What might a French philosopher living in 17th century Amsterdam have to do with the stagnation of progress regarding the origin and treatment of depression in the 21st century? And not just any philosopher, but the father of modern Western philosophy, Rene Descartes.
In his latest book, Professor Edward Bullmore challenges the reader, and the medical establishment, to re-evaluate the treatment of depression by “drawing attention to the deep historical roots of some aspects of the modern medical mindset…inspired by Descartes”. Further, that “the greatest possible respect for Descartes as a writer, mathematician and thinker…shouldn’t blind us to potentially useful new ways of understanding and treating mental health symptoms which aren’t predicated on a split between mind and body”.
Professor Bullmore explains, “I think the impact of Descartes and his dualist theory of a material machine-like body and an immaterial god-like mind has been foundational in the triumph of western medicine. This split between body and mind traditionally prevents doctors thinking about the major depressive disorder as caused by disorders of the body.” And this is the salient point. Because how treatment is metered out is “represented organizationally in the division between medical and mental health services in the British NHS, for example…” and because of this “it can make it difficult for the many patients with both physical and mental health symptoms to find “joined-up” treatment. With all due respect to Descartes, who was writing 400 years ago, dualism is a philosophical constraint on the way we conventionally think about depression that we shouldn’t be blind to”.
Depression, for millions of people, continues to be a maddeningly slippery issue to understand and treat. For Professor Bullmore, interest in its treatment goes back to the early 1980s when “at that time the dominant idea was that depression was caused by an imbalance of neurotransmitters in the brain: not enough serotonin, for example. To this day, more than 30 years later, many patients are treated for depression with SSRIs – the serotonin reuptake inhibitors exemplified by Prozac – on the grounds that these and related drugs work as anti-depressants because they boost levels of serotonin in the brain”.
“…it became clear…”, he explains, “…(in) around 2010, that we needed to think differently about how to treat depression because the old model of boosting serotonin (or noradrenaline or dopamine) as a panacea for all patients with depression was not delivering ever for more effective new drugs, and therapeutic progress in real-life had stalled.”
Another French thinker of repute, Michel Foucault, expressed similar concerns that “western medicine has dehumanized or mechanized the patient”, echoing “another criticism of Cartesian dualism, by succeeding “in treating the physical disease as if it was a biological machine gone wrong. But this intense medical focus on physical mechanism, which follows directly from Descartes, comes at the cost of disregarding any mental aspects of the patient – like their personality, their sense of humour, their sexual orientation – which doctors can’t explain in terms of genes, cells, molecules and the other components of the body machine.”
This promising new way of approaching the treatment of depression might well represent a paradigm shift. And if “the most powerful lever of change in the history of medicine was always the advent of a new treatment” then what might this new treatment be? “If we had a new drug for depression…” Professor Bullmore explains, “…that worked well for some of the many patients, about a third, who don’t recover entirely after treatment with SSRIs or psychotherapy, that would be a big step forward. If we had a blood test or a biomarker that we could use to predict which patients with MDD were particularly likely to respond well to this new drug that would be epochal”.
