When Dante and Virgil pass through the threshold of Hell, they see a number of souls frantically running behind an empty flag. Bumblebees and wasps fly all around them, biting them. They are bleeding. Repellent worms devour their blood mixed with tears on the ground.
These are the souls of Sloth, those who lived to be lazy, to be indolent for lack of will, to be cowardly, to be indifferent. They refused to decide, they did not make any commitment to others, they saw their life as tedious and devoid of purpose, so they did not experience the power of human freedom while they were alive.
Since they did not experience the world in their lifetime, now they are constantly and shamefully stimulated and forced to move.
Dante's intuitive ability sets, in the first Cantica of the Divine Comedy, all the possible façons d'être of human beings that actually cause suffering not only for the person but also for those around him. Among these, Dante collocates the people that are not even worthy of being accepted in Hell, those who are identified through a disdainful contempt: Sloth.
Of course, the inability to live with enthusiasm and awareness is the subject of the meditation of other great literature, such as Romanticism and especially twentieth century literature. However, Dante's ability to portray, albeit by antithesis, the atmosphere of total misery and physical and spiritual disintegration that is characteristic of those who can only look at themselves during their lives is unparalleled.
Dante used the term Sloth, but today, those who are not able to dedicate themselves to something fascinating and that cannot rejoice at anything, are more commonly defined as depressed.
For a definition of depression
Science today considers depression as a disease characterized by mood swings, low self-esteem, and loss of interest or pleasure in usual activities. Commonly endogenous depression, which is established without appreciable causes, is distinguished from reactive depression, which is triggered by a particular event. Bipolar disorders, characterized by an alternating of depressive episodes and maniac episodes, are generally considered a separate form of depression. In the international systems of classification of diseases depression is among the so-called mood disorders and is divided into unipolar depression and bipolar depression.
Depression is a very serious psychopathology that affects the cognitive, emotional and behavioral life of people. It is characterized by symptoms such as a deep sense of sadness, inability to feel pleasure and interest, desperation and sense of personal ineptitude, as well as feelings of guilt and low self-esteem, poor memory and concentration, and ideas of suicide. However, physical symptoms, such as weakness, psychomotor agitation, abnormal circadian rhythm and sleep-wake cycle, appetite and sexual disorders, are frequently manifested.
Nowadays, its reach is considerably widespread all over the world and its severity may be sufficient to produce social disability (or even suicide) alongside high social and health costs. In fact, according to recent estimates of the World Health Organization, by 2020, depression will be the second leading cause of disability among chronic diseases. Depression is currently the leading cause of illness for women between 15 and 44, both in developed and in developing countries, and the third cause for men of the same age group. The disease's manifestation in the general population throughout a lifetime is estimated between 4.6% and 17%, with differences due to the geographical area (rural or urban) and the presence of other risk factors that can affect the emergence of the disease. For reasons that remain unclear, women are more likely to be affected than men, with an estimated ratio of 2:1. Also, depression is typically associated with an increased rate of risk of cardiovascular diseases, mortality and suicide.
The average age of the onset is about 25 but, generally, two peaks, one between 15 and 19 and the other between 25 and 29, are distinguishable. Usually depression is considered a chronic disease, characterized by a number of relapses over the years, which may be interspersed by periods of complete or partial remission.
The genesis of depression is attributed to several causes: biological, psychological and social. According to this idea, depression is the result of stressful life event(s), which, separately, could have a minimal effect, but instead, could affect an individual with particular genetic, psychological and social characteristics, and could lead to the development of depressive symptoms.
This paper aims to further analyze each of these three variables.
I. Depression from a biological point of view
Over the past few years, various theories, which were proposed when the first psychotropic drugs were discovered, have changed because of the accumulation of evidence for and against them.
The monoamminergic hypothesis, for example, has focused its attention on the possible role of malfunctions in the physiology of the systems, in which neurotransmitters, such as dopamine, epinephrine, serotonin, are involved. The genesis and maintenance of psychological and physical symptoms of depression were attributed mainly to a decrease in the concentration of serotonin in the brain, and this led to the production of large families of antidepressant drugs, based on enhancing serotonin transmission. This hypothesis has been revised in the recent years with a substantial shift from abnormalities of neuroamminergic neurotransmitters to alterations in their receptors. A study conducted with the SPECT (single photon emission computerized tomography), has demonstrated a reduction of the binding of serotonin transporters in depressed patients. Even with regards to dopamine, neuroimaging techniques have shown a lower binding capacity and a reduced density of the carrier.
However, because the brain is composed by an intricate neural network, in which groups of cells and entire functional areas are maintained in close connection with one another through the action of several neurotransmitters, currently, the most accepted hypothesis is that the etiology of depressive disorders does not depend mainly on a dysfunction of a single neurotransmitter system but rather on an imbalance of multiple systems, morphologically and functionally related to each other.
With this in mind, neuroscience has investigated the role played by other neurotransmitters and neuroactive molecules in depression. Glutamate, for example, is an amino acid that mediates excitatory neurotransmission and plays an important role in the phenomena of learning and memory. It appears that it might occur through mutations or polymorphisms in the gene that encodes the transcription of the NMDA (N-methyl-D-aspartate) receptor in the hippocampus. In particular, researchers showed, as based on the analysis of the behavior of rats placed in front of unsolvable tasks, that the introduction in the brain of BDNF (Brain-derived neurotrophic factor) produces an antidepressant effect in some animal models. This suggests that the involvement of nerve growth factors and thus of a modified plasticity could be responsible for depressive symptoms. Under conditions of stress, the BDNF gene is repressed and therefore its synthesis is reduced, while the neurons located in the hippocampus go to atrophy and apoptosis. Neuroimaging studies conducted on depressed patients showed a reduction in the volume of hippocampus brain structures, confirming the hypothesis that there is a reduction in number, function, and volume of the hippocampus' neurons associated with depression. It was also observed that prolonged treatment with antidepressants could increase the expression of BDNF and that of its receptor trk-b in other structures of the brain.
Another strand of research is one that suggests the presence of alterations at the level of molecules that are responsible for signal transductions from receptors to the cell (second messengers). Most of the receptors of serotonin are associated with G proteins, which modulate the activation of the second messenger cAMP (cyclic adenosine monophosphate), which in turn causes cell activation. The involvement of this protein in mood disorders was highlighted by several pharmacological studies conducted on animal models: the antidepressants regulate different subunits of the protein and its gene expression in different brain areas. In general, neuro-peptides are recognized to have a key role in the neurobiology of depression.
Finally, regarding to the role of the endocrine system, in different subtypes of depression researchers were able to identify the role of CRH (corticotropin releasing hormone) and the subsequent function of cortisol. An increased secretion of CRH and, therefore, an increased circulation of cortisol seem to be responsible for psychomotor agitation, insomnia and decreased appetite. A reduced activity of CHR and a reduced cortisol level seem to be related to other depressive symptoms, such as fatigue, hypersomnia and hyperphagia.
Another neuropeptide probably involved in depression is the substance P, which acts as a neurobiological mediator in response to pain. This substance is involved in stress response and is produced in areas of the central nervous system (CNS) that are responsible for the regulation of affectivity. The antagonist action of the substance P is starting to be used, with some positive outcomes in the treatment of depression. Furthermore, the use of the thyroid hormone (which has the effect of stimulating metabolism and psychophisiological activation), in conjunction with other antidepressants, has become common practice, confirming the involvement of the endocrine system in depressive disorders.
Currently, the drugs used in cases of depression are called SSRIs (selective Serotonin reuptake inhibitors). These drugs include fluoxetine, paroxetine, citalopram and others that have high specificity for serotonin systems. SSRIs are also used in the treatment of other mental illnesses, such as obsessive-compulsive disorder, panic disorder, or bulimia.
Unfortunately, the extreme prevalence of diagnosed depressive disorder, even in the event of slight uncomfortable conditions and the apparent ease of the use of SSRIs, even in basic medicine and in a wide range of disorders, are leading to an uncontrollable administration of antidepressants that, according to some statistics, are among the top pharmaceutical products sold worldwide.
Antidepressants have proved to be effective in mitigating particular symptoms. However, the interplay between the biological factors that seems to be responsible for depression and the world in which the individual is living originates a complicated set of interactions that cannot be reduced to a single answer for the treatment.
II. The psychological approach
The dominant conceptualizations, proposed to improve the understanding of depression, are the psychological and psychodynamic models.
Psychodynamic models rely extensively on intra-psychic conflicts; depressed people emotionally punish themselves rather than openly express anger against other people. Another key factor is the need for dependency, which appears to be the result of trauma occurred in early childhood. This model proposes that an individual who has received insufficient rewards during childhood, as an adult tends to develop the feelings of not being worthy of love. These conditions, combined with personal losses, as the death of a loved one, or recurring criticisms can produce depression.
In general, however, psychoanalysts consider depression as an epochal disease or, rather, the place where the psychoanalyst encounters, more than elsewhere, moral pain and hatred, guilt and mourning. This is the time of the rupture, the real collapse of the subject, the crumbling of the socially and culturally adaptive shell. If this is cured, it can lead to an emotional transformation in the patient. In summary, for psychoanalysts depression signals a need for change.
Cognitive psychology, however, considers depression as the outcome of a cognitive depressive configuration, based on a negative idea of the self, the world and the future. In other words, for the depressed individual the concept of self is pejorative, the world is hostile and the future is bleak. If so, most people do not become depressed when certain events occur, but when the same events are seen through the cognitive depressive configuration as the evidence of a personal lack of value. Therefore depression is not caused by a particular event, but rather by the personal interpretation of the subject.
On the other hand, the behavioral approach argues that depression is established when a person acts in a way that rarely leads to positive consequences. The lack of rewards produces a decrease of activity, which in turn leads to a further decrease of positive consequences. This scarcity of positive consequences can occur for several reasons: the person may feel like reinforcing only few events, and is unable to feel involved in events that would reinforce himself, or fail to take the actions that are necessary to earn the reinforcement.
Differently, the impotence model suggests that depression is the result of a previous experience of adverse conditions that the individual cannot control. As a logical consequence, the powerless individual learns that his answers and their outcomes are independent from each other; consequently the actions that seem to have a purpose actually prove to be futile. In other words, the experience of powerlessness teaches the subject that he cannot control his life, and are responsible for an apathetic and depressed lifestyle.
Finally, the constructivist model is built on the assumption that the mind constructs reality in the same way that reality constructs the mind, in accordance with a circular perspective. Depression is the result of the interaction of the subject with his living environment, in particular with an environment that does not recognize this interaction, but uses it for its affirmation.
III. Notes for a perspective that highlights the role of a social and cultural context.
It would be interesting to ask if depression is always a symptom of unhappiness. In this regard, the anthropological disciplines that deal with emotions have made great progress, which are all findings of skilled researchers who spent months and years living with the most diverse populations across the globe. What their studies tell is that every culture has its palette of emotions, which are meaningful only if included within the system they belong to.
Anger, laughter, joy but also melancholy and sadness are universal experiences, but they occur often in presence of opposed phenomena and with different intensity. For example, for Polynesians, excess of joy or anger is frowned upon, thus the whole group lives in constant moderation interspersed with moments of collective madness. By contrast, mourning must be turned into joy for the mothers of the Brazilian favelas, where child mortality is high.
In general the emotions should be interpreted in the cultural heritage of a particular society; in other words, emotions belong to a language that can be understood only after one becomes acquainted with the cultural and social context in which they are expressed.
In short, humanity, when studied in terms of emotions, appears to be very complex, because, as Bateson believes, the emotions are to be understood as part of an ecological system and thus require a dynamic balance. Therefore, the concepts of happiness and unhappiness are questionable parameters, because they claim to reduce the frame of mind to those needs, gaps that must be filled, or to the contrary.
Even philosophers demonstrate interest in the frames of mind that characterize humanity, both in absolute terms and relative to specific contexts.
The reflections of Schopenhauer (1788-1860) and Nietzsche (1844-1900) appear to be significant for this purpose.
Schopenhauer believed that life is a continuous struggle for existence, the repetition of the same story in different forms but with the certainty of final defeat. Living means having to satisfy needs, but once the need is met, the individual falls into satiety and boredom. In order to escape from these states, the noluntas, the state of non-willingness that leads the individual to isolation through his removal from the greater society, in a sort of depressive solution, is required.
For Nietzsche, however, only the pre-socratic Greek civilization has a strong tragic sense, which is an excited acceptance of life, courage before one's fate, glorification of vital values. Its secret is in the spirit of Dionysus (the image of instinctive strength and health, creative drunkenness, sensual passion, symbol of a humanity in agreement with nature).
However, with Euripides, the dionysian element was removed from tragedy in favor of moral and intellectual ones. The clear brightness towards life is then transformed in syllogistic superficiality: Socrates stands with his mad presumption to understand and to dominate life with reason. But Socrates (and with him his followers) is equivocal, in the same way as the whole moral of perfection, even the Christian one.
Christianity views earthly values and pleasures as sin. Such elements represent all that is weak, abject, not well done. In light of these, we may view Christianity as the religion of compassion. But compassion encumbers the law of development, which is the law of selection. The Christian God is a degenerated God that contradicts lives, instead of being their transfiguration. The cross is a conspiracy against health, beauty, success, goodness of the soul, even against life: in short, it is a hymn to depression and against any vital enthusiasm.
These positions view depression as intrinsic to life (as is the case with Schopenauer) or as a result of a social and cultural context that denies joy (as Nietzsche observes). The latter view contradicts the former, which in turn reduced by the fact that depression is an existential state that can be found in different times and spaces. Thus, it does not only appear to be typical of a capitalist and individualistic society.
Everything that is human is the result of an evolution that provided the maintenance or development of the tools that allow the individual to survive. Therefore, we must acknowledge that the propensity to depression has its own function in the formation of a person.
Certainly, depression implies a fall of energy and enthusiasm towards the activities of life-in particular distractions and pleasures - and, when it becomes deeper, it has also the effect of slowing down the metabolism and facilitating the emergence of other diseases.
But the isolationist tendency, which accompanies depression, is necessary in order to adapt to loss, disappointment or relational contexts that do not allow other forms of coping. Depression may not only provide the opportunity to process a loss or a strenuous experience, it may also help understand the consequences of painful events in our lives: it may represent the only possible way, for a specific individual, to stay in the world.
Each phenomenon of depression should be placed within the context in which it manifests itself, in order to identify its purpose. However, if this goal precludes the vital movement and appears to be harmful for the individual, a cure that may introduce other lifestyles to the depressive dimension must be adopted.
Again the diagnosis and the treatment must be evaluated in a specific cultural context and the motivations of the group within which the person lives. Then, the reproach should not take on the form of anger, as is described in the Divine Comedy, it should be respectful and able to understand the reasons behind depression, and not just issue opinions, while teaching to appreciate the interlocutor.
D. Alighieri, Divine Comedy, Inferno, cantoIII
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D. Goleman, Emotional Intelligence, Bur, 1999