The following article appeared in the Fall 2012 issue of Inquiring Mind.
POPPING PILLS FOR DEPRESSION:
A BUDDHIST VIEW
By B. Alan Wallace
The whole of the Buddha’s teachings stems from compassion, the wish that all beings may be free from suffering and its causes. In today’s world, one of the most oppressive and debilitating kinds of suffering is depression. Far more than fleeting experiences of sadness, the clinically diagnosed mental disorder known as major depression is disabling in that it interferes with our ability to work, sleep, study, eat and enjoy once-pleasurable activities. The World Health Organization notes that mental ill health is increasing, and predicts that one in four persons will develop one or more mental disorders during their lives. By the year 2020, depression is expected to be the highest-ranking cause of disease in the developed world.
In order to treat depression effectively, we must identify the specific causes and circumstances that contribute to individual cases. Otherwise, there is the danger that we may blindly treat its symptoms without addressing its underlying causes. According to recent studies, it seems highly unlikely that depression arises purely from chemical imbalances, except in rare cases of vitamin deficiencies, stroke and so on. Further, a synthesis of hundreds of studies indicates that antidepressants are no more effective in treating depression arising from these types of causes than in treating depression arising from stress-related causes. This implies that depression is best understood as a mental, not a neurological, disorder.
I find it helpful to draw a distinction between these two kinds of disorders. Neurological disorders, such as autism, stem primarily from objective, biological factors, which in turn affect subjective experience. Mental disorders stem primarily from subjective mental processes, which in turn affect the brain. My underlying hypothesis here is that the mind and brain are causally interrelated but are not identical. Evidence suggests that depression is best understood as a mental disorder, so effective cures will be found by examining its principal psychological causes. This way of distinguishing between mental and neurological disorders helps to explain why our rapidly growing knowledge of the brain has not resulted in a corresponding degree of progress in developing drugs to treat mental diseases.
According to Buddhist psychology, major depression is itself not regarded as a “mental affliction” (kilesa) per se but is rather a symptom of the underlying afflictions of craving, hostility and delusion. All mental afflictions are characterized by their quality of disrupting the balance of the mind, resulting in unwholesome behavior, which in turn gives rise to suffering for ourselves and others. Buddhist practice—comprised of the cultivation of ethics, samadhi and wisdom—is intended to remedy these true causes of human misery.
If we look for the afflictive psychological processes within the Buddhist context that may result in depression, we may find that the so-called Five Hindrances, or “obscurations,” play a crucial role. These include (1) craving and attachment to hedonic pleasures, including those related to wealth, power and fame (resulting in chronic frustration and anxiety); (2) malevolence and resentment; (3) attention deficit and dullness; (4) attention hyperactivity and guilt; and (5) debilitating uncertainty. The Buddha declared that, “So long as these five obscurations are not abandoned, one considers himself as indebted, sick, in bonds, enslaved and lost in a desert track” (Sāmaññaphala Sutta). This is clearly a description of mental ill health, and it implies a fundamental, distinctive characteristic of the Buddhist worldview, namely that the mind of a person that is prone to all the above obscurations may be normal but it is not healthy.
Depression that stems from any of those obscurations is indirectly soothed with the cultivation of ethical discipline based on nonviolence and benevolence, and directly calmed with samadhi, or focused attention. Through training in samadhi, involving the cultivation of mindfulness and introspection, one learns how to overcome the habitual tendency of negative rumination and to develop a sense of physical and mental ease, together with the enhancement of attentional stability and clarity. The healing efficacy of such meditative practice is further augmented with the cultivation of the sublime virtues of lovingkindness, compassion, empathetic joy and equanimity.
Delusion lies at the root of the mental afflictions of craving and hostility, and it is of two kinds: inborn and acquired. Inborn forms of delusion include the cognitive biases of viewing the impermanent as permanent, mistaking the true sources of suffering and genuine happiness, and falsely reifying inner and outer phenomena as “I” and “mine.” So on the basis of exceptional mental balance achieved through the practice of samadhi, one may effectively venture into the practice of insight meditation, resulting in the liberating wisdom of realizing the nature of impermanence, suffering and non-self. Such wisdom serves as a direct antidote to depression by healing its most fundamental causes of misapprehending the nature of reality.
It is important not to mistake the mental disorder of depression with sadness and disillusionment that stem from deepening insight into the nature of reality. Such unhappiness may be aroused, for example, by a personal sense of disenchantment with the unsatisfying pursuit of hedonic pleasure, or overwhelming sympathy for the suffering and misery of others, accompanied by a sense of helplessness to alleviate their pain.
Such sadness may serve as a key element in finding a more authentic, altruistic and fulfilling way of life, as well as more effective ways to be of service to others. Meditation may in fact arouse such reality-based dismay, and well-rounded Buddhist practice may result in a meaningful shift in one’s worldview, values and way of life that enables one to overcome such unhappiness from its source.
Through the course of our lives we may compound our innate delusional tendencies to misapprehend reality with kinds of delusion that we pick up from our cultural environment and education. In my view, scientific materialism is a kind of acquired delusion that dominates modern education, scientific inquiry and the popular media. This is the view that the whole of reality consists of nothing more than mass-energy, space-time and their derivative properties. Materialists also commonly believe that only physical processes have causal efficacy, implying that the only influences on the brain are physical ones. This belief ignores the causal efficacy of meaningful information, which cannot be measured by mindless machines but can be detected by subjective, conscious intelligence.
The only kinds of natural phenomena scientists can measure with their instruments of technology are objective, physical and quantifiable. But mental processes—in contrast to their behavioral expressions and neural correlates—are subjective, have no physical attributes and are qualitative. So they are invisible to scientific methods of measurement. Materialists therefore equate that which they can’t measure—subjective experience—with that which they can measure. This implies a kind of “methodolatry” by which one assumes that the third-person methods of inquiry of science constitute “the one true path” to understanding the natural world, while discounting the insights and discoveries that may be made through first-person introspection and contemplative inquiry. So I reject both this exclusionist approach to understanding nature, as well as its reductionist conclusions, for they are not validated by empirical evidence or by logical argument.
Materialists commonly equate people with their brains, which operate according to the amoral, mindless laws of physics and chemistry. Many people, including myself, find this belief to be not only unsubstantiated by empirical evidence but also dehumanizing, disempowering and demoralizing. Indoctrination into this belief system—especially when it is presented as being integral to any scientific worldview—may itself be a major, indirect cause of depression in the modern world. It is crucial to note that many scientists do not adhere to the metaphysical principles of materialism. This clearly implies that it is not a necessary feature of scientific thinking.
But there are many researchers in the field of mental health who regard all mental disorders simply as brain disorders, implying that the primary way to treat them is with drugs or other physical interventions. In the “developed world,” where materialism is most influential, people are popping more pills than ever, with one in five adults in the United States now taking at least one psychiatric drug. In the meantime, the drug industry spends billions of dollars to increase its sales by advertising directly to the public, in addition to marketing targeted at mental healthcare professionals. Their efforts have paid off. During the decade from 1996 to 2005, the number of Americans taking antidepressants doubled from 13.3 million to 27 million, and in 2008, sales of antidepressants totaled a staggering $9.6 billion in the U.S. alone. Millions of people are clearly desperate for relief from misery.
There is a heavy price to pay for this long-term dependency on drugs—beyond the obvious monetary burden—and that is that such drugs treat only the symptoms of almost all cases of depression, resulting in prolonged drug dependence, with its wide range of possible negative side effects. While the pharmaceutical industry claims that antidepressants help about seventy-five percent of those who take them, the failure of such drugs for the remaining twenty-five percent may actually lead to further despair, as people conclude that they are irreversibly damaged neurologically.
Scientifically, it is crucial to determine whether the benefits for the seventy-five percent majority truly result from drug therapy or the placebo effect. According to a study published in 2002 in the American Journal of Psychiatry, up to seventy-five percent of the efficacy attributed to antidepressants is actually due to the placebo effect, which is a misnomer for the efficacy of the subjective, conscious response to meaningful information. Other studies show that the worse the side effects, the stronger the placebo effect. Patients become convinced that the drug they are taking is so strong it’s making them nauseated and impotent, so they falsely conclude it must be strong enough to lift their depression. Moreover, people who take an antidepressant are more likely to relapse when the antidepressant is discontinued, in contrast to patients who recover with a placebo and then have the placebo withdrawn.
Landmark research published in the Journal of the American Medical Association in 2010 indicates that the benefits of antidepressants are “nonexistent to negligible” in patients with mild, moderate and even severe depression, and that high doses of antidepressants are hardly more effective than low ones. Only in patients with very severe symptoms (about thirteen percent of people with depression) was there a statistically significant drug benefit. Consequently, worldwide sales of antidepressants, which peaked at $15 billion in 2003, are now expected to fall to under $6 billion by 2016.
While cognitive scientists have come to recognize that subjective mental processes play a significant role in inducing depression, scientific inquiry into the causes and treatments of depression, under the pervasive influence of materialist beliefs and methodologies, has thus far focused primarily on physical factors. Meanwhile, neuroscientists express perplexity that despite their rapidly growing knowledge of the brain, they have made little progress in developing drugs to suppress the symptoms of, let alone heal, mental diseases, which materialists insist are nothing more than brain disorders. This is the inevitable conclusion of the reductionist motto, “the mind is what the brain does.” It would be fascinating to see unbiased scientific research conducted on the effects of materialistic reductionism on depression and other mental disorders.
In summary, failure to identify and treat the true causes of depression has resulted in an overreliance on drugs and an underutilization of methods that heal it from its source. Pharmaceutical drugs do play an important role in helping to manage the symptoms of mental ill health, including anxiety disorders, attention deficit hyperactivity disorder and depression. For example, in cases of very severe depression, antidepressants help to restore enough emotional balance so that people can benefit from other forms of treatment such as mindfulness-based cognitive-behavioral therapy. But since mental disorders, as I have defined them, in contrast to neurological disorders, are primarily caused by subjective, psychological factors rather than objective, biological ones, we must turn to first-person experience to identify their true causes.
There is a wonderful complementarity between the rigorous third-person methodologies of modern science and the rigorous first-person methodologies of Buddhism and other contemplative traditions. For the first time in human history we have ready access to both systems of inquiry, each with its own strengths and limitations. Given the reality of suffering and its sources, and humanity’s urgent need to find relief from mental disorders, it is imperative to put aside ideological and methodological prejudices, both scientific and religious. We now have the opportunity to integrate contemplative and scientific methods of inquiry to provide a comprehensive understanding of human existence that fully embraces both the subjective and objective aspects of the natural world, without reducing either one to the other. This approach holds great promise for healing the afflictions of the modern world.
B. Alan Wallace, author of Meditations of a Buddhist Skeptic: A Manifesto for the Mind Sciences and Contemplative Practice, is the founder and president of the Santa Barbara Institute for Consciousness Studies. A Buddhist monk for fourteen years, with a doctorate in religious studies from Stanford University, he has been teaching Buddhist philosophy and meditation worldwide since 1976.
© 2012 Inquiring Mind