Unfriendly Environment

The brain can sometimes be seen as a drama replicating one's own, mirroring the stress of the outside world and translating the fears and worries and heartbreaks that shape a person's existence into an array of chemical reactions that we are only just beginning to understand.

Certain genetic and biological abnormalities may predispose some people to depression or bipolar more than others, but this still does not explain the whimsical and selective nature of these beasts and why they spare one person and so mercilessly savage another.

According to the Surgeon General's landmark 1999 Report on Mental Health, stressful life events loom large in depression. For the elderly, grief following the death of a loved one is an important risk factor for both major and minor depression. At least 10 to 20 percent of widows and widowers develop clinical depression during the first year of bereavement.

But just as significant are the 80 to 90 percent of those widows and widowers who escape depression's wrath, suggesting that some of the victims may bear more than their own personal loss. According to the Surgeon General:

"The compelling impact of past parental neglect, physical and sexual abuse, and other forms of maltreatment on both adult emotional well-being and brain function is now firmly established for depression."

Research in both rodents and primates shows maternal deprivation stresses young animals and may predispose them to a lifetime of overreaction to stress.

But man is a thinking animal. According to cognitive theories, depression arises from a subjective feeling of helplessness and entrapment. The critical factor is the interpretation of the stressful event rather than the actual event, itself. For example, the Report states, a romantic breakup will trigger a much stronger emotional response if the affected person believes: "I am incomplete and empty without her love," or "I will never find another who makes me feel the way he does."

Adolescent girls suffer from depression in far greater numbers than boys, possibly because they are more socially-oriented and more dependent on positive social relationships. Also, girls may dwell more on negative events than do boys.

Negative thinking in itself may not be sufficient to engender depression, but when a pattern of thinking is embedded in an already mildly-depressed mood, a downward spiral may ensue.

There is uncertainty over whether a negative mindset actually precedes depression or makes its appearance only after a person is depressed, or is a consequence of a previous, perhaps unnoticed, depressive episode. Moreover we have yet another factor at play, here, that of temperament and personality. According to the Report:

"The study of personality and temperament is gaining momentum. Neuroticism predisposes to anxiety and depression. Having an easy-going temperament, on the other hand, protects against depression. Further, those with severe personality disorder are particularly likely to have a history of early adversity or maltreatment."

But whether a shy child, say, remains vulnerable into adulthood also depends on parental influence and life experience, thus completing that neat little circle of upbringing, personal disposition, life history, and stressful events that we refer to collectively as environment. And when we talk about environment, the Report need look no further than women:

In a study of Old Order Amish in Pennsylvania, the rate of depression was extremely low, and equivalent for men and women (as opposed to double that of men in the general population). This was enough for the Surgeon General to conclude:

"Something about the environment thus appears to interact with a woman's biology to cause a disproportionate incidence of depressive episodes among women."

And nowhere is this more apparent than amongst poor young women, who are at the greatest risk for depression. According to the Report:

"They have disproportionately higher rates of past exposure to trauma, including rape, sexual abuse, crime victimization, and physical abuse; poorer support systems; and greater barriers to treatment, including financial hardship and lack of insurance."

Single mothers are in an even worse bind, their risk being double that of their married counterparts.

And once again, we have cognitive factors coming into play:

"Because women tend to use more ruminative ways of coping (eg, thinking and talking about a problem, rather than seeking out a distracting activity) and, on average, have less economic power, they may be more likely to perceive their problems as less solvable. That perception increases the likelihood of feeling helpless or entrapped by one's problem."

Of course, this leaves begging a basic question: If the environment is so strongly linked to the mental distress of much of the population, shouldn't we be seeking to address some key issues, to right some obvious social wrongs?

If say depression turned out to be the equivalent of black lung disease, wouldn't it make sense find and root out some of the actual causes?

Or have we truly given up on the idea that we can change the world for the better, that we must settle, instead, for our medications and talking therapies? Has Prozac Nation, in effect, replaced equal justice under law?

The Surgeon General, predictably, didn't get into all of that. Thirty or so years ago, back in the sixties, a person in his position might have fired off a few zingers. Then again, thirty years ago the Surgeon General and everyone else all but ignored mental health, so we should probably be grateful for what we have.

In the meantime, knowing how environmentally unfriendly the world actually is - both for the well-off and their less fortunate counterparts - and that it will continue to get worse before it gets better, it pays now more than ever to look after yourself.

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John McManamy

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Former Surgeon General David Satcher: Past abuse is now firmly established for depression.