Dr Pies is Professor Emeritus of Psychiatry and Lecturer on Bioethics and Humanities, SUNY Upstate Medical University; Clinical Professor of Psychiatry, Tufts University School of Medicine; and Editor in Chief Emeritus of 

 (2007-2010). Dr Pies is the author of several books. A collection of his works can be found on

Ronald W. Pies, MD

“Let me be very clear: The scenes of chaos at the Capitol do not reflect the true America. This is not who we are.” —

Psychiatrists need no lecture on the concept of “denial.” After all, it was Anna Freud who first identified and explained this well-known defense mechanism, over 70 years ago.

 In brief, as Dr Rui Miguel Costa put it in a recent paper,

“By denial, individuals cope with stressors by not acknowledging their reality and/or their consequences. This can range from common resistance to accept consequences of certain events to psychotic denial, in which even denial of physical aspects of immediate surroundings can happen. In a broader sense, denial may include negation, constructing fantasies to replace the stressor, minimizing the stressor, and maximizing what could make one dismiss the stressor . . .”

The days and weeks leading up to the egregious mob takeover of the U.S. Capitol building suggest that denial was very much in evidence, among multiple persons and agencies. In retrospect, it seems clear that authorities at several levels of government either ignored or denied the reality of the nightmare that was about to unfold. Thus, Alex Newhouse—an expert on far-right extremism—

“The attack on the U.S. Capitol building on January 6 was shocking, but no one following right-wing activity on social media should have been surprised. The attempt by President Donald Trump’s far-right supporters to violently stop Congress from certifying the Electoral College vote and formalizing Joe Biden’s election victory was consistent with their openly expressed hopes and plans . . . By surveying social media data from mid-December to Jan. 5, I discovered thousands of posts referring to the planned protests as if they were a coming revolution. In some circles, the event became synonymous with a final battle . . . when ordinary Americans would take back the government.”

The days and weeks leading up to the egregious mob takeover of the U.S. Capitol building suggest that denial was in play-- and the culminating event was perhaps only a prelude to what may lie ahead. Can Americans work together to restore domestic tranquility?

In the aftermath of the Capitol riot, it was left to novelist Francine Prose to express 

“Perhaps the most powerful shocks, the most painful surprises, are the ones that we saw coming yet refused to believe would happen. Our ability to fear something and, at the same time, assume it will never occur is one aspect of human nature that seems particularly ill-suited to our continued wellbeing and survival . . .”

Denying the American Legacy of Seditious Violence

President-elect Biden’s speech to the nation on January 6 was, in my view, heartfelt and moving. I am among those who would dearly like to believe that the unspeakable actions of the Capitol building mob “. . . 

do not reflect the true America. This is not who we are.”

 And yet,with all due respect to Mr. Biden, I believe our history as a nation suggests that the violent takeover of the Capitol building does indeedreflect 

 of “who we are” as a nation. To claim otherwise, even with noble intentions, is to engage in some degree of denial.

As Professor of History Shannon M. Smith recently wrote, the violent takeover of the Capitol is part of “. . . a long history in the U.S. of local, state and national political leaders encouraging white supremacist groups to challenge or overthrow democratic governments . . . [and] today, white supremacists appear to interpret politicians’ remarks as support for their cause of a 

 to create a white-dominated government.”

To cite but 1 example of the “long history,” there was the coup and riot staged in Wilmington, NC, in 1898. As Brent Staples explains:

“The uprising was engineered by white supremacists who unseated a government that had been elected by an alliance that included black citizens and white progressives. Scores of black citizens were killed during the uprising . . . and prominent blacks and whites were banished from the city under threat of death. White supremacists eventually hijacked the state government, stripped black citizens of the right to vote and brought black political participation to a close.”

In short, scenes of men with Confederate flags parading through the defiled Capitol building last week—though unprecedented—should not be seen as merely an aberration in our history. But is this sort of event really representative of “who we are,” to use Mr. Biden’s phrase? The answer is complex. In my view, the tensions and animosities that led to the American Civil War have never been fully resolved and continue to surface to this day. Journalist Edward Ball, author of 

“We cannot come to terms with the Civil War because it presents us with an unacceptable kind of self-knowledge. We think, as Americans, that we possess a heroic past, and we like to think of our history as one of progress and the spread of freedom, even transcendence. But the Civil War tells us that we possess a tragic history instead, over which we must continually paste a mask of hope.”

Indeed, we might redefine “denial” in the terms Ball uses: the defense mechanism whereby we bury “an unacceptable kind of self-knowledge.” In this broader sense, denial grades into its kindred defense mechanism, 

And yet, “who we are”—as a country and a people—is not fixed in the stars or written in stone. If the American experience has taught us anything, it is that we can address and correct our past mistakes; otherwise, there would be no 13th Amendment or Civil Rights Act. The process of change is often slow and painful--and, as the unconscionable attack on the Capitol has demonstrated, sometimes violent. Yet in the end, I count myself a believer in Martin Luther King’s teaching: “The arc of the moral universe is long, but it bends toward justice.”

 is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of 

Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style. 

The views expressed in this article are those of the author and do not necessarily reflect the opinions of

1. WATCH: President-elect Joe Biden delivers remarks on situation in DC. WSLS 10. Accessed January 12, 2020. 

https://www.wsls.com/news/politics/2021/01/06/watch-live-president-elect-joe-biden-speaks-on-economy/

. New York: International Universities Press; 1946.

3. Costa RM. Denial (Defense Mechanism). In: Zeigler-Hill V, Shackelford T, eds. 

Encyclopedia of Personality and Individual Differences.

 Cham, Switzerland: Springer; 2017. https://doi.org/10.1007/978-3-319-28099-8_1373-1

4. Newhouse A. Far-right activists on social media telegraphed violence weeks in advance of the attack on the US Capitol. 

 January 8, 2021. Accessed January 12, 2020. 

https://theconversation.com/far-right-activists-on-social-media-telegraphed-violence-weeks-in-advance-of-the-attack-on-the-us-capitol-152861

5. Prose F. Anyone shocked by the US Capitol attack has ignored an awful lot of warning signs. 

https://www.theguardian.com/commentisfree/2021/jan/11/us-capitol-attack-warning-signs-charlottesville-michigan

6. Smith SM. US Capitol protesters, egged on by Trump, are part of a long history of white supremacists hearing politicians’ words as encouragement. 

 January 7, 2021.Accessed January 12, 2021. 

https://theconversation.com/us-capitol-protesters-egged-on-by-trump-are-part-of-a-long-history-of-white-supremacists-hearing-politicians-words-as-encouragement-152867

7. Staples B. When Democracy Died in Wilmington, NC. 

 January 8, 2006. Accessed January 12, 2021. 

https://www.nytimes.com/2006/01/08/opinion/when-democracy-died-in-wilmington-nc.html

8 Ball E. An American Tragedy. The Opinionator. 

 April 11, 2011. Accessed January 12, 2021. 

https://opinionator.blogs.nytimes.com/2011/04/11/an-american-tragedy/

9. Dr Martin Luther King Jr. “Remaining Awake Through a Great Revolution.” Speech given at the National Cathedral, March 31, 1968.

Articles

What role does denial play in the collective American psyche?

Denial, The Capitol Takeover, and a Tragic American Legacy

 with Awais Aftab, MD, I have received a good deal of feedback on my positions, both pro and con. Upon further reflection, I would like to clarify my position regarding the following comments I made in the interview:

And, yes—we often hear anecdotes concerning patients who tell their current clinician some version of, ‘My psychiatrist said I have a chemical imbalance . . .’ But where is the evidence that this is what patients were actually told? Who has contacted the patient’s psychiatrist, or reviewed his/her case notes, to see if that was really what the patient was told? To my knowledge, there has never been a study examining the other side of the story—and, to be clear: patients are not infallible recorders of what their doctors tell them.

I regret that I did not state my point more clearly. In particular, I inadvertently implied that the psychiatrist’s recollections or case notes are, in some sense, always dispositive regarding what patients were actually or really told, as if psychiatrists were infallible recorders of what was said in a session. This was not my intention, nor is it my belief. Just as patients may sometimes misperceive or misunderstand a point or statement made by the psychiatrist, so, too, psychiatrists may err in what they recall or in what they write in their notes. And, yes: some clinicians may consciously or unconsciously misstate what they told the patient, for various reasons. (I have had personal experience with my own physicians writing comments in their session notes that did not correspond to what I recalled from the meeting!)

My point in the interview was that any valid claim or report regarding what patients have been told about so-called “chemical imbalances” must take into account not only the patient’s recollection, but also: what psychiatrists themselves recall saying; what they intended to convey; and in what context the term 

For example, did the psychiatrist say something like, “Your illness is definitely caused by a chemical imbalance”? Or was it more like, “We don’t know the precise causes of depression, but chemical changes in the brain may play some role, along with psychological, social, and environmental factors”? There is nothing fundamentally wrong or misleading, of course, with the second type of explanation.

In addition, the therapeutic alliance is built on trust. Accordingly, our patients’ reports should always be considered prima facie credible, absent extraordinarily compelling evidence to the contrary (eg, obvious delusions, documented malingering, and so on). But credible—ie, worthy of belief or confidence—does not necessarily mean factually correct in all aspects and details. The same may be said, of course, of claims made by clinicians. 

To put these matters in a broader context: a recent study evaluated the prevalence of etiological beliefs about depression in a sample of acutely distressed psychiatric patients in an intensive hospital treatment program. The study found that the most commonly endorsed explanation for depression was not one invoking the chemical imbalance notion; rather, psychosocial explanations of depression were the most commonly endorsed etiology, with the chemical imbalance belief coming in second. The authors noted that popular beliefs about what causes depression “may be adopted from a variety of external sources, including television advertisements, anti-stigma campaigns promoting biogenetic explanations, and 

Beliefs may also evolve from patients’ individual experience with treatment; for example, “participants who cannot explain the cause of their depression or pinpoint a triggering event may eventually attribute their depression to hidden, unknown biological mechanisms. Or if psychological therapies had failed in the past, participants may come to believe depression must be due to biological causes.”

All of this is simply to note that popularization of the chemical imbalance canard is almost certainly an over-determined effect, in which the role of psychiatrists (or other clinicians) is but 1 possible causal factor.

I believe that in the near decade since I described the chemical imbalance notion as 

 psychiatry has matured and deepened in its mode of explanation to patients—though research on that point is sorely needed. For now, the best explanation we have is that clinically significant depression is the outcome of biological, psychosocial, environmental, and even 

 The relative contribution of any single component almost certainly varies from patient to patient, and case to case. I believe that well-informed psychiatrists have known and embraced that holistic view for decades. The remaining challenge lies in communicating it clearly and consistently to our patients—and on that score, we can all do better.

I am aware that the American Psychiatric Association once had a statement posted on their public education website that referred to "imbalances in brain chemistry." I am happy to report that, in response to my conferring with the APA, the old statement has been 

"While the precise mechanism of action of psychiatric medications is not fully understood, they may beneficially modulate chemical signaling and communication within the brain, which may reduce some symptoms of psychiatric disorders

is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of

Thanks to Awais Aftab, MD, for his collegial and trenchant interview and to Joe Pierre, MD, for referring me to the Schroder et al1 study.

1. Schroder HS, Duda JM, Christensen K, et al. Stressors and chemical imbalances: Beliefs about the causes of depression in an acute psychiatric treatment sample. 

2. Pies R. Psychiatry’s new brain-mind and the legend of the “chemical imbalance.” 

. July 11, 2011. Accessed January 5, 2021.

https://www.psychiatrictimes.com/view/psychiatrys-new-brain-mind-and-legend-chemical-imbalance

3. Pies R. Psychiatry and the dark night of the soul. 

TM. Dec. 14, 2020. Accessed January 5, 2021. 

https://www.psychiatrictimes.com/view/psychiatry-dark-night-soul

Is there a way to find balance in discussing the chemical imbalance theory of depression?

What We Tell Patients about Depression, and What They Say They Have Been Told

“There are many ways not to be happy that do not equal depression.”—

Christian Robbins was 16 when he took his life during the first month of the pandemic. According to 

 and the boy’s father, Christian had suffered a number of pandemic-related losses, including closure of his school; cancellation of a family vacation; and isolation from his friends. Quite understandably, his grieving father has been haunted by the question, “What if the pandemic never happened? Would my son still be alive?”

Of course, it is impossible to know. The Centers for Disease Control reported that between June 24, 2020 and June 30, 2020, about 1 in 4 young adults (aged 18 to 24 years) had seriously considered suicide in the 30 days before completing 

 But attributing a completed suicide primarily to the pandemic is probably a considerable over-simplification. For example, in the case of Christian Robbins, 

 report notes that the young man “had been struggling for months with depression and early symptoms of bipolar disorder.” Moreover, Christian had told his father of “a voice inside [that] was whispering how worthless he was, how he was hated by everyone.”

It is tempting to hypothesize that Christian’s suicide was largely a result of a (bipolar) major depressive episode, possibly complicated by psychotic features. The pandemic and its attendant losses seem likely to have been the immediate precipitants. But 

 suggests other possibilities, and compels us to consider mental and emotional states that are not discussed at all in the DSM-5, to my knowledge, and may confer a high risk of suicide even when the individual does not meet full DSM criteria for a major depressive episode.

Moreover, there are good reasons, at times, to shift our perspective from the strictly clinical to the quintessentially spiritual; specifically, to what some mystics and theologians have called “the dark night of the soul.” First, though, we need to examine 2 closely related concepts that are not part of the DSM’s nosology.

Demoralization is succinctly described in 

Demoralization is a syndrome clinically separated from depression. It is characterized by a combination of distress and subjective incompetence; the loss of meaning and purpose in life; the lack of perceived social support; a sense of being trapped and personal failure; a cognitive attitude of pessimism, and hopelessness/helplessness. Moreover, this psychological state has a significant role in negatively influencing a patient’s quality of life, coping styles, and dignity. It is associated with [suicidal] ideation; a higher wish for hastened death; and a worsening of the prognosis in patients affected by medical illness.

A more existential description of demoralization is provided by psychologist 

: demoralization is “an overarching psycho-spiritual crisis in which victims feel generally disoriented and unable to locate meaning, purpose, or sources of need fulfilment.”

Note that both descriptions involve a loss of meaning and purpose in life. We can easily envision many people suffering emotionally during the current pandemic who may not meet DSM-5 criteria for a major depressive disorder, but who would fit these descriptions of demoralization—and who might well become suicidal because of that mental and emotional state.

 psychiatrist Kenneth Gilbert, MD, described a trait he has observed in many individuals with substance use disorders who wind up fatally overdosing on opioids. He opined that these individuals do not seem to “feel that their own lives are worth protecting” or that “their own lives are worth living.” Gilbert further described such fatal outcomes as deaths of despair and wondered whether “without a sense of meaning or engagement, [these individuals] might have no reason to protect their own lives.”

Despair is understood broadly as “an entire want of hope.”

 I believe Gilbert is correct in conceptualizing this as an existential problem—with important implications for psychiatry. Indeed, 

, and colleagues has linked despair with higher rates of substance misuse and suicidality in young adults.

 Using data from structured interviews, Copeland et al derived 7 indicators of despair: feelings of hopelessness, helplessness, feeling unloved or worthless, experiencing worry, self-pity, and loneliness.

Importantly, whereas many participants with depression also reported despair, most individuals reporting despair did not meet formal criteria for a depressive disorder.

 The import of the Copeland et al study is simply this: we must look beyond the DSM categories of depression if we are to recognize young people (and probably others) who are truly suffering and at risk for substance abuse and suicide.

The phrase, “dark night of the soul” is often used informally to describe an extremely difficult and painful period in one’s life, for example, after the death of a loved one; the break-up of a marriage; or the diagnosis of a life-threatening illness. For many, the loneliness, isolation and fear associated with the coronavirus disease 2019 pandemic is, indeed, a dark night of the soul. There is nothing wrong with these informal usages, and they have obvious links to the concepts of demoralization and despair, as we have defined them. But they differ significantly from the original meaning and context of the phrase, as first conceived by the Spanish mystic, John of the Cross (1541-1597 AD).

John was a member of the Carmelite religious order, which he was trying to reform. The thanks he got was imprisonment by his Carmelite brethren, during which John composed his remarkable poem, “

 (The Canadian singer, Loreena McKennitt, has set the poem quite 

On a dark night,
Kindled in love with yearnings–oh, happy chance!–
I went forth without being observed,
My house being now at rest.

John’s poem is essentially a spiritual odyssey. It recounts “

the journey of the soul from its bodily home to its union with God

 This mystical concept may seem too esoteric to have relevance in clinical psychiatry; but as we will see, the dark night may be understood more existentially, in ways that have considerable relevance to our profession.

, the psychotherapist and former Catholic monk, Thomas Moore, makes an important observation. He writes, “The dark night calls for a spiritual response, not only a therapeutic one.” The dark night calls upon the affected person “to remain in the present, not bound or deluded by the past and not imprisoned in a fixed and defensive idea about the future…the most difficult challenge is to let the process take place, and yet that is the only release from the pressure of the dark night.”

Sadly, not everyone will survive the dark night of the soul. Some of those Moore mentions, like the poet Anne Sexton, will die by their own hand. Those who do survive have come to realize, as Moore puts it, that “life is never as bright and successful and meaningful as you might imagine”.

 And yet, these survivors have found—or rather, created—new meaning in their lives.

Moore cites as an example the pianist Leon Fleischer, who died recently at the age of 92. At the age of 36, Fleischer suffered a mysterious neurological affliction that essentially crippled his right hand and nearly ended his career. None of the treatments he received helped, and Fleischer fell into a 2-year period of despair, to the point of considering suicide. But then, an epiphany: 

, “I suddenly came to the realization that my connection with music was greater than just as a two-handed piano player.”

 Fleischer essentially re-invented himself, becoming a teacher, a conductor, and a performer of the left-handed repertoire for piano. As Moore puts it, “it was the expansion of his musical vision that saved him.”

The Midwife and the Dark Night of the Soul

As therapists, we need, in the first place, to appreciate and recognize the dark night of the soul as it afflicts and transforms our patients. We also need to recognize and assess the degree of demoralization and despair our patients may be experiencing, as these have implications for substance abuse and suicidality.

At the same time, we need to distinguish the dark night of the soul from various states of disease and disorder, such as major depressive disorder—which, in some unfortunate cases, may be the outcome of an unsuccessful spiritual journey. The dark night itself is not a disease, but part of the price we pay for being vulnerable human beings.

We need not be observantly religious to help our patients through their dark night, nor need we enter into the mystical world of John of the Cross. Rather, we can act as midwives to our patients’ inner transformation—supporting and encouraging them as they struggle to give birth, often painfully, to new meaning in their lives. As philosopher Peter Wilberg has put it, this kind of healing: “is no longer identified with mental, emotional or bodily ‘recovery’ but rather, with self–discovery – the birth of a newly felt bodily sense of self…[and] the metaphor of 

 comes from the Greek word “maieutikos,” meaning “of midwifery.” In one of Plato’s “Dialogues” (the 

), Socrates—the son of a midwife—applies the term 

 to his method of bringing forth new ideas by reasoning and dialogue. He thought the technique “

analogous to those a midwife uses in delivering a baby

 The maieutic concept of care does not require us to set aside our medical training or biological knowledge, which are essential parts of our identity as psychiatric physicians. Rather, the metaphor of the midwife enlarges our understanding of medical healing to include our ministering to the soul—especially during its darkest night.

 Share comments with your colleagues by emailing 

. Comments may be shared online pending review and editing for style.

2. Wan W. For months, he helped his son keep suicidal thoughts at bay. Then came the pandemic. 

. November 23, 2020. Accessed December 2, 2020.

https://www.washingtonpost.com/health/2020/11/23/covid-pandemic-rise-suicides/

3. Czeisler MÉ, Lane RI, Petrosky E, et al. Mental health, substance use, and suicidal ideation during the COVID-19 pandemic — United States, June 24–30, 2020. 

4. Bower B. ‘Deaths of despair’ are rising. It’s time to define despair. 

 November 2, 2020. Accessed December 2, 2020. 

https://www.sciencenews.org/article/deaths-of-despair-depression-mental-health-covid-19-pandemic

5. Battaglia Y, Zerbinati L, Piazza G, et al. The use of demoralization scale in Italian kidney transplant recipients. 

 April 1, 2016. Accessed December 2, 2020. 

https://newint.org/columns/essays/2016/04/01/psycho-spiritual-crisis

 Nov. 24, 2020. Accessed December 2, 2020. 

https://www.psychiatrictimes.com/view/dying-dream

9. Copeland WE, Gaydosh L, Hill SN, et al. Associations of despair with suicidality and substance misuse among young adults. 

10. St. John of the Cross. The Dark Night. 

The Collected Works of St. Jon of the Cross

. Trans. Kieran Kavanagh and Otilio Rodriguez. ICS Publications; Revised edition, 1991.

11. Loreena McKennitt. The dark night of the soul. Accessed December 2, 2020. 

https://www.youtube.com/watch?v=MclLF473XtA

12. The Dark Night of the Soul. Accessed December 2, 2020. https://makeheaven.com/st-john-of-the-cross.html

13. Huizenga T. Leon Fleisher, the pianist who reinvented himself, dies At 92. 

https://www.npr.org/sections/deceptivecadence/2020/08/02/702978476/leon-fleisher-the-pianist-who-reinvented-himself-dies-at-92

Phenomenological Medicine and Organismic Therapy

https://existentialmedicine.wordpress.com/phenomenological-medicine-and-organismic-therapy/

15. Maieutic. Merriam-Webster Dictionary. Accessed December 2, 2020. 

https://www.merriam-webster.com/dictionary/maieutic

Pies RW: Care of the soul in the time of Covid-19. 

. March 23, 2020. Accessed December 2, 2020. 

https://www.psychiatrictimes.com/view/care-soul-time-covid-19

Pies RW. Is the country experiencing a mental health pandemic? 

 Oct. 13, 2020. Accessed December 2, 2020.

https://www.psychiatrictimes.com/view/are-we-really-witnessing-mental-health-pandemic

The anatomy of unhappiness is more complex than DSM-5’s categories.

Psychiatry and the Dark Night of the Soul

The lexicographer Samuel Johnson is credited (perhaps spuriously) with this acerbic review of a manuscript: “Your manuscript is both good and original; but the part that is good is not original, and the part that is original is not good.”

Although that may be too harsh an assessment of the recent report by the British Psychological Society (BPS) “

 the report misses many opportunities for enhancing our understanding of clinically significant depression.

This article represents my assessment of the BPS report (verdict 1) followed by selected comments by a freelance journalist (verdict 2). The blogger, Lucy Dimbylow, has permitted me to quote 

 to the BPS report. Her remarks have particular import and gravitas, owing to Dimbylow’s history of “recurrent episodes of paralyzing depression.”

Verdict 1: The Good, the Bad, and the Insensitive

The BPS report—prepared by a group of mostly academic clinician-researchers—is intended as “an up-to-date summary of what the research says” about depression, aimed at “everyone who has an interest in depression—those of us who experience it, our friends and family, and those of us who provide services to help.” To the report’s credit, it covers a broad range of factors that may contribute to clinically significant depression, ranging from the biological to the sociocultural. Indeed, the foreword to the report, written by Paul Gilbert, PhD, explicitly invokes the biopsychosocial approach embraced by academic psychiatry. But it is precisely in this respect that the BPS report largely fails. In effect, it gives appropriate attention to psychosocial and cultural factors in depression, but mostly neglects and largely devalues the biological factors that underlie severe depressive illness. As for somatic treatments, including antidepressants, the report’s tone and posture might be characterized as disgruntled acquiescence.

The report immediately sets off alarm bells with its central argument “that depression is best thought of as an experience, or a set of experiences, rather than as a disease.” Later, the BPS editors double down: “The most important message of this report is that depression is not a disease but a human experience: a complex, understandable set of psychological responses to the events and circumstances of our lives.”

The illogic of these claims is breathtaking. They imply that the terms 

 are somehow disjunctive or mutually exclusive. But it is trivially obvious that all diseases also constitute experiences and that some experiences are constituted by the presence of disease. Furthermore, everything that happens to us in life is an experience. Applying that term to depression clarifies nothing. (The BPS might have been on firmer ground had they argued that clinically severe depression is a profoundly life-altering set of experiences). More importantly, reducing clinical depression to a set of experiences is a bit like describing the coronavirus 2019 (COVID-19) pandemic as a set of viral events. This same trivializing tendency was evident in the 

For many who have suffered with the most severe and recurrent forms of depression—strikingly, relapse and recurrence are barely mentioned in the report—the BPS formulation will likely feel like the height of insensitivity. More on that from Dimbylow.

The editors/authors of the BPS report next seek to undermine the biological basis of clinical depression by asserting: “For many people, depression is unlikely to be the result of an underlying biological disease process or chemical imbalance in the brain and nervous system. Even if there are changes in the brain when people are depressed, these are often consequences not primary causes

Let us leave aside the matter of how the BPS editors established that depression is unlikely to be the result of biological factors. Their main conceptual error is in supposing that changes in the brain of individuals with depression do not tell us very much, because we do not know if they are primary causes, or merely consequences of having depression. (Ironically, the pioneers of the biogenic amine hypothesis acknowledged the problem of 

) On the contrary: whether they are causes or consequences, once the brain develops abnormalities in clinical depression (or major depression), these brain changes take on a pathogenic life of their own. Indeed, they are associated with a variety of cognitive and executive functioning problems that cause serious adverse effects in the life of the individual with depression.

Thus, in major depression, “Recurrent impairments in several domains including, but not limited to, executive function, learning and memory, processing speed, and attention and concentration, are associated with poor psychosocial and occupational outcomes.”

 Furthermore, structural alterations in some brain regions of patients with depression—in particular, the anterior cingulate cortex—may be associated with 

both affective and cognitive impairments in major depression

Although the evidence is limited and preliminary, it appears that antidepressant treatment can ameliorate some of these cognitive problems. For example, 

 involving elderly patients with recurrent major depressive disorder found that 8-week treatment with duloxetine resulted in a significant improvement in composite measures of cognition, compared to placebo.

 Not surprisingly, the BPS report barely discusses the benefits of antidepressant treatment—

—but spills a great deal of ink discussing its potential risks and side effects.

Nothing I have said is meant to diminish the importance of psychosocial, cultural, and environmental factors in the genesis of clinical depression; nor do I doubt the need for a holistic approach to depression. But the question must be asked: what makes it so difficult for the BPS to acknowledge the importance of biological factors in major depression? And more important: why does the BPS refuse to acknowledge that clinically significant depression—while quite obviously an experience—also represents 

 To the BPS report’s credit, it does contain a number of balloon quotes from individuals who have actually suffered from clinical depression, and some such accounts help convey depression’s “disorder-ness.” An individual shared:

When I have low mood, it can last as long as between a couple of weeks to 2 years, with 6 months average. I feel desperate, ‘Emotional Death.’ I am frightened of the future, I fear life and welcome death. I have attempted suicide several times since I have no hope and fear the future, since I don’t think I will ever get better.

Personal accounts of this nature help rescue the BPS report—just barely—from anodyne inconsequence, and lead us to 

Verdict 2: Gaslighting on an extreme level

 expresses the profoundly disruptive and incapacitating nature of severe, recurrent depressive illness, including the risk of serious self-injury and suicide. This is in marked contrast to the tone of casual understatement in the BPS report, in the single paragraph devoted to self-harm: “…in addition to receiving good physical care for their injuries, people who self-harm should be offered an assessment of their psychological and social needs.” She writes:

My life, almost since I can remember, has been plagued by recurrent episodes of paralyzing depression. I’ve tried to end my life more times than I can remember, and my body is covered in scars. I’ve been in ambulances, in intensive care, and sectioned in a psych hospital. I’ve been a missing person with the local police force searching for me.

But according to the British Psychological Society (BPS), I’m not ill: I have what they describe in their new report, 

‘Common human experiences’ have no relation whatsoever to the severe, enduring clinical depression that leaves me bleeding on the bathroom floor or semi-conscious in the back of an ambulance.

According to the BPS, though, clinical depression isn’t even an illness.

[Then] how do they explain the fact that medication (usually) keeps me stable, or that trying to come off my anti-psychotic led to the best part of 2 months in a psych unit? How do they explain the way my mood can crash from totally fine to abject, suicidal despair with no external trigger?

Although there are often psychosocial stressors and losses that help explain clinical depression, Dimbylow is quite right in noting that severe depression can occur with no evident external trigger. Characteristically, the BPS subtly devalues this fact, arguing that, “Sometimes it can seem that depression comes out of the blue. It can feel as if there is no explanation for depression but that it has just happened.” Furthermore, while placing heavy emphasis on the risks of medication, the BPS report says essentially nothing about the risks of discontinuing medication—a point made very forcefully by Dimbylow.

It’s gaslighting on an extreme level, and what makes it desperately sad is that it comes from an authority that should be firmly on the side of those of us who live with mental health conditions like major clinical depression.

Right now, I’m glad that I’m in a strong mental state, and not standing on that bridge waiting to jump. Because had I read the report while in a severe depressive crisis, it would have pushed me—literally—over the edge.

After reading the BPS report, an ancient proverb came to mind: “There are none so blind as those who will not see.” It is especially galling when those who refuse to see are entrusted with the care of desperately sick and suffering individuals. It is one thing to hear this from a psychiatrist. It is quite another, and perhaps more powerful, thing, to hear it from Lucy Dimbylow.

 Thanks to Joseph Pierre, MD, for bringing the BPS report and Dimbylow’s blog to my attention, and for comments on the BPS report.

1. Your manuscript is good and original, but what is original is not good; what is good is not original. Quote Investigator. Updated June 17, 2013. Accessed November 9, 2020: 

https://quoteinvestigator.com/2013/06/17/good-original/

2. The British Psychological Society. Understanding depression: why adults experience depression and what can help. October 9, 2020. Accessed October 30, 2020.

https://www.bps.org.uk/news-and-policy/new-report-explains-why-so-many-us-are-depressed-and-how-we-can-build-less

3. Pies R. Trivializing the suffering of psychosis. 

.December 22, 2014.December 22, 2014. Accessed October 30, 2020.

4. Schildkraut JJ. The catecholamine hypothesis of affective disorders: a review of supporting evidence. 

5. Zuckerman H, Pan Z, Park C, et al. Recognition and treatment of cognitive dysfunction in major depressive disorder. 

A controversial report from the British Psychological Society draws a pair of sharp rejoinders. 

Ronald W. Pies, MD

Articles

Denial, The Capitol Takeover, and a Tragic American Legacy

What We Tell Patients about Depression, and What They Say They Have Been Told

Psychiatry and the Dark Night of the Soul

Is Depression a Disease?

What Kind of Science Is Psychiatry?

Screening Instruments Do Work for Bipolar Disorder, But Not by Themselves

How Avicenna Recognized Melancholia and Mixed States—1000 Years Before Modern Psychiatry

The Upside and Downside of Religion, Spirituality, and Health

Masks, Machismo, and the American Man-Child

Culture Wars, COVID-19, and Countertransference: What America’s Cultural Rifts Might Mean for Psychiatry