Intended for healthcare professionals


Autonomy, stress, and treatment of depression

BMJ 2008; 336 doi: (Published 08 May 2008) Cite this as: BMJ 2008;336:1046
  1. Paul Biegler, honorary research associate123
  1. 1School of Philosophy and Bioethics, Monash University, Clayton, Victoria 3800, Australia
  2. 2Emergency Department, Sandringham Hospital, Sandringham, Victoria
  3. 3Faculty of Medicine, Nursing and Health Sciences, Monash University
  1. Correspondence to: P Biegler pbiegler{at}
  • Accepted 11 February 2008

Psychotherapy canhelp patients understand the triggers for depression and how to deal with them. Paul Biegler argues that these effects should be given moral weight when deciding on treatment

Most guidelines on the treatment of less severe forms of depression conclude that antidepressants and psychotherapy have similar efficacy and recommend that either can be used.1 2 The evidence for these recommendations derives from studies that measure reduction of symptoms on instruments such as the Hamilton rating scale. However, these studies fail to take into account the role of self knowledge in the success of evidence based psychotherapy and the potential importance it has for depressed people. Psychotherapy affords people with depression greater autonomy in decisions and actions that relate to the object, or trigger, of the depressed response. Patient autonomy is rightly given considerable weight in medicine, and it should have greater influence on the discussions that guide treatment in depression.

Depression as a response to stressors

Some years ago, the philosopher and physician Carl Elliot wondered what might be wrong with using antidepressants to treat a melancholy Sisyphus, sentenced in perpetuity to pushing a big rock up a steep hill, only to see it roll back down again. Elliot concluded that to modify the affective response of Sisyphus with a drug was to ignore “certain larger aspects of his predicament connected to boulders, mountains, and eternity.”3 Elliot’s concerns—that the use of antidepressants fails to deal with the context in which the depression occurs—are given impetus by data showing that nearly 70% of depressive episodes are triggered by psychosocial stressors.4 Moreover, it is increasingly likely that many of the changes in brain chemistry that feature in depression, and that are targeted by antidepressants, follow from increased production of cortisol in response to stress.5

It is acknowledged that genetic predisposition6 and individual …

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