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Jean Kim M.D.

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Why Do We Misunderstand Depression?

Depression is a complex and serious illness—not a matter of Like 16

willpower alone.
Posted Dec 28, 2017

The suicide of beloved comedian Robin Williams several years ago launched a collective dialogue about mental illness. Many
have poignantly noted the ways depression and other mental illnesses can ravage the individual psyche, and the ways people
can seek help if needed. Others have noted that Williams probably had access to the best care, and it still wasn’t enough.

But as a psychiatrist who has grappled with it both professionally and personally, depression can be a multilayered beast,
interlaced with one’s personality, vulnerabilities, and upbringing, all intermingling with the dark shades of misfiring brain
chemistry. This complexity leads to ongoing confusion and debate over how much mental illness relies on personal resolve
versus personal biology.

Too often, people are quick to stigmatize depression and other mental illnesses as forms of moral weakness or lack of
willpower, especially in individualistic America. It’s even worse when Hollywood celebrities join the gambit with overly one-
sided or misinformed opinions, like actor Tom Cruise critiquing Brooke Shields’ use of medication for postpartum depression,
or Kiss frontman Gene Simmons recently telling a depressed teen, “F*** you, then kill yourself.”

People are quick to judge therapy or medication as a crutch in this oh-so-simple game of mind over matter: Such treatments
are seen as either an easy tool for wimpy people who can’t solve their own problems or a toxic mind-control method created
by conspiratorial forces.

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But with Williams’ death, something seemed to shift. People started to recognize that depression must relate to biology,
because who would give up such an outwardly gifted life? Williams was always busy making the rest of us happy, and we
adored him for it. For such a source of outward joy to crumble so violently—what happened?

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Depression’s biology skews your vision and distorts reality. It sprays a fog that makes the afflicted person feel that nothing is
ever good enough, that people hate you or you hate them, and that you will never feel secure in your world, no matter what.
Sometimes it is accompanied by anxiety, which brings crippling panic, feelings of danger, racing thoughts of doom, and
obsessions with misery, plaguing you in the dark of night or jerking you awake at the crack of dawn. You feel a horrible, self-
punishing sense of isolation and loneliness. And yet, you can appear outwardly perfect, seeming to have it all together. You
frenetically play-act while you feel your soul is dying.

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To varying degrees, the foundations of your background can help or harm you. If you have supportive parents, financial stability,
good friends, or a job you love, you might do well despite some negative biology. Others have resilience, overcoming negative
socioeconomic or situational circumstances and ending up with a positive outlook, as long as they are not saddled with certain
genetic vulnerabilities.

Confounding matters is the influence of external stressors and trauma on a person’s neurobiology, particularly in childhood.
Several studies have shown that abuse and trauma can affect one’s hypothalamic-pituitary-adrenal (HPA) axis, which triggers
one’s fight-or-flight response. The HPA axis is a circuit between your brain, your hormone glands, and the rest of your body.
The different parts are constantly signaling each other.

For example, you see and hear someone yelling at you. Your brain recognizes it and signals the parts of the brain—the
hypothalamus and pituitary—that release hormones to signal your adrenal glands, which in turn release chemicals that raise
your heart rate and blood pressure. You go into hyperalert mode until the threat passes and other hormones shut down your
signaling loop. However, prolonged stress exposure can actually modify your HPA axis’ thresholds over time so that your
system does not turn off easily, or is hyperreactive to minor, even nonexistent threats. Your brain chemistry changes to one that
is more easily prone to anxiety and depression, since the same chemicals and signals are involved in this fear response.

Your brain is even more sensitive during childhood, which renders this population especially vulnerable to future mental illness.
Early intervention, in these cases, may lead to better long-term outcomes. But even in adulthood, the HPA axis can be
malleable. Both medications and therapy—and often, the combination of the two—have been shown to help restore its
balance, which I have witnessed in research and clinical practice.
Another factor is epigenetics, a burgeoning field where scientists are realizing that the genome can partially change its code in
response to outside stressors or influences. So some people who might have a genetic tendency toward depression, anxiety,
or schizophrenia may not develop those conditions if they grow up in a safe, nurturing environment. But if they are exposed to
even minor trauma, parts of their genome involved in the HPA axis or other neurochemical circuits in the brain might get
activated—like a railroad switch, leading one down a more perilous track.

However, there are some genes that switch on from the beginning with a severe and intractable course, and no amount of love
and support can overcome them. Virginia State Senator Creigh Deeds’ late son was a classic example of someone who,
despite having a solid and well-off family, developed a serious mental illness. He became acutely delusional and committed
suicide after attacking his father. Robin Williams also likely battled his condition valiantly for many years, but may have taken a
turn for the worse after the additional biological stressors of open-heart surgery and Parkinson’s disease, both of which are
known to exacerbate and/or cause depression. (His family later stated he had Lewy Body Dementia, a progressive disorder
related to Parkinson's.) These treatment-resistant cases indicate the ongoing need for more cutting-edge medical and genetic
research into what causes devastating conditions like schizophrenia, severe bipolar, and psychotic depression, as well as
how to develop better treatments.

The brain is the most complex organ in our body. It runs like a polyphonic symphony compared to the simple percussion
section of the heart or the synchronized cellos of the liver. We have only scratched the surface of how it functions, although we
are making amazing advances in the last few decades thanks to new strides in DNA and genetic research and neuroimaging.
Medications and psychotherapy and treatments like electroconvulsive therapy (ECT) are important and can be helpful, but our
complement of tools remains relatively limited (and admittedly crude) in light of the brain’s immense complexity, and the
complicating factors of life itself: how people interact with their world, talk to people, their aspirations and goals, their
heartbreaks, their tragedies, their flaws. The brain and the universe are in constant flux, playing with and against each other,
with the mind struggling to make sense of how to survive out there and the world pushing back against the brain’s physical
limitations.

For the unfortunately common perception that depression and anxiety are just a matter of “snapping out of it” and “pushing
ahead” or “just being happy and grateful,” we need to step back and recognize the immensity of what we are dealing with. The
brain is miraculous, whether you come to that recognition via faith or evolutionary science. It's not a simple toy box or video
game. Even without understanding advanced neurobiology, you can recognize that the brain is, really, everything to us. We see
what happens with even small strokes or traumatic brain injuries—how your ability to talk, think, speak, and move all quickly get
affected, and how limited our ability to treat even small damages is. Our behavior and our moods are no different; they are also
part of the central package.

These tragedies should be a clarion call for Americans and others around the world to recognize that mental illness is real, is
nobody’s “fault,” and that there is no shame in getting help. Mental illness is physical and medical, but it is also even more
intricate than that; mental illness ties into our very existence, our interaction with everyone and everything. The prognosis of
each person runs on a spectrum relative to their genetic loading and their environment. At least on a limited but important part
of that spectrum, we as mental health professionals can intervene and help some people hang on, improve, come back
against biology, and soothe against environment. For those that we can save, the rest of us must stand watch and bring them
to light instead of losing them to falsehoods and misplaced moral codes about independence.

After all, is it stronger and more effective to till a large field alone, or with a team of fellow human beings alongside you?

A version of this article was originally published in The Daily Beast on August 20, 2014.

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About the Author
Jean Kim, M.D. is a psychiatrist and writer working in Washington, DC.

Online:
Jean Kim MD

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