Conclusions

Mood disorder has an important neurobiological basis. This stretches from a vulnerability, which seems to be attributable to polymorphism in genes critical to stress regulation, through the impact that early experience has on the subsequent programming of the brain for stress responses, to the final responsiveness when encountering particular personal adversity in later life. Biological studies have highlighted the role of key brain areas within the limbic system such as the cingulate cortex and amygdala. We are still a long way from understanding, with any precision, the critical connections and cellular mechanisms, but the function of monoamine neurones generally, and serotonergic projections in particular, is closely associated with mood regulation. Peptide neurotransmitters have long seemed likely to play a central role in stress regulation, and their potential as targets for antidepressant drug action may yet be fulfilled. Finally, observations in the most chronic illnesses and in the elderly with depression have highlighted the possibility of a functional neuropathology underlying severe mood disorder that remains poorly understood.

The approaches of clinicians to the phenomenon of depression still polarize around the biological and the psychosocial. The main purpose is sometimes little more than an assertion of professional territory. This is both regrettable and unnecessary. Any account of depression that claims to be purely social or even psychological misses the point that we are also, in our natures, biological. It is possible to embrace the biology of depressive illness as a fact, while simultaneously acknowledging that it is expressed, and in particular experienced, by patients in psychological terms. Dualism has done psychiatry no favours by teaching us to create a dichotomy between a world of brainless minds and another of mindless brains. The fact that there is an underlying biology which can be unified with a brain-based psychology is, in itself, evidence neither for nor against the likely effect of biological versus psychological treatment. Only with an integrated understanding of the biology and the psychology of mood disorder will we understand the potential and limitations for treatments based on drugs or talking.

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