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Relationship Imbalance Instead of Chemical Imbalance

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For the last thirty years ago a story has been built up about depression that it’s caused by a “chemical imbalance”, specifically too little serotonin in the brain. I say “story” because, in fact, there is no scientific evidence to back up this pronouncement. If you don’t believe me, you can read some experts in this area like Marcia Angell, the former editor of The New England Journal of Medicine who has issued some pointed and well-researched critiques of the pharmaceutical industry, especially pertaining to psychiatry. Now a new, large-scale study came out published by the journal Molecular Psychiatry, which conducted a large review of studies surrounding links between serotonin levels and depression and found that, in fact, no link exists.

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We could talk for a long time about how this happened, and the huge profits raked in by both the pharmaceutical industry and prominent figures in academic psychiatry–but we won’t. That’s not what this post is about. Instead, I’d like to let you know some forgotten truths about depression, a perspective that I hope you find empowering. Our view is this: Most depression is interpersonal, not purely personal, and not chemical. In other words, the experience of depression is a response created by our relationship with other people, especially our most intimate relationships.

As a family therapist, I have of course treated many families with a depressed member. When I’m talking about depression here I am referring to moderate depression where the person is still able to function, despite their suffering. Even in cases of severe depression, however, some of the ideas we have about depression as interpersonal still hold true. Often it is thought that there is something “wrong” with the brain of the depressed person that must be fixed. My buddy and co-blogger Dave Keith, a psychiatrist who sees families and rarely prescribes medication, believes that the depressed person is the the healthiest one in the family. In one of our earlier posts he writes, “I believe that the depression we view as individual pathology is actually a response to a real perception of the pathology in others. It is an effort which is recognized as a failure to do something about the pain in the world…” Sometimes “the world” is the family in which the depressed person lives. The depressed person often perceives, correctly and mostly unconsciously, the troubling imbalances, unresolved conflict, a kind of stuck pain in the patterns of relationship in a family or couple.

Have you ever heard the idea, first espoused by Sigmund Freud, of “depression as anger turned inward”? I’m often amazed how this little gem of wisdom has gotten largely forgotten. From my years of clinical experience, I can attest that this is most often true. Scratch a depression and you find (suppressed) anger underneath. A question for a depressed person: “Let’s suppose you had a green light to wring someone’s neck. Who would it be?” I’ve never met a depressed person, who, with a little coaxing and reassurance, couldn’t name someone. And that “someone” is usually a person central to their lives.

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Suppressed anger leads to despair which leads to feelings of powerlessness=depression. When I say “suppressed anger” I don’t mean just not expressing anger toward a significant other. Many times I’ve met depressed people, mostly women, who didn’t even let themselves know that they were angry. Somehow they didn’t feel entitled to be angry, or felt guilty about any anger that surfaced. Equally important, they had a partner who didn’t want to hear their anger, or their needs. The woman can’t use her voice. The range of expression in the relationship is blocked.

One of my favorite questions to a woman (or man) in a conflict-avoidant relationship is, “When did you stop trying to change your husband?” They almost always say, “I don’t want to change him!” To which I respond, “Of course you do! You should. He needs to change.” An alive dynamic in a couple involves partners changing each other, getting the partner to stretch outside his or her comfort zone. We don’t try to change our partner’s character, but we do, at times, need to change what our partner does with us. That’s what dynamism looks like in a partnership. When a woman (or man) feels a prohibition against expressing needs, demands, or anger, that’s a recipe for feelings to go underground. That’s a breeding ground for depression.

These are just a few ideas of ways to think about depression other than as a “chemical imbalance”. More ideas to follow. Feel free to send questions on anything you’d like me to address.

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