THE MEANING OF DEPRESSION AND TREATMENT

We are used to taking it for granted that it is normal to feel sad, discouraged, grief-stricken, even desperate at times. Some people seem more removed from these feelings, but others are often prey to them. Life is difficult: disappointments, betrayals, defeats, illness, and grief are part of everyone's existence, some more, some less. But is this observation, so obvious, enough to explain all the pain that can afflict a human being? Why can this pain become so deep and persistent that nothing can alleviate it? Where does the midday devil come from, the one who attacks some people and drains them of their will to live? And why do others wake up at the same time, at 3 a.m., the hour of the wolf, drenched in sweat and filled with dark thoughts?

Depression is a mystery from its very name. The ancients called it melancholia (i.e. "black bile", a gloomy mood due to a malfunction of the viscera) or acedia, literally "indifference, disinterest" (in which case they considered it a vice, a moral affection). The term "depression," which literally means "crushed, dejected," was not used in medical circles until the 19th century. What are these different terms referring to?

The answer is not easy: a loss of the will to live, a deep sadness, a feeling of emptiness, and above all, an overwhelming psychological pain. But the pain of depression, even if we call it the pain of an injury, a physical trauma, or a toothache, seems to be of a different nature. In fact, it is not clear that depression is always pain. On the one hand, depression can cause excruciating pain similar to that caused by bereavement or serious loss; on the other hand, tedium vitae, the loss of all joy and interest in life, is also a form of depression. Thus, sometimes depression appears as a positive state of suffering; at other times it appears as a purely negative situation of total lack of pleasure. But can there be an absence of pleasure without it being immediately pain (cf. Phaedo, 60B)?

In the first of this series of articles, I emphasized the very close relationship between anxiety and depression. In addition to clinical observations, I relied on the statement of one of Freud's earliest students, Karl Abraham, who wrote in 1912: "Anxiety and depression are related in the same way as fear and pain. In the second article, I described the characteristics and origins of anxiety and fear. Now it is time to explain how I believe depression arises and how it relates to fear. I repeat a warning I made earlier: not a single concept in the following lines is original. For almost all of my statements, I would have had to cite the list of authors who inspired them, but this already long post would have turned into an interminable academic article, which I did not want. Of my own, there are only two things: the fact that everything I have written has been verified by decades of clinical practice, and the unifying idea that has guided me.

So let us start at the beginning: pain is what causes fear. One is always afraid of pain, both physical and psychological. Aristotle wrote: "[Fear is] suffering from an imminent and inescapable evil. What is a greater evil for a human being than pain? Is it not pain that we fear in the face of the evils that frighten us most, such as death, illness, the loss of loved ones? All these conditions instill fear in us because we think of them as causes of pain, regardless of whether they really are. Kirillov explains this very effectively in The Demons, when he asks his interlocutor to imagine "a stone the size of a large house; it is suspended and you are under it: if it falls on your head, does it hurt? The interlocutor replies that he would be destroyed by terror, but is then forced to admit that if the stone really fell, he would not even have time to notice it. He then concludes, Kirillov: "But (...) as it hangs, you will be very afraid that it will hurt you. The first of the scientists, the first of the doctors, everyone will be very afraid. Everyone will know that it does not hurt, but everyone will be afraid that it will hurt" (Fyodor Michailovich Dostoevsky - The Demons, Part 1, Ch. Three, VIII).

Psychological pain has two components: the suffering caused by the anticipation of a perceived imminent and inescapable evil, and the suffering of despair. These two states are not distinct, but form a continuum that includes all possible situations in between. The suffering of expectation, which we call anxiety or fear, gives rise to a myriad of attempts to defend against evil. These attempts manifest themselves in the form of psychological and behavioral symptoms, generating the various syndromes of mental illness, more or less severe depending on the limitations and distortions they cause in the life of the sufferer (the article "What is Anxiety?" is partly devoted to this topic).

The suffering of despair, on the other hand, is always the same, albeit in varying degrees of severity: depression. I talked about this in connection with the ???????????????????????????????? theory I mentioned in the first article of this series. What the suffering of despair is, we can understand very well by thinking about a terrible test that, until a few years ago, was used by pharmaceutical companies to evaluate the effectiveness and relative potency of antidepressant drugs. The test - known as Porsolt's or forced swimming or desperate swimming - consisted of placing a mouse in a glass cylinder filled with water from which the small animal could not escape. Initially, the mouse would react by trying to escape itself, struggling to climb the walls of the cylinder. Then it would resign itself to swimming and continue to do so desperately until the moment it gave up and allowed itself to drown. The idea behind this test was that if the mouse had taken an effective antidepressant medication, then its forced swimming time would be prolonged compared to the mouse that had taken a less effective medication or no medication at all. Interestingly, this is exactly what happened, demonstrating that even in a mouse, the time of capitulation is determined not only by physical collapse, but also by exhaustion of the ability to "hold on psychologically" (otherwise the antidepressant medication would not have changed the forced swim time).

Depression, then, is the state of surrender and submission to evil: letting oneself drown like the test mouse. I have said that evil always involves some pain for human beings. In the previous two articles, I argued that psychological pain always has the same cause: loneliness. I did not mean the experience of isolation or even the feeling of being abandoned or unloved. These events can be dramatic, but that is not what I was referring to. The loneliness I was talking about is the loneliness created by one's own aggression. It includes a number of different emotions (e.g., anger, hatred, envy, greed), all of which are characterized by hostile and destructive desires directed at those close to them. These aggressive impulses inevitably create a deep sense of inner loneliness, regardless of the external conditions of life.

Adults tend to delude themselves into thinking that childhood is immune or almost immune to these feelings: the opposite is true. Human beings learn to have hostile impulses very early, perhaps even during intrauterine life, and in any case they show that they possess them from the first months of life. The reason is simple: the child is born open to the world, and therefore extremely vulnerable. From now on, and in the next few lines, I will no longer speak of my own direct experience, but will report the results of other people's research and what I think I can deduce from observations I have made on adult patients. This, of course, is the most controversial part of this article: I do not pretend that anyone will take it as true, I am content that it is considered quite likely.

Various and multiple sources of knowledge (ethological studies of attachment, systematic observation of infants, prenatal ultrasound, etc.) have gradually contradicted the old psychoanalytic theory that the infant was incapable of perceiving the external world as such and that there was an early stage in which the human infant did not distinguish between subject and object. On the contrary, we now know that the infant recognizes its environment (including through processes of neurological and sensory maturation) and distinguishes it as other than itself. This openness to the world, coupled with the infant's physical weakness and need for total care, exposes him or her to frustrations and disappointments. These are almost unavoidable events that are usually unnoticed by adults or, if noticed, seem completely irrelevant. From the infant's point of view, however, these events are likely to be so many small disasters.

Frustrations have their usefulness in teaching the child that the world and others are not always available to his desires and needs; unfortunately, they also teach him to hate: why this happens is much less obvious than we are used to thinking. The fact is, however, that the infant's anger is inevitably directed at those closest to him: family members and caregivers. This anger destroys, if only momentarily, the bonds of love and attachment, creating a sense of exclusion (which is in fact self-exclusion) from which the first feelings of envy are born. At the same time, the child feels that his love has been rejected, and from this feeling he learns greed, that is, the determination to keep his positive feelings for himself and not to give them to anyone else.

Anger, envy, and greed give rise to the most painful experience of loneliness there can be, that of betraying those who care for us, our "benefactors". This is the first tremendous experience of depression that no human being has ever been able to avoid, as a psychoanalyst of the past, Melanie Klein, had already argued (although she arrived at it in a different way than I have). Then, in the vast majority of childhood stories, the warmth of love prevails: attachment to close people is restored and strengthened; life goes on - amid joys and sorrows, loves and resentments - even for the new human being, who will forget these very old experiences, although he will forever keep traces of them in his heart.

Subsequently, each person will develop his or her own peculiar way of dealing with aggressive impulses, which will then be further shaped in the course of life, depending also on a number of personal factors: genetic and biological constitution, experiences of the generations from which he or she comes, the course of postnatal depression, and, in general, the events of his or her childhood (even the Oedipus complex: fear not, fellow psychoanalysts). Some will be better able to control their aggression, others will be dominated by it; some will use it for positive purposes, others will use it to satisfy their own thirst for power; some will be tormented by guilt, others will sadistically enjoy their evilness. The possible adventures of evil are many and varied, almost as many as those of good and as many human beings.

The fact remains that the evil that is most feared, that causes the most pain, is precisely the evil that Dante depicted as a frozen lake and placed in the ninth circle of Hell, at the antipodes of love. The continuum between fear/anxiety and depression to which I alluded is created when a person begins to fear being overwhelmed by his own evil. Mind you, not in those who are "nastier," but in those who feel (for reasons related to the personal factors I mentioned earlier) that the nastiness is about to overwhelm them. At that moment, the fear of the old loneliness returns, the fear of which he, like everyone else, had experienced in his very distant past. It is, however, a pathological fear that contains the seeds of betrayal: it does not save, but on the contrary, it drags down (Mt 14:24-33). Those who feel it have the impression that evil is now an "imminent and inescapable evil" for them. And so, frightened and desperate, he begins to fight with all his strength, like a mouse in a glass cylinder.

The only thing that can save him from the cold of the hellish ice and cure his depression (the cure, according to the insiders) is the warmth of love. We must be clear here, however, because a lot of nonsense runs under the label of "healing through love. The love that heals is certainly not self-love (an expression that has no meaning in this context), nor is it the love of good people by profession (psychiatrists, psychologists, psychoanalysts, and psycho-somethings of all stripes). What heals is never to be loved (least of all by them), but to love. That is why there is always something divine in healing, if it is true healing: because love (whether we are believers or not) remains a transcendent experience, a gift that comes to us from afar. Love is God, or at least a god.

What can be done, with great humility and care, is to learn to recognize and overcome the resistances and defenses that the sick person puts up against love: first of all, the most dangerous ones, those that come in the form of fake loves, simia amoris. There are many ways to do this, including the princely method of classical psychoanalysis (i.e., transference analysis), as well as those drugs that can, at least temporarily, give the anxious and desperate the strength to keep swimming.

However, this is a subject I will discuss in a future article.