severe depression, it may be appropriate to "process" the experience in terms of what might have been learned from it.

Again: I think we need much more research on this whole issue, and I hope some day to get some going! Thanks for listening, and take care.

Best regards,
Ron Pies MD

By Ronald Pies MD (not verified) on 10 Mar 2010 #permalink

I think most of the criticism of the ART view both online and offline (including my own here) isn't focused so much on whether rumination might sometimes help you solve problems, but on whether that's a viable explanation for depression as an adaptation. Few people would argue that depression never provides any useful insights; but that's not really the critical issue. The critical issue is whether it's plausible to think that depression remains prevalent in the human population because it promotes rumination and hence problem-solving, and that's a much harder line to swallow.

For one thing, as I pointed out in my post, most of the things depressive people tend to ruminate over are things that other people don't worry about in the first place. In that sense, saying that depression is adaptive because it helps you solve problems is a bit like saying that cigarettes are adaptive because they "solve the problem" of nicotine craving. It's no good just to show that some proportion of people suffering from depression experience some rumination-induced insight that leads to a transition to a more positive state (and of course, one could question how far we should trust people's introspective evaluations anyway); one has to show that those people are actually better off than comparable people without a depressive disposition would have been. That's the part that seems difficult (for me at least) to believe. It's not that the idea that depression might be adaptive (under some circumstances) is implausible; it's just that there are many other plausible explanations for that adaptation, most of which seem to have much more going for them than ART (not least the fact that ART can't explain animal models of depression, because animals generally don't ruminate).

...the glamorizing of mental illnesses is always an appealing pop notion and especially now that we are learning so much about the brain so fast....if only...a couple of points and a few references....lehrer is a bit 2 pop 4 mi tastes, but he does tell a good story...n he has sellebrity charisma..

- the mentally ill brain's 1st defense, and it works quite well is "I'm not sick, I'm special." maybe, but it is genetically misshaped proteins and misfiring circuits that cause the trouble...
- let me recommend the two Dana Foundation panel lectures on these topics...Kay Jameison Hutchinson has star pwr as well..

finally we'll be learning much mor abt this and other brain disorders pretty soon...grossly simplifying i see it as a "reward deficit disorder"..

Thanks for mentioning my post. You raised valid points about the complexity of some of the issues, such as clinical diagnosis. But after examining the Andrews & Thomson Psych Review article again, it seems like an even bigger crock of sh*t. ART is cavalier about any distinction between sadness and severe depression. In fact, the authors explicitly dismiss voices of reason such as Lewis Wolpert who stated:

"Sadness and low levels of depression are adaptive since they lead the individual to try and make up a loss. By contrast, severe or clinical depression is not adaptive, but can be thought of as sadness having become malignant."

[Thanks to @Verilliance for pointing out the Wolpert article.]

And for a paper claiming that depression is an evolved response, they sure avoided a direct discussion of its effects on reproductive fitness. For that I recommend Is Mental Illness Good For You?

"The trouble with these theories is that natural selection doesn't care whether you are good at poetry or solving problems through prolonged rumination. Natural selection only cares how many children you have â more accurately, how many children you have who survive to breed themselves."

Finally, the idea that obtaining crucial insights from depression depends on "whether you possess at the time the combination of cognitive chops, inclination, and social and/or professional support to generate some insight" already presupposes that the individual benefits from social, financial, and intellectual advantages independent of depression. Unfortunately, the low-income working mother without health insurance can't afford the luxury of weekly therapy sessions.

Dear Mr. Dobbs,
At least one prominent evolutionary biologist is unhappy with the Analytic Rumination Hypothesis. Jerry Coyne, who is the author of the widely admired book Why Evolution is True, has posted some trenchant criticisms on his blog. I believe that they are well worth considering.
William Stewart

By William Stewart (not verified) on 15 Mar 2010 #permalink

Mr. Dobbs,
Thank you for this article. I referenced it in my essay on Sylvia Plath's The Bell Jar . It was interesting