As a Doctor, I Misunderstood Depression

When I first started out as a psychiatrist, I was taught to think about depression as a well-defined medical condition, one that likely had underlying biological causes, similar to diabetes or Parkinson's. But after years of working in the field, I realized that this is not just oversimplified; it's actually inaccurate.

Unlike conditions with clear medical pathologies, like damaged neurons and Parkinson's, depression doesn't have any well-established biological markers. And thinking of it purely in medical terms simply leads many patients and doctors down the wrong path, focusing on treating symptoms with drugs rather than addressing the real causes. So today, I want to pull back the curtains and share what depression really is, what causes it, and why so many people have the wrong idea about it.

For those of you who don't know me, I'm Dr. Ysef WT during. I'm a board-certified psychiatrist with over 10 years of experience and a former FDA medical officer.

**Part One: What is Depression?**

When I first started residency, we always talked about depression as if it was this well-defined medical condition. And from my attendings, I'd hear phrases like, "Depression is a serious medical condition," "It's a serious mood disorder." And then, when I would talk to my patients and I'd ask them to describe what it was like being depressed, they'd say things with a lot of certainty. They'd say things like, "Well, it's not just normal sadness. It's like being in this dark tunnel and there's no light at the end," or "It's this kind of sadness that comes out of nowhere and it just takes over you." And honestly, their confidence made it seem like they were describing something concrete and well understood. If you kind of just had it, you just knew.

But that perspective faded for me the longer I worked as a psychiatrist. And it was really when I began to evaluate the diagnostic criteria that clinicians and scientists use to diagnose depression. That is, the DSM. This is the Diagnostic and Statistical Manual. And for those of you who are not aware of it, this is essentially the book that all psychiatrists use in the US to diagnose all mental health conditions. And when I started to use this book, the more I realized that the condition of depression was anything but well-defined.

So let's look at it together, and I'll show you what I mean. And so, in order to be diagnosed with major depressive disorder, or clinical depression as people often colloquially call it, you have to have five out of nine of the following criteria for more than two weeks, and at least one of them has to be depressed mood or diminished interest or pleasure.

So, as you're looking at these criteria on your screen at the moment, I want to draw your attention to a few things that are really worth noticing with this criteria. The first thing is that there are no biological tests in there. So there's no imaging study in there, like you would have say in Parkinson's disease where you could image the brain and you would see destruction of the dopaminergic neurons, substantia. There's no blood tests for serotonin or cortisol or anything like that. The entire diagnosis is based on symptoms that someone subjectively reports. That means that getting a diagnosis of depression is in no way contingent on there being any underlying pathology. You simply get this diagnosis if you report the symptoms.

The second thing that I want you to notice is that there is no consideration of contextual stresses. For example, if your spouse died, and you were sad for two weeks, and you couldn't sleep, and you gained some weight, and you're having a hard time concentrating, and you felt fatigued, you would qualify for a diagnosis of major depression, and you would be eligible for drug treatment. There would be no adjustment for the fact that grief would be a natural response to this loss. You would still get this diagnosis of clinical depression or major depressive disorder, even though your sadness would be a completely natural response to the loss. And I don't think many people would consider this to be a sign of any underlying pathology or anything that's not working well in your brain. This is important because it means you can simply get this diagnosis by having a completely normal and human response to suffering that occurs in life.

The next thing that I want to bring your attention to is that the criteria is very arbitrary. And that's when we look at these cutoffs. You have to think, "Hmm, why are the cutoffs like that?" Are you only clinically depressed if you're sad for two weeks? Why not one week? Why not three weeks? Why do you only need five out of nine of these symptoms? Why not four out of nine or six out of nine? And when you look into the history of the DSM, what you essentially learn is that these criteria were voted on by committees, by leaders in the field of psychiatry. And when they're asked to justify why they chose those cutoffs, they essentially say, "It just kind of felt right."

The thing that I want you to be aware of with the criteria of depression is that it was essentially just researchers voting on this criteria. They weren't, you know, finding some pathology in the brain that kind of linked down to these different symptoms. And there was this way that they chose the symptoms because they thought that it all flowed from one place. No, they, they just went out and they asked doctors, "What do you think are the symptoms of depression?" And they, they voted on it. So the criteria for this condition is arbitrary, simply voted on by scientists.

And the last point that I want to make about this criteria is that there is a huge amount of ways that you could meet criteria for depression. Really, the variability in the symptom combinations is enormous according to this criteria. One of the symptoms of depression is you could lose a lot of weight, or you could gain a lot of weight. You could sleep too much, or you could be getting not enough sleep. You could feel agitated a lot of time, or you could feel sluggish. And honestly, these are really polar different ways of feeling. But any combination of these symptoms could actually qualify someone for depression, even though they look really different. And in fact, when you do the math on this, there are 10,377 possible combinations of symptoms that could meet the criteria for a major depressive disorder. That means that people who are getting diagnosed with depression as it is today are very likely not experiencing the same thing at all.

And this is exactly what researchers find when they look at clinical trials conducted in patients with depression. They find that they're actually reporting very different things. For instance, we have this study right now by Allen Fried and Randolph Nesse. And they looked at the combination of symptoms people reported in the study. This is a very well-known depression study. And what they found was there were over 1,030 unique symptom profiles reported by the 3,700 depressed outpatients. Nearly 50% of the profiles were reported by only one individual. What that means is they found that around 50% of the symptoms that someone would report to get that diagnosis of depression were only endorsed by one individual. And they found that the most commonly endorsed combination of symptoms to get diagnosed with depression was only reported by 1.28% of the population. And so, what this shows is that people are experiencing really different things when they're diagnosed with depression.

Now, why is it important to be aware of all of these nuances in the way depression is diagnosed? Well, it matters because it shows that we're not dealing with a typical medical diagnosis. Because a typical medical diagnosis in other areas of medicine actually tells you a lot about the condition. For instance, it will tell you where the pathology is. It'll help you understand why the symptoms come about because of the underlying pathology. And it'll help you understand what is going to happen with the condition. Now, none of these things are true with the diagnosis of depression. Because it does not map to any well-understood underlying pathological process. Again, coming back to the diagnosis of Parkinson's, if you had Parkinson's disease, you know that the injury is in the substantia. You know it's involved in the dopaminergic pathways. And then it makes sense that there's slowed movement. It makes sense that there's some cognitive problems because you know that destruction of the dopaminergic neurons is going to disrupt the parts of the brain that deals with those processes. And also, with that diagnosis, you know the clinical course. You know that it's a progressive neurodegenerative disease and you're going to see what happens.

Now, none of this is true with depression. You know, we don't know what the underlying pathology is. The symptoms that you have to endorse to get this diagnosis, it doesn't flow from any underlying lesion. And honestly, if someone gets this diagnosis, you can't really tell what's going to happen to them. Some people are going to recover really quickly, and some people are going to have progressive and long courses of depression. So the diagnosis doesn't really tell you much. And that's why many people say that depression is less of a diagnosis and it's more of a label. That is, it is a name that we give to people that endorse a group of symptoms that a committee voted on to define as depression.

And it's not just me that feels this way, that depression isn't a real diagnosis, but it's more of a label. Because in fact, many researchers have the same concerns. And when we look at the National Institute of Mental Health, they have stopped using the DSM to guide their research because they have said that these are arbitrary symptom clusters and that they do not reflect any biologically valid condition. And therefore, it's simply not useful in advancing psychiatric research.

I want to show you what the director of the NIMH said about the DSM and DSM diagnosis, just like depression. And check this out. Here's what he said. He said, "While the DSM has been described as a Bible for the field, he wrote, it is at best a dictionary, creating a set of labels and defining each. Although the manual's strength has been to standardize these labels, he wrote, the weakness is its lack of validity." And when he's talking about validity, he's talking about the symptoms mapping to an underlying consistent biological process. And then he finally says, "Here's some shots fired. Patients with mental disorders deserve better." This is the leader of arguably the largest mental health research organization in the world, essentially saying that the DSM diagnoses really aren't valid and they aren't helpful in research.

So let's have a little recap. Let's talk about what depression really is. And so, here, here's my answer after being a psychiatrist in the field for 10 years. Well, first and foremost, it's a label. It simply describes a set of symptoms that were arbitrarily chosen by committee. Secondly, for depression as currently defined, you don't need to have any underlying pathology. Again, it is just the symptoms. And thirdly, there are over 10,000 different combinations of symptoms that could qualify someone as being clinically depressed. Meaning that people who are diagnosed with depression, they look very different from one another. So this is really a diagnosis that is fuzzy and somewhat arbitrary.

But some people are going to argue, "Ysep, who cares? This is just a useful way to describe symptoms that people experience when they're very sad and it's impacting their life. Using this criteria, even if it's not perfect, might still be a very practical way to identify people who need help." And fair enough, that might be correct. But here's the problem: we don't talk about depression as a fuzzy label. Instead, we're often using terms like "serious medical condition" or we're comparing it to diabetes. And this leads so many people to believe that there is some underlying problem with depression. And I think that is really important to look into.

And so, in this next section, we're going to look at the evidence base surrounding what actually causes depression. So let's dive into that. But very quickly, I want to ask, if you enjoy content that questions the usual approach to mental health and gives you accurate information about psychiatry and meds that help you make more informed decisions, be sure to like this video and hit subscribe so that you don't miss out on any of our future videos.

So now that we've talked about depression, let's talk about what causes this. Now, trying to find the underlying causes of depression has been something that researchers have been looking for for decades. And how they do this is they have various hypotheses. They look at things that they think would be correlated with depression, and then they see if they turn up in statistically higher amounts in groups who are depressed rather than people who are not depressed. And the factors that people have been very interested in in depression are things like life hardship, abnormal levels of neurotransmitters, brain changes seen on neuroimaging, and genetic changes. And so, in this next section, I'm going to show you what researchers have found.

Now, so let's start by looking at life hardship. So when researchers have looked at this area, what, what they have found is that lack of social support, childhood maltreatment or abuse, and stressful life events are all associated with a Cohen's D effect size of roughly about one. And because I know a lot of you listening to this aren't statisticians, you may not be familiar with the Cohen's D effect size. But essentially, it's a measure of showing how big of a difference a variable makes in two outcomes, with the outcomes being being depressed and being not depressed. With the outcomes being being depressed and being not depressed. So for interpretation, an effect size of 0.2 is considered a small effect. An effect size of 0.5 is a medium effect. And an effect size of 0.8 or greater is considered a large effect in the scientific community. So a Cohen's D effect size of one suggests a very large and meaningful effect that those factors are having on people either being depressed or not depressed.

Now, to help you just understand this visually, let's just quickly look at some graphics here. Now, these graphics aren't from the article, but they're just useful demonstrating this point. If we were to say that the X-axis on the bottom, maybe I'm just going to make this up, it's the likelihood that you're going to be depressed. And the dark blue are people who have the variable associated with depression. And the more pink color are the people who don't. And so, if there was a variable and the effect size was 0.2, you would see that it would not make that much of a difference in differentiating those two groups from one another. They would be still very similar. But as you have higher and higher effect size, that variable is associated with a much larger shift. And so, going all the way down to 0.8, you could see that that blue group, that has that variable, compared to that, that pink group, is actually much different. You know, they shifted a lot to the right. They're much more likely to have depression. And that's just at 0.8. So because, you know, as I mentioned previously, the effect size for, you know, childhood maltreatment, lack of social support, stressful life events, that has an effect size of one. So those graphs would be even more far apart, and, you know, showing that it's associated with a much larger effect.

So, moving on now, let's now talk about brain imaging findings. And to do this, we're going to look at the study by Niles R. Winter and this was in 2022. And essentially, what they found in their analysis of neuroimaging markers for depression was that the largest significant effect size associated with depressed patients was small. That was 0.2. That would be this graph here. And essentially, what you see is even the variable, you know, when they look at the brains of depressed people and they try and find things that make them different, the groups are so similar that it's hardly able to differentiate depressed patients from non-depressed patients. And that's essentially what they conclude in their findings. They say that the study results suggests that patients with depression and healthy controls are remarkably similar regarding neural signatures of common neuroimaging modalities. So what this essentially means is that when you image the brains of depressed and non-depressed patients, they essentially look the same. You know, there are no differences there.

Now, the next underlying causal factor that we want to talk about has got to be neurotransmitters or serotonin. This is the chemical imbalance. This was investigated very publicly by Joanna Moncrieff. She did this big systematic umbrella review of the evidence recently and was widely covered in the news, where they looked at every single study out there that measured the level of neurotransmitters in either the spinal fluid of patients or after they had died. They were looking at serotonin receptors, any piece of evidence out there that was trying to correlate neurotransmitter levels and depression. And essentially, they found there was no evidence that depression was linked to any imbalance of serotonin. And this is what they concluded. They say, "The main areas of serotonin research provide no consistent evidence of there being an association between serotonin and depression and no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations." And there was some evidence that was consistent with the possibility that long-term antidepressant use actually reduced serotonin concentrations. And so this review was really the nail in the coffin for anyone thinking that depression was associated with low serotonin. Which is obviously very interesting because it strikes at the heart of why we use SSRIs like Lexapro and Prozac. I'm going to put a pin in that and we'll talk about that later on, because this section is really just about the causes of depression. So we're going to move on now and we're going to talk about the genetic factors. Are there any genes essentially associated with being depressed?

And so Richard Border and his team back in 2019, 19, they published an article where they looked at a lot of genes in a very large population of people to see if there were certain genes that were associated with depression. And essentially, here is what they found in their review. You know, this is published in the journal, the American Journal of Psychiatry, super mainstream, very popular journal. Here is what he found: "The study results do not support previous depression candidate gene findings in which large genetic differences are frequently reported in samples order of magnitude smaller than those examined here." Essentially saying this is a much bigger study, smaller studies which have found kind of genes which they thought may have been causing depression. And so he says, "Instead, the results suggest that early hypotheses about depression candidate genes were incorrect and that the large number of associations reported in the depression candidate gene literature are likely to be false positives." Essentially saying that there is no evidence that there's any kind of single gene or small group of genes which are largely responsible for why people get depressed.

Now, I want to provide a little bit of nuance there because I do think it's important. Because personally, I do believe that there is a genetic component to depression. But it's not caused by any single genetic factor or any small group. But that it's actually polygenic, and there's multiple combinations of genes that may contribute to people being depressed. And the way I want to make this argument to you and kind of share it to you is by looking at Ken Kendler's research, where he was looking at the relationship between the personality trait of neuroticism, as well as stressful life events, and how that contributed to people getting depressed. And so Ken looked at a large population of people, it was about 7,500. And what he did was he gave them a personality questionnaire for neuroticism, and then he also looked at, you know, 11 different types of stressful life events. And then he wanted to see, were the people who had more neuroticism, were they more susceptible to having depression if they underwent stressful life events?

For those of you who aren't familiar with the term neuroticism, I'm going to go into a couple of representative questions that they ask people about to determine if they were, you know, quote unquote neurotic. And so here were some of the questions: "Are you the type of person whose feelings are easily hurt?" Another question is, "Are you the type of person who is rather nervous?" And third, "Are you the type of person who is a worrier?" And so those were the type of questions that they were asking this population to determine whether they were on this sort of neurotic spectrum of personality. And just so you have a sense, what the stressful life events were that they also investigated in this group of patients, there are 11 of them, and we're going to show them on the screen now.

And so what Ken and his researchers did in this study was that they looked at how likely it was that someone would become depressed after having one of these terrible stressful life events. And here's what they found. This is kind of a busy graph, but I want to walk you through this. And so on the left is men, and on the right is women. This on the X-axis, where it says None, Minor, Low, Moderate, High Moderate, and Severe, they're talking about stressful life events. Now, if you had a severe stressful life event, that means that something happened to you, one of those 11 events, and it was judged by the person to have significant impact in their life going forward. It was not just like a time-limited stressor. It was something that the person deemed was going to have a big impact going forward. These different colored lines that you're seeing here, these are the levels of neuroticism. So the top line are people who scored the highest on that neuroticism scale. And the green line is the people who scored the lowest. And essentially, what the research showed was people who had neurotic personality traits just tended to be affected more by serious stressful life events. And so once you started to have these kind of high moderate stressful life events, people who had high levels of neuroticism were much more likely to have depressive episodes than people down here on this green line, who, even though they were having significant stresses, they did not become depressed. And this held true essentially for men and women. And so the conclusion to all of this is that having a neurotic personality actually predisposes some people to have more depressive episodes if they are stressed.

This is important when we think about the causes of depression because your personality definitely is heritable, just like other things are heritable. You know, height is, you know, 70% heritable. Intelligence is heritable. And so why wouldn't personality traits be heritable? The way that they've been able to determine that personality is heritable is by looking at twin studies. And so they get identical twins, and then they get fraternal twins. And so with identical twins, you know, obviously they, they share 100% of the genetic makeup, same egg, same sperm, that just divides, but it's the same. But with fraternal twins, they're only sharing 50% of the genetic material. And so what you do is you look at these two groups of people, and then you see how common do they have that same personality. And with something like the neurotic traits, it's, it's something like 80% of them have, if you have an identical twin who's highly neurotic, 80% chance that the other one's going to be highly neurotic. But when you look at fraternal twins, it's like 50/50. And so they then look at that difference between how frequently it occurs, and you're able to say, "Yes, you know, it looks like these identical twins are sharing more of these characteristics, and so it's likely that that personality trait is heritable." And these studies are really useful because obviously, you know, with fraternal twins and also identical twins, they grow up in the same environment. And so you can kind of eliminate that as a potential variable that's that's making them different. And so, yes, you know, personality, just like intelligence, and just like many other things, are heritable. But they are polygenic, meaning they're not caused by any single gene. These traits are caused by multiple genes coming together.

And so, moving forward, you know, people have looked into this. If you see this article, this is by Ray Power. What they do find is that personality, uh, not just neuroticism, but also other things like extroversion and such, it is heritable. And most twin studies show that it ranges from 40% to 60%. And that's roughly in line with intelligence when you look at other studies there. Okay.

So let's conclude this section. What do we know about the causes of depression? Well, one, I would say that the evidence shows that depression is currently best thought of as a response to life hardship, whether it's childhood maltreatment, things like social isolation, or as a response to life stresses. And then the second thing is that people who have more neurotic traits are more likely to become depressed when exposed to high stresses. And this is a heritable trait, and it's influenced by many genes. But I would hardly say that being neurotic is like a biological disease or a problem. But rather, it's like a personality trait. And it's hard to say that this is just a detrimental personality trait in all aspects. Like, sure, maybe if you're really neurotic, it could drive you to substance abuse or something like that. But I also know a lot of neurotic people who are very conscientious, and they're always mindful of their health, and they're looking into it, and they're making, you know, maybe more conservative decisions about that, and it helps them. And so it's hard to say that if someone is neurotic, that that's really a pathology. Rather, it's just a personality trait that tends to predispose people to depression.

And finally, there are no biological deficits that have been found. The brains of depressed people, whether it's abnormal circuits in the brain, whether it's, you know, abnormal genes, or whether it's some kind of serotonin deficiency, uh, none of the research has actually found that.

So now let's kind of come back to to the same thing. So if depression is best thought of as this kind of fuzzy label, and that most evidence points towards it being caused by life stresses and environmental factors, why do we always seem to be talking about it as if it's some kind of biological or genetic condition? And that's what we're going to talk about in the next section. Section three: The Problem with How We Talk About Depression.

And to kick off this section, we're going to look at the most popular YouTube video out there for what depression is. And I want to show you a section that really captures the medical way that we talk about depression. Let's check it out quickly.

"If they feel guilty or ashamed, point out that depression is a medical condition, just like asthma or diabetes. It's not a weakness or a personality trait, and they shouldn't expect themselves to just get over it anymore more than they could will themselves to get over a broken arm."

Okay, so that language is really kind of captures a lot of what I hear in the media about this. Now, let's move on and let's look at a piece of journalism from Health Harvard. And so this article is "What Causes Depression?" And as you go into this, I mean, right off the bat, it says, you know, "Okay, so depression isn't just a chemical imbalance, but in fact, there are many possible causes, including faulty mood regulation by the brain, genetic vulnerability, and stressful life events." That's not true from what we just looked at. There's not a lot of evidence about faulty mood regulation by the brain. There's evidence for stressful life events. And essentially, as you mood, I'm not going to go through the whole article, but I want to show, as you move through this article, the emphasis is clearly on the biology here. They talk a lot about, uh, neurotransmitters and how, you know, neurons communicate and different areas of the brain communicate between one another. They talk about sophisticated imaging that's looking into the brain to try and find reasons why people are depressed. And you'll essentially, you know, they'll say, "Researchers are exploring links between the sluggish production of new neurons in the hippocampus and low moods." They talk about nerve growth and new connections. And then there's, you know, photos of the brain. And essentially, what you take away from this article is that there is a huge emphasis on the biology of depression. And they're not mentioning the things that, at least we know from looking at the research, are actually associated with depression quite frequently, like the stressful life events, childhood mistreatment, and social isolation.

And this is what a lot of the communication about depression really looks like out there. It is constantly communicating depression as being this biological process. But why are they doing that when that's not supported by the evidence? And so now I want to go into some of the reasons I believe this is happening. I'm going to start with a helpful reason, you know, an optimistic spin on this. So one of the reasons they might be talking about it in medical terms, and I've heard this before and it's reasonable, and that is that historically, depression has been seen as this kind of moral or personal failing. And so when you frame the condition like a medical condition, like diabetes, it has the effect of reducing stigma and it encourages people to seek help. Because when you position depression as something out of someone's control, it often makes it more acceptable for that individual to go to their doctor for treatment rather than suffering in silence. And although this may not be true, this might just get people in the door and talking about depression so they can get access to care. And maybe that wouldn't be bad, except that when a lot of people go to their doctors thinking about depression in this way, they're almost, at least what I see, you know, personal experience here, a lot of them aren't told by their doctors, "Well, hey, you know, it's not actually that simple. It's not just a medical condition. There's a lot of factors and stresses in your life that could be causing this, and we should have a look at them and help you." In fact, a lot of people go into doctors, seek them for 15-minute visits now, and just get meds. This kind of white lie, I don't really think is helpful, at least in the way, um, psychiatry is practiced these days. So that's the kind of the destigmatization argument for referring to it as a medical condition.

Now, I want to talk about what I believe are some of the more sinister reasons why we so often hear about depression being this medical condition. And the first one is that it actually really benefits the pharmaceutical industry. So the pharmaceutical companies and the academic doctors out there who develop psychiatric meds, they really have a vested interest in promoting the idea that depression is primarily a biological condition. Let's check out this article from a drug company that makes Zoloft quickly.

"Whatever you do, you feel numb and don't enjoy the things you once loved. Things just don't feel like they used to. These are some symptoms of depression, a serious medical condition affecting over 20 million Americans. While the cause is unknown, depression may be related to an imbalance of natural chemicals between nerve cells in the brain. Prescription Zoloft works to correct this imbalance. You just shouldn't have to feel this way anymore."

So, just for some historical context, in the '90s and the 2000s, uh, there were a lot of these commercials out there that talked about this chemical imbalance. And that's why so many people to this day still believe that. And it makes sense that the drug company would want to push this idea because when you conceptualize depression as a medical condition caused by chemical imbalance, then they can justify the need to use their products because their products work on altering these neurotransmitters. And so it's essentially a way to promote the need of their medications, even if it is at the expense of misleading the public about what the evidence shows to be the true causes of depression, which really isn't any kind of chemical imbalance.

The next factor that I want to talk about, which I think is a real major one for why we often talk about depression as a medical condition, is really the economics of healthcare. Now, this isn't really something people talk a lot about, but I think it's very, very important. Our current healthcare system, at least in the US, and I think this is the same in the UK and Australia and other places, it is a model that prioritizes really brief appointments and medication management. And that's because it is more profitable than providing time-consuming and therapeutic care. Now, a lot of this is influenced by insurance reimbursement. And so I want to go over how psychiatrists are reimbursed by insurance to give you an idea. So a CPT, this is a visit code, a 99213. This is a 15-minute visit code. In general, you'd probably get around $100 from Medicare if you saw someone for 15 minutes. Now, let's say, for instance, you didn't want to just see someone for 15 minutes, you want to see them for 15 minutes and then do some psychotherapy. You would bill a 99213 plus a 9833. That's a psychotherapy 30-minute add-on. And so you would get $100 plus $75, and so that would be $175.

Now, to really understand the financial incentives and why people are kind of like pushed towards seeing people in such short periods, if we were to do some math and we would to work out what is a more profitable way to see people, is it more profitable to see just these 15-minute med management visits or to do these, you know, these visits and then the psychotherapy add-on? When you actually calculate the math out, you could make $400 an hour if you saw four people in 15 minutes. Versus on average, if you wanted to meet someone and do psychotherapy with them and help them each time, you'd be making around $247 an hour. And this is exactly the kind of incentive I think that can push people towards describing depression as a medical condition because it's really hard to justify the way you would treat someone in these 15-minute visits unless you did it in that way. And, and this is why so many patients, they go in, they see their doctor for like 15 minutes, and they say, "You know, what's going on? What's happening to me?" And they say, "Well, you know, there's probably a genetic component, probably a mood disorder, you know, there may be some kind of chemical imbalance. But don't worry, we've got these medications, and they're going to work on the cause of depression." That's a much easier thing to tell someone if you're incentivized to see them in 15 minutes rather than these longer periods. And so I actually think a lot of doctors use this language because talking about depression in another way kind of opens up this whole can of worms. All of a sudden, they have to do psychotherapy, which really isn't reimbursed well. They may need to understand them in a way that they couldn't understand them in a 15-minute visit, and then help link them up with different specialists. And so they don't do it. And because of that, we, we kind of have this unholy alliance where I think a lot of doctors use this language just because it's expedient and it's more kind of profitable for them and the healthcare system to kind of just turn through the patients. Now, I don't want to throw doctors and psychiatrists under the bus completely here, because most of them who I talk to, they absolutely hate this system. They hate having to be incentivized to see people in these short visits. But that being said, you know, there still are a lot of doctors that kind of go on with this and they perpetuate this problem.

Now, the final reason why I actually think we talk a lot about depression as this chemical imbalance is actually really sinister. And, um, this is me kind of wearing my tin foil hat, but I actually think we do it in a way for political convenience. And I say that because I think that it's actually helpful for politicians or people in power to say that people are depressed because of a chemical imbalance or some kind of genetic reason. And that's because depression can be caused by many societal issues, you know, such as economic instability, inflation, a lack of affordable housing, social isolation. And these societal changes are uncomfortable to discuss, especially because they may threaten powerful political and economic groups. And so it's politically easier to simply frame the reasons why people are unhappy as being from a medical condition rather than, I don't know, looking at the tax code, which seems to benefit people who make more money and have assets. And rather than kind of re, yeah, reforming the tax code or figuring out why housing is so expensive and why groceries are so expensive. Because all of these things, they're super legitimate and they make people unhappy. And when you don't address them and you just say, "Well, you know, we've got rising levels of depression," you could just kind of maybe justify dealing with them by just saying, "We need better access to mental health care," rather than kind of making real political changes.

So let's wrap up this video now and let's talk about how the way we look at depression as this kind of medical condition has really affected patients. And the first thing I'll say is that the unfortunate impact is that many patients believe the opposite of what the evidence actually shows. They think that depression is this well-defined medical condition. They think that the majority of it is caused by biological or genetic factors. And as a result, they're more likely to believe that a medication is the main solution to treating their depression. Now, I'm not trying to say that medication never has its place, okay? People, put your pitchforks down. We'll get to it. But what I am saying is that the way we talk about depression often distracts people from its most prominent causes, such as childhood trauma, social isolation, stressful life events. And it leads people to think that their brain is malfunctioning in some way, and that medication is the only way to fix that. But the truth is, and what I finally see now as a psychiatrist, is that most people would benefit from simply addressing the root causes of their depression rather than numbing their symptoms with medications that don't act on any underlying cause.

And so when you treat the root causes of depression, it can look like various different things. I mean, these could be all different types of psychotherapy, depending on the problem that you're struggling with. You could be working on interpersonal skills because you're struggling in your relationship, or you're struggling with your colleagues, or you're having a hard time making friends. You may even do interventions outside of mental health, like career coaching, if you hate what you do and you need to find a new way to make money and do it in alignment with something that you love. Seeing a career coach might be way better than taking a medication and way more useful. And so I think often times we're shut off for like really going at the core problems that are actually causing the depression, and we just distract a lot of people with this medical language, and it leads them in the wrong direction. And so taking all of this together, you know, when we frame depression as this medical problem, it really benefits drug companies who want to sell medications, and it benefits healthcare systems who essentially thrive on these quick transactional visits. But it disempowers patients. It doesn't help them. It makes them feel like there's something inherently wrong with them that needs to be fixed by some drug, which they could stay on for decades, and that is then really hard to get off later on, instead of truly helping them.

I've kind of bashed the meds a little bit, so let's talk about where they fit in. If you are going to take meds for depression, the first thing you need is to have a good doctor. And this means someone who's actually going to spend time with you, and they're going to look at all of the different causes of depression. They need to rule out common medical conditions that mimic depression, things like sleep apnea, or even dietary issues, or substance abuse. Staying on the dietary issues for a second, now that I work in helping people come off psychiatric meds, I'm seeing so many people who have been on psychiatric meds for decades who simply changed their diets, they started doing ketogenic, anti-inflammatory diets, and they felt a lot better and allowed them to come off. And honestly, if you are having depression and you do not know where it's coming from, you need to consider some dietary changes because that is a medical cause, you know, that may be contributing to you feeling this way. And the unfortunate thing is, a lot of doctors aren't looking at these other factors with their patients to try and rule them out before kind of parking them on meds. And so you really need to have a doctor that's going to do a thorough evaluation of why you're depressed.

And so if you've seen this doctor, and you've had this very thorough evaluation, and maybe, and you've done the psychotherapy, and you've done the career coaching, or any of these interventions, and maybe you've done your diet, and you're still feeling unhappy, then go ahead and take antidepressants. There's absolutely nothing wrong with them. That is, in fact, how they should be used. They should be used as this last resort when everything else has been tried. The unfortunate reality that I see now is that most people are not getting this thorough workup, and they're simply, they're kind of just getting shuffled through the system and put on meds, and then they have their meds simply just adjusted by their doctors who don't really understand what's going on in their life and haven't really done this full workup.

Well, there you have it. That is my take on depression. I know it is a bold take, but I believe it is an accurate one. I would love to get your feedback on how you view this perspective on depression and how it's being kind of pushed on people these days. Please tell me about it in the comments below this video.