“Why are you depressed?”

Perhaps one of the least helpful questions to ask a person with depression, “why are you depressed?” is nonetheless also the most common sense question to ask.

According to the World Health Organisation: depression is the world's leading cause of disability in terms of 'Years Lived with Disability' (YLD), and the fourth leading contributor to global disease burden as measured in Disability Adjusted Life Years (DALYs - “The sum of years of potential life lost due to premature mortality and the years of productive life lost due to disability.”)

Yet 'depression' is not an homogeneous condition. Rather, it is symptomatic of a range of illnesses, and may arise from a variety of causes, both physical and 'psychological'. For the sufferer, none of these causes may be apparent or obvious; lending a sense of mystery to this potentially debilitating condition. Like Churchill's 'Black Dog', we might even ascribe sinister metaphors to this ineffable thing that comes and goes according to its own logic. The 'why' of depression is indeed the pivotal question, not only in the pursuit of treatment and relief, but also with regard to the sufferer's own sense of understanding and control. At the very least, knowing why you are depressed might deny this condition some of its mystery and power.

We tend to think of depression as a modern problem, and it would therefore seem obvious to look for modern solutions. But in addition to seeking the best contemporary medical and psychological care, it would at least do no harm to inquire into some pre-modern opinions on the nature of depression. Of particular interest to me are the thoughts and reasons of the 13th Century philosopher: Thomas Aquinas. Let us therefore see what 'the Dumb Ox' had to say about the 'Black Dog'.

It may come as a surprise to learn that despite living in the Thirteenth Century, Aquinas was aware of the term 'depression', or its Latin equivalent (aggravatio – being weighed down), in the same general sense as we know it today:

“The soul, through being depressed so as to be unable to attend freely to outward things, withdraws to itself, closing itself up as it were.”

Not only was Aquinas aware of depression, he also subjected it to analysis:

“The effects of the soul's passions are sometimes named metaphorically…and in this way fervor is ascribed to love, expansion to pleasure, and depression to sorrow. For a man is said to be depressed, through being hindered in his own movement by some weight.”

From the outset, Aquinas displays an acuity missing from modern discussions of depression. He identifies immediately that the term 'depression' is used only metaphorically to describe the human condition. The original meaning of depression is to be 'pressed down' by something, as when a person is physically weighed down by a heavy object. Aquinas informs us that the psychological reality behind the metaphor is in fact 'sorrow'. This observation shifts the discussion from the mysterious element called 'depression' to the much more familiar psychological condition we know as 'sorrow'. Aquinas goes on to explain the function of sorrow:

“Sorrow is caused by a present evil: and this evil, from the very fact that it is repugnant to the movement of the will, depresses the soul, inasmuch as it hinders it from enjoying that which it wishes to enjoy.”

It is important to note at this point that Aquinas is referring to 'evil' in a general sense, as anything contrary or harmful to the good. This would include 'physical evil' such as injury and disease, as well as 'moral evil', and even more generally 'evil' circumstances such as misfortune and failure. Aquinas explains that sorrow is our natural response to the presence of some evil or ill, and that the degree of our sorrow is relative to our hope at avoiding or overcoming this evil. Hence he concludes:

“If, on the other hand, the strength of the evil be such as to exclude the hope of evasion, then even the interior movement of the afflicted soul is absolutely hindered, so that it cannot turn aside either this way or that. Sometimes even the external movement of the body is paralyzed, so that a man becomes completely stupefied.”

Depression is the effect of sorrow, and sorrow is a natural response to a present evil. The stronger the evil, the less our hope of avoiding it, and hence the greater our sorrow and depression. The problem for so many modern cases of depression is that we are not – collectively or individually – aware of any such 'evil' causes in our lives. Indeed, the lack of an obvious cause is characteristic of many depressive illnesses.

Does this mean that modern depression defies Aquinas' description? Or are we somehow oblivious to the 'evils' Aquinas wrote about?

As a tired ethicist, I must concur on this issue with those who suspect that 'modern life' is somehow contrary to human happiness, and that we are in fact oblivious to the ways in which it harms us. Having collectively abandoned the understanding of good and evil handed down to us by prior generations, how could we determine for ourselves the necessary ingredients for a fulfilled and happy human life? How can we identify the deficiencies in our way of life, without an objective account of the things that ought to fulfil us?

Having witnessed this illiteracy in the context of ethics, it should come as no surprise to witness its repercussions in a different aspect of human life.

Consider a brief list of goods held by traditional ethics to constitute the basic ingredients of human fulfilment: life (including health, and the provision of basic needs such as food, shelter, clothing, and transport), friendship, family, work, play, marriage, offspring, knowledge of the truth, appreciation of beauty, integrity, respect for others, love of others, and even religious belief and practice. Each of these things (and this is by no means a definitive list) has been demonstrated across the history of humanity to provide an irreducible and irreplaceable type of fulfilment.

If we wish to pursue Aquinas' analysis of depression to its logical conclusions, we could start by considering how well or how truly each of the goods on this list is incorporated into our lives. Contemporary attempts to manage depression correspond to this view, whether it be by advocating better sleep, nutrition, exercise, and spending time with friends, or through psychological treatments such as cognitive behavioural therapy, which help to break down false and counterproductive habits of thought.

Indeed, Aquinas directly endorses these approaches to the treatment of depression, under the general principle that: “every pleasure brings relief by assuaging any kind of sorrow, due to any cause whatever”. It is important to note that Aquinas defines pleasure as the enjoyment of a suitable good, which is very different from the modern understanding of pleasure for its own sake. For Aquinas, it follows that the enjoyment of friendship is a suitable form of pleasure, capable of diminishing sorrow and depression:

“When one is in pain, it is natural that the sympathy of a friend should afford consolation”

Aquinas also advocates sleep and baths for the alleviation of sorrow, observing that:

“Whatever restores the bodily nature to its due state of vital movement, is opposed to sorrow and assuages it.”

His approval for 'bodily remedies' could even be taken as in principle support for some forms of anti-depressant medication, where such medication helps to restore normal functioning:

“Moreover such remedies, from the very fact that they bring nature back to its normal state, are causes of pleasure; for this is precisely in what pleasure consists, as stated above. Therefore, since every pleasure assuages sorrow, sorrow is assuaged by such like bodily remedies.”

But Aquinas reserves his highest recommendation for the pleasure implicit in the contemplation of truth:

“The greatest of all pleasures consists in the contemplation of truth. Now every pleasure assuages pain as stated above: hence the contemplation of truth assuages pain or sorrow, and the more so, the more perfectly one is a lover of wisdom. And therefore in the midst of tribulations men rejoice in the contemplation of Divine things and of future Happiness”

It is difficult to read these final words without immediately reflecting on the status of 'truth' in contemporary Western culture. Many cases of depression have a physical component and respond well to treatment with drugs. But surely other factors must be at work if we are really facing an epidemic.

If the contemplation of truth is both our greatest pleasure, and a panacea for sorrow and depression, we should not be at all surprised by the prevalence and growth of depression in a society that has all but abandoned the concept of truth outside of various pragmatic enterprises such as law, finance, and the natural sciences. Friendship, we can accept; better sleep and a long bath are uncontroversial. But truth: what is that? as someone said about 2,000 years ago.

So it is unlikely that the contemplation of truth, or other basic goods will be promoted as a solution to depression in the near future – unless they can be packaged and sold in tablet form, or somehow explored through the lens of randomised controlled trials. But until then, will we be equipped to find a solution to the puzzling phenomenon of depression in the midst of 21st Century abundance?

Zac Alstin works at the Southern Cross Bioethics Institute in Adelaide, South Australia.