Depression is a kind of chronic psychic pain; there is no getting used to it. This distilled misery will afflict one in five of us at some point in our lifetimes. Philip Gold, a senior researcher at the US National Institutes of Health, knows this all too well – he has been researching it for around fifty years and has suffered it himself. In his new book, he summarises the findings of his work, in particular the dramatic progress that he and his colleagues have recently made. As he says towards the end, ‘it is difficult for me to express how excited and pleased I am by these breakthroughs after so many years of not getting to the core … of depressive illness’.

And it is an illness, he argues. Depression, Gold believes, is the normal human stress response gone horribly wrong, distorted and extended well beyond its usual duration, wreaking havoc on both the brain and the body. Owing to genetics and adverse experiences, some of us are sensitised to developing this chronic overactivation of the stress response, which not only generates feelings of fear and self-hatred but also damages the cells and tissues of the body, leading to premature coronary artery disease, diabetes, osteoporosis and strokes. Help, though, is at hand: researchers are currently developing and testing more than thirty new drugs, together with other interventions, from psychedelics and ketamine to magnetic stimulation of the brain and compounds designed to inoculate vulnerable individuals before they get depressed. Many of these will take effect within hours, instead of the weeks that traditional antidepressants take to work.

There will be those who are aggravated by this medical understanding of depression. For decades, psychiatry has squared off against its critics, successors to the ‘anti-psychiatry’ movement of the 1960s. They argue that depression (and other mental-health problems) are best thought of not as illnesses but as ‘problems of living’ – understandable responses to circumstances, including the deranged character of modern life. They worry that pathologising depression will inaccurately and unhelpfully locate the problem in the individual rather than society, and encourage reliance on medication rather than getting to the root causes of the problem. 

Such worries aren’t entirely baseless, but often wind up making a straw man of the opposition. In fact, Gold acknowledges the influence of a person’s environment, both present and past, on the development of depression and points to various aspects of contemporary life as likely culprits.

As for the biological science, it is in places fascinating. Following the controversy as to whether SSRIs (selective serotonin reuptake inhibitors) such as Prozac work (the answer seems to be that they do), it is interesting to learn that in recent months researchers have finally pinpointed the neurochemical that is the key player in the effect of these drugs (spoiler: it’s not serotonin). The cycles between mania and depression in bipolar disorder, meanwhile, turn out often to be tied to the lunar cycle, a finding that hints at just how strange and unknown our biology and psychology really are. The book’s scientific material can be tough going at times – some passages become a word-and-acronym salad of brain structures and chemicals – but it’s hard to see how that could have been avoided.

The only significant flaw in the book is its treatment of psychotherapy, and here the problem is not what you might expect. Far from marginalising it, Gold eulogises it, seeming to rely more on psychoanalytic dogma than on fifty years of research into psychotherapy.

Updating traditional psychoanalytic theory in light of his work on the stress system, he tells us that psychodynamic therapy works by enabling the client to excavate and finally grieve losses from their past, thus relieving the stress that these unhealed wounds have been generating. 

But if this is how psychodynamic therapy works, why is it that all other forms of therapy perform just as well while using different methods? And why don’t Gold’s patients actually recover due to therapy?

One patient, we are told, had an ‘excellent’ therapist who had been ‘masterful’ in her efforts to help the patient resolve her trauma, and yet the patient still came before Gold severely depressed and suicidal after several years of therapy. Gold himself attended therapy four times weekly for six years with a senior psychoanalyst. While it was of ‘immeasurable assistance’ in a range of ways, the process was ‘accelerated considerably’ when he started taking an antidepressant after four years of therapy. It is fortunate for these therapists, an uncharitable reader might think, that their assistance could not be measured. 

But perhaps we should be more charitable: therapy alone may not end a major depression, but Gold points to evidence that therapy combined with medication is more effective than either alone. In a case study drawn from his own work as a therapist, it is only once the patient responds to antidepressant medication that he is able to see clearly the unhelpful habits – perfectionism, overwork and approval-seeking – that have blighted his life and resolve to make the appropriate changes so as to live better and avert the risk of divorce. Without medication, there would have been no remission, but without therapy, the patient might not have known what to do with it.

Therapy is admittedly the focus of only one chapter in the book, the rest of which is a welcome update on developments in depression research, to which Gold has made a very great contribution. His passion for it is palpable and his concern for his patients heartfelt. It is easy to share his excitement as he moves towards his conclusion.

In the last few chapters of the book, he is able to shower the reader with details of promising new treatments – it’s an embarrassment of riches. Sceptics may say that breakthroughs in psychiatry are liable to be overhyped. We should all hope that on this occasion the excitement is justified.