Thanks for this, Todd. It’s perfect for Mental Health Awareness Day.
I’d like to point out that many different therapeutic approaches have been shown to have similar positive effects in treating depression. I get a bit uneasy when posts seem to promote CBT as the go-to just because it’s labeled 'evidence-based.' There are plenty of studies showing other approaches—like emotion-focused therapy, psychodynamic therapy, and even Gestalt therapy—are also effective for treating conditions like depression. While CBT is often favored by psychologists (for a variety of reasons), I think it’s important to give people more options when seeking support and not overlook other approaches that can be just as helpful.
Absolutely. And sometimes psychodynamic therapy, problem-solving therapy, or mindfulness and compassion based therapies work. Even more recently positive psychological interventions that target kindness and strengths. Good call.
I am a retired psychiatrist who has been treated for major depression for over 40 years, and have had a wide variety of psychotherapies (as well as meds), from fairly non- directive psychodynamic psychotherapy to EMDR to DNMS ( which has kind of fallen off the map) to ACT to CBT to kind of free-form supportive therapy. Psychotherapies tend to go in and out of style and their use and effectiveness often depend on the practitioner’s preference and expertise. I realize that CBT today is touted as being superior because it is evidence based, but personally I found it to be sterile, rigid, and was unhelpful for me. I do believe, as Yalom said, that it is the relationship that heals. At least that was the main curative factor for me- that, and being on appropriate meds.
At one point, Freud wrote a paper titled "Mourning and Melancholia" (melancholia being the word for depression).
His theory was that when someone experiences a significant loss, they unconsciously internalize aspects of the lost "love object," leading to self-criticism and negative feelings directed towards themselves. So in essence, loss feelings turned inward.
The "love object" could be a person, a job, a sense of identity, a life goal, etc.
While I don't normally look to Freud's theories, this makes so much sense to me as an explanation for depression. It also explains why so many people go through it... because loss is inherent to the human experience. 😔
Depression should be so normalized at this point. In an ideal world, taking time off work to recover from depression would be as common as taking maternity/paternity leave. Just my two cents.
Aaron Beck attributed depression to the sense or perception of loss too. I wonder if that’s coincidental or was he inspired by Freud. I guess I should look into it.
One thing that I’d like to offer for consideration about Depression:
It is overwhelmingly contextual. As you note: there are lot of ways that Depression can manifest. Likewise, there are a lot of situations where even extremely mild Depressive symptoms can be disabling.
In my current role, my team and I oversee the medical leaves of 800 aviation professionals each year. A good 25-40% of those leaves are related to mental illness symptoms.
Now - one thing that I learned early on was that Depression in a pilot is vastly different from Depression in a Flight Attendant which in turn is quite different from Depression in an Aircraft Mechanic. Different symptoms create different problems in each role.
Low mood isn’t a big deal for a mechanic; at least at first. We’re all familiar with the grumpy mechanic stereotypes. However, low mood in a flight attendant is highly problematic. Meanwhile - attention to detail is supremely important for a pilot.
Meanwhile, I’m aware of several of my office worker colleagues that are all functioning modestly well in their jobs while seeking treatment and support. The condition doesn’t interfere with their ability to work much at all. They collaborate with my department to coordinate some accommodations and get access to additional resources to help them manage.
This highlights the importance of listening to what your body and mind are telling you and seeking support as soon as possible. Good things are possible even if it doesn’t feel that way.
The network of symptoms is a really interesting way of making sense of depression, and how individualised the experience really is. What are your thoughts on how we meet the mental health needs if we focus on individual therapy approaches, where there seems to be such a shortage of psychologists globally. How could we best use individual therapy + population/community level approaches which bring elements of psychoeducation and skills training as a preventative approach?
Steph, you hit the big question. Honestly, at this point with 6 month to year long waitlists, even supportive therapy by people with a BA/BS is needed. We have to create programs to let people with less training get in there and help people in disasters, with test anxiety, with loneliness, and maladies that might not need a therapist with a PhD.
These are simply great questions that we must start contending with. I don't have the answers. I hope you ask the surgeon general as to me this is bigger than the focus on smartphones.
When I tried to understand what can be done with depression , from what I could find it looks like the only thing that “universally “ as in across cultures, sort of work is: “productive physical labor with other people under sunlight “
Thank you. It’s really hard to imagine interventions working smoothly with a woman living in India under the rule of not just a husband but every male in the family and a 21 year old from Menlo Park dissatisfied with his/her job at Google.
You’re absolutely right. Which is why when we think of chronic low grade depression it’s dysthymia - which others often don’t understand. Or just waking up for 6 days in a row with a backdrop of disenchantment with no clear precipitating event.
What I believe is therapy can help everyone diagnosis be damned.
Right. And with good intentions people confuse rules of thumbs that are fully integrated and automated as rules. And then you lose more and more people you could have helped
Nothing naive in these complicated waters. I've spent years trying to get through the 1893 tome, the anatomy of melancholy by Robert Burton. It preceded everything that has been said in psychology about depression. So who knows? Not me.
Thanks for this wonderful post. I would be so interested to see a couple of examples of "individualized network models." The more we can visualize the individual landscapes of contributing factors, the more we can extrapolate an understanding of trends that could help more people over time. I've never seen a network model like the one you shared! Thank you again.
Thanks Meredith! Same, I would love to see them as well. I have moved to constantly think about every person suffering as holding a series of contingency statements that must be unearthed. Which situations bring out what about your self? What occurs within that alters how you behave and react in situations?
I totally agree with you on this thinking. It is definitely connected to the Internal Family Systems approach as well, which is all about understanding how different "parts" of a person show up in different situations.
"As a psychologist who studies emotional disorders, this topic is of paramount importance.." I am not usually a nerd, but I do like the English language. This topic is not a psychologist who studies anything. It may be of paramount importance. Since this sentence is in bold in your email, you may wish to transform it into better English. I started reading this because I liked a note you posted. Perhaps I am in the wrong place.
My apologies if I was rude, but my intentions were good. I was reading a novel (a rare moment), decided to look at my emails, my head was still in my novel but I saw your error in English and wondered how people with 100s of paying subscribers (I have an argument with Substack on their use of the words 'paid subscribers' because that is the wrong way around) could make such a simple error and then decided you would probably be pleased to have it pointed out. I would be thrilled with 50 paying subscribers, even though I give the money to a homeless shelter, but life was never meant to be fair. Keep writing.
Thanks for this, Todd. It’s perfect for Mental Health Awareness Day.
I’d like to point out that many different therapeutic approaches have been shown to have similar positive effects in treating depression. I get a bit uneasy when posts seem to promote CBT as the go-to just because it’s labeled 'evidence-based.' There are plenty of studies showing other approaches—like emotion-focused therapy, psychodynamic therapy, and even Gestalt therapy—are also effective for treating conditions like depression. While CBT is often favored by psychologists (for a variety of reasons), I think it’s important to give people more options when seeking support and not overlook other approaches that can be just as helpful.
Absolutely. And sometimes psychodynamic therapy, problem-solving therapy, or mindfulness and compassion based therapies work. Even more recently positive psychological interventions that target kindness and strengths. Good call.
I am a retired psychiatrist who has been treated for major depression for over 40 years, and have had a wide variety of psychotherapies (as well as meds), from fairly non- directive psychodynamic psychotherapy to EMDR to DNMS ( which has kind of fallen off the map) to ACT to CBT to kind of free-form supportive therapy. Psychotherapies tend to go in and out of style and their use and effectiveness often depend on the practitioner’s preference and expertise. I realize that CBT today is touted as being superior because it is evidence based, but personally I found it to be sterile, rigid, and was unhelpful for me. I do believe, as Yalom said, that it is the relationship that heals. At least that was the main curative factor for me- that, and being on appropriate meds.
At one point, Freud wrote a paper titled "Mourning and Melancholia" (melancholia being the word for depression).
His theory was that when someone experiences a significant loss, they unconsciously internalize aspects of the lost "love object," leading to self-criticism and negative feelings directed towards themselves. So in essence, loss feelings turned inward.
The "love object" could be a person, a job, a sense of identity, a life goal, etc.
While I don't normally look to Freud's theories, this makes so much sense to me as an explanation for depression. It also explains why so many people go through it... because loss is inherent to the human experience. 😔
Depression should be so normalized at this point. In an ideal world, taking time off work to recover from depression would be as common as taking maternity/paternity leave. Just my two cents.
Thank you for this piece. Sharing!
never knew of this Freudian model. this is why I love comments. Makes perfect sense and so ahead of its time.
Thank you!
Aaron Beck attributed depression to the sense or perception of loss too. I wonder if that’s coincidental or was he inspired by Freud. I guess I should look into it.
Let us know what you find, Kuku!
Great post Todd.
One thing that I’d like to offer for consideration about Depression:
It is overwhelmingly contextual. As you note: there are lot of ways that Depression can manifest. Likewise, there are a lot of situations where even extremely mild Depressive symptoms can be disabling.
In my current role, my team and I oversee the medical leaves of 800 aviation professionals each year. A good 25-40% of those leaves are related to mental illness symptoms.
Now - one thing that I learned early on was that Depression in a pilot is vastly different from Depression in a Flight Attendant which in turn is quite different from Depression in an Aircraft Mechanic. Different symptoms create different problems in each role.
Low mood isn’t a big deal for a mechanic; at least at first. We’re all familiar with the grumpy mechanic stereotypes. However, low mood in a flight attendant is highly problematic. Meanwhile - attention to detail is supremely important for a pilot.
Meanwhile, I’m aware of several of my office worker colleagues that are all functioning modestly well in their jobs while seeking treatment and support. The condition doesn’t interfere with their ability to work much at all. They collaborate with my department to coordinate some accommodations and get access to additional resources to help them manage.
This highlights the importance of listening to what your body and mind are telling you and seeking support as soon as possible. Good things are possible even if it doesn’t feel that way.
This is a great addition. Excellent point about how easy it is to miss the seemingly fully functioning wounded.
Great overview of this complex condition.
Thanks Gail!
The network of symptoms is a really interesting way of making sense of depression, and how individualised the experience really is. What are your thoughts on how we meet the mental health needs if we focus on individual therapy approaches, where there seems to be such a shortage of psychologists globally. How could we best use individual therapy + population/community level approaches which bring elements of psychoeducation and skills training as a preventative approach?
Steph, you hit the big question. Honestly, at this point with 6 month to year long waitlists, even supportive therapy by people with a BA/BS is needed. We have to create programs to let people with less training get in there and help people in disasters, with test anxiety, with loneliness, and maladies that might not need a therapist with a PhD.
These are simply great questions that we must start contending with. I don't have the answers. I hope you ask the surgeon general as to me this is bigger than the focus on smartphones.
Thanks!
When I tried to understand what can be done with depression , from what I could find it looks like the only thing that “universally “ as in across cultures, sort of work is: “productive physical labor with other people under sunlight “
Thank you. It’s really hard to imagine interventions working smoothly with a woman living in India under the rule of not just a husband but every male in the family and a 21 year old from Menlo Park dissatisfied with his/her job at Google.
Of course! It’s not the “silver bullet”, I am pretty sure there’s no one (maybe there will be? AI + chemistry?)
its the closest to "everything else beinf equal" sort of thinking
like "drink water", "take a walk"
i know that abstract advise is not very useful, but we developed some "rules of thumb" that can help
and lots of time tgese simple rules are under appreciated, in my opinion
You’re absolutely right. Which is why when we think of chronic low grade depression it’s dysthymia - which others often don’t understand. Or just waking up for 6 days in a row with a backdrop of disenchantment with no clear precipitating event.
What I believe is therapy can help everyone diagnosis be damned.
Thanks!
My own history of treatment is not great, unfortunately
So I was/am looking for “simple “ solutions and I guess simple is a problem
I do believe that proper professional help is always better
But I also believe that most therapist (engineers, cooks …) are mediocre
So what do we, lay people, do?
I mean what do you think about it?
Right. And with good intentions people confuse rules of thumbs that are fully integrated and automated as rules. And then you lose more and more people you could have helped
I see
You talk about a danger of relying on these rather pro help
I do not disagree, but I want to understand better.
Do you think there is a spectrum though? I feel like there is a huge distance between clinical depression and “melancholy “
Am i being naive?
Nothing naive in these complicated waters. I've spent years trying to get through the 1893 tome, the anatomy of melancholy by Robert Burton. It preceded everything that has been said in psychology about depression. So who knows? Not me.
Thanks for this wonderful post. I would be so interested to see a couple of examples of "individualized network models." The more we can visualize the individual landscapes of contributing factors, the more we can extrapolate an understanding of trends that could help more people over time. I've never seen a network model like the one you shared! Thank you again.
Thanks Meredith! Same, I would love to see them as well. I have moved to constantly think about every person suffering as holding a series of contingency statements that must be unearthed. Which situations bring out what about your self? What occurs within that alters how you behave and react in situations?
I totally agree with you on this thinking. It is definitely connected to the Internal Family Systems approach as well, which is all about understanding how different "parts" of a person show up in different situations.
"As a psychologist who studies emotional disorders, this topic is of paramount importance.." I am not usually a nerd, but I do like the English language. This topic is not a psychologist who studies anything. It may be of paramount importance. Since this sentence is in bold in your email, you may wish to transform it into better English. I started reading this because I liked a note you posted. Perhaps I am in the wrong place.
Humans make errors. It happens. I don’t have a team. It’s just me. The money goes to my favorite causes. Mostly criminal justice reform.
fixed. thanks.
My apologies if I was rude, but my intentions were good. I was reading a novel (a rare moment), decided to look at my emails, my head was still in my novel but I saw your error in English and wondered how people with 100s of paying subscribers (I have an argument with Substack on their use of the words 'paid subscribers' because that is the wrong way around) could make such a simple error and then decided you would probably be pleased to have it pointed out. I would be thrilled with 50 paying subscribers, even though I give the money to a homeless shelter, but life was never meant to be fair. Keep writing.