“I forgot to ask why she’s depressed.” I felt my head tilt a bit at my colleague’s comment. At the time, I thought to myself, "Why on earth would anyone ask someone that?" In a medical setting, the question felt as bizarre as asking someone with epilepsy why they were seizing. He is depressed because he has depression. Simple.

With each year, I’ve grown in respect for the often-overlooked question.

Most mental health professionals are trained in the bio-psycho-social-spiritual (sometimes the spiritual is left off) model of mental health. Still, what emphasis is placed in any of these quadrants tends to vary by profession. Individual therapists tend to focus on the psychological piece, that is, how is this person’s beliefs or experience of their circumstances affecting their well-being?

Social workers tend to expand this to include the person’s experiences within their environment and social context. Is this person’s experience of poverty or isolation affecting their happiness?

Prescribers tend to zero in on the biological aspects of health while existential or spiritual counselors are more likely to focus on things like meaning, faith, and loss.

Depression (and psychological health) is anything but simple.

For some time, the medical model reined in terms of a primary explanation of mental illness. It provided a stark relief from what often came across as blaming within traditional psychoanalytic explanations. It’s not your fault, it’s not your parents’ fault, your brain is sick. Research showing differences between depressed brains and healthy brains provide support (Sacher et al, 2012).

The promise of medication also offers hope of as a respite from depression. I remember watching commercials of sad-faced and smiley-faced cartoons correcting their ‘chemical imbalance’ through these medications. In my undergraduate psychology classes, I learned a more technical version. I wondered,
"Where are people receiving testing on their serotonin levels?" Systemic reviews have since found little to no relation between serotonin and depression (Moncrieff et al, 2022). This is not to say that serotonin-focused antidepressants do not play a critical role in the treatment of depression, just that a causal link has never been established.

More recent research showing alterations in connectivity and activity within the brain as well as novel antidepressant methods that intervene through magnetic stimulation or targeting the GABA-Glutamate system have provided an alternative biological explanation (Duman et al, 2019). This is exciting. Yet, still incomplete. Many things affect the brain. Taxi drivers who spend hours memorizing roadways show brain changes in areas linked to memory, like the hippocampus (Maguire et al, 2000).

It would be fair to ask if psychological or social experiences account for some of the brain changes linked with depression. Preliminary research involving rats suggests that chronic stress could modify this GABA-Glutamate cycle and induce depression (Xu et al, 2020). Research targeting new treatments focused on this cycle is seeking to better understand if a biological intervention can correct this.

A biological solution for a condition that may be, in part, for some, very tentatively, socially triggered? That’s fascinating.

Still, for many, factors such as grief, trauma, low self-worth, role transitions, lost sense of meaning, identity issues, relationships, and so forth appear to play a role in depression for many making community and psychological interventions often necessary. It’s difficult to reach freedom from a condition that could be, in part, related to chronic stress when you are, well, continuously chronically stressed. Above and beyond this, the meaning allotted to this stress and how someone relates to it would logically play a role. The meaning we ascribe to our suffering tends to have a strong effect on our resilience through it.

Perhaps the proportions to which biological, psychological, social, and spiritual factors vary from person to person.

Nonetheless, a thorough walkthrough of each of these areas followed by a whole-person approach may be central to effective depression treatment. Further, as has been brought forth by many others, maybe the first question we ought to ask is, "What happened?" rather than "What’s wrong" (Milton, 2022).