What’s in a word? Or, in this case, several words: disease, disorder, illness, condition. These are all used to define depression, along with many other mental health issues. Does it matter?
Yes, says Robert Sapolsky, a professor of neurology at Stanford, former MacArthur Fellow and expert on human behavior: “I think [depression] is absolutely a disease. I believe that it is as much of a biological disorder as is, say, diabetes.”
Michael Yapko, a psychologist, lecturer, author and authority on depression, also says yes — but for the very opposite reason. “There are 227 different symptom combinations that could all correctly yield a diagnosis of depression,” he says. “Telling people depression is an illness misses the mark. It is partially wrong, and people who are depressed don’t feel diseased. They feel crappy. Calling it a disease doesn’t motivate them to go get help, which is why the majority don’t get help.”
Something is clearly wrong when someone has depression. If it’s a disease, why is it so hard to treat medically? But if it’s not a disease, then what is it?
Definitions and Implications
According to the American Psychiatric Association, “Depression (major depressive disorder) is a common and serious medical illness that negatively affects how you feel, the way you think and how you act.” The APA uses both “disorder” and “illness” to describe it.
Let’s take a closer look at these terms, as defined by the Oxford English Dictionary:
— Disorder: An illness that disrupts normal physical or mental functions.
— Illness: A disease or period of sickness affecting the body or mind.
— Disease: A disorder of structure or function in a human, animal, or plant, especially one that produces specific symptoms or that affects a specific location and is not simply a direct result of physical injury.
The terms chase one another in a circle. They all mean approximately the same thing, and each seems to describe depression. Yapko doesn’t argue with that, per se. “The idea of disease, the textbook definition, is of a condition that impairs function and has specific signs and symptoms,” he says. “The problem I have isn’t the textbook definition. It is the implication of that definition.”
Yapko feels that comparing depression to other biological illnesses such as heart disease and diabetes is insufficient. “While there is no question that [depression] has a biological component to it, it is about much more than biology. The disease label doesn’t really speak to that,” he says.
Yapko believes that viewing depression as an illness drives people to look for biological treatments. “It’s why antidepressants are the most common form of treatment in the U.S. today. It leads people to search for biological solutions, whether it is deep brain stimulation or the wonders of ketamine,” he says. “It’s not that those things shouldn’t be part of the arsenal [of treatment], but biological treatment alone is undertreatment. To frame it as a disease and imply that biology is what it is about is misleading to people.”
As evidence for that, Yapko argues that changing the focus from earlier descriptions of depression as emotional weakness or pathological character traits to a biological/medical construct was intended to remove the stigma and encourage more people to seek help. “But that didn’t work,” he says. “Currently only 20 to 25 percent of sufferers seek treatment from a mental health professional, and 70 to 80 percent of antidepressant medications are prescribed by nonpsychiatrists — by general practitioners, cardiologists, obstetricians — who don’t have the background and training in their usage. And they don’t follow up, so they don’t find out that about half [of patients] don’t follow through on their meds because of side effects.”
In addition, Yapko feels the disease label undervalues the deep psychological components of depression. “You can’t change thinking and heart disease goes away, the way you can change thinking and depression goes away,” he argues.
Semantics or Deeper Meaning?
Sapolsky, in a way, agrees that definitions of disease are problematic. “I don’t have a great definition. I’ve always liked the opposite definition, where health equals having the same diseases as everyone else,” he says. “The thing about ‘disease’ is that it’s a moving target, often a social construct — and that’s not just postmodernist babble.”
Still, Sapolsky holds to the notion that disease is the proper way to describe depression, and that it’s more than just a debate about semantics. “I think it’s vastly deeper, and not just some nonsense about whether insurance will reimburse it,” he says. “For far too many people suffering from major depression, or anxiety disorders or PTSD, it doesn’t count as a disease in their head, and thus it’s something approaching being some sort of Calvinist moral failing, something that someone should be able to overcome with some gumption and resolve — something which, if you’re paralyzed by it, instead means that you’re weak and self-indulgent. It’s incredibly important that people realize that it is a biological disorder. It’s enormously harmful not recognizing it for being the disease that it is.”
If not a disease, how would Yapko label depression? “I prefer calling it a complex disorder and more heavily emphasize the social components as we find them out, as we learn about coping and problem-solving skills and that they have preventive value.” He says that learning those skills have been proven to help people “evolve perspectives that insulate them against depression. For all the money poured into research, I would prefer it going to prevention than to finding a magic drug. I can safely predict there will never be a pill that cures depression any more than there will be a pill that cures poverty or abuse or any other social condition.”
“I am not anti-biology,” Yapko concludes. “I am just kvetching that biology is oversold.” However it’s sold, depression remains a serious condition, and the importance of seeking treatment is one area all mental health providers agree on.
More from U.S. News