A Review of Charles L. Whitfield’s The Truth About Depression: Choices for Healing, By Richard A. Chefetz, M.D.

(from Journal of Nervous & Mental Illness, Nov 04)

In the this volume, the author’s message reads like this: 1. the abuse and neglect of children creates wounded and un-blossomed adults, 2. much of adult “depression” is related to an outgrowth of childhood trauma, 3. the pharmaceutical industry prays to the God of Profits (not Prophets), 4. neuroscientists can demonstrate, conclusively, that childhood trauma alters the developmental course of neural structure and function, 5. pharmacotherapy does not represent a panacea for these problems, and 6. attending to the basics of living a life: sleep, diet, exercise, safe relationships at home and in community, and cultivation of a spiritual life are enormously helpful to healing psychic wounds. Dr. Whitfield cites and organizes the content of several hundred studies that show the connection between child maltreatment and adult psychopathology. He uses broad strokes of his writing brush to paint the picture he clearly intends. In doing so he performs a service by making absolutely clear the evidence for his assertions. So, would I recommend this book to my patients, my colleagues, my friends?

What is really good in “The Truth About Depression?” After a series of orienting tasks, chapters five through nine, on the evidence showing the neuroscientific understanding of childhood trauma ought to be digestible for a bright patient or non-medical colleague, let alone psychiatrists who have not followed developments in neuroscience very closely in the last ten years or more. The author does a lot of summarizing of research, and his tables with their collation of study results are not only an excellent resource for information, but their annotation makes clear and supports the text in showing how developmental neurobiology is not just a scripted genetic “done deal,” but is rather a process that is highly vulnerable to imprinting by early adverse events in a child’s life. These results are the harbinger of adult psychopathology. No intellectually honest person could read this material and not come away convinced of these relationships. We no longer have to rely on efforts like those of Freud, to show that “infantile neurosis” creates “adult neurosis.” While the ‘Freud Bashers’ seem to be recently having a ‘party’ at the potential expense of overlooking what he did get right, and there was a lot of that, Whitfield takes no prisoners in knocking down any remaining myths about the links between childhood trauma and adult psychiatric illness.

Charles Whitfield is one of the first clinicians writing for the layman to tout the spectacular data coming from the collaboration of Kaiser Permanete’s Vincent Felliti and the Center for Disease Control’s Rob Anda, and their colleagues. Working with an n of now over 17,000 patients, their data conclusively shows how as the number of adverse childhood experiences (ACEs) rises past a cumulative count of four, the risk of major medical and psychiatric illness soars. Childhood trauma is bad for bodies and minds.

The author wisely points out the power of “naming” a process correctly. There is indeed a big difference in talking with people about having grief than the more amorphous term “depression.” “Stuck grief,” in my experience, is a much more useful perspective than chronic depression. Proper naming of a person’s situation creates the possibility of hope, a sorely needed ingredient in healing.

I don’t agree that antidepressants are routinely not much better than placebos. I think that the point is that they are not always, but “often enough” better than placebos. Maybe I find this because I am so reluctant to prescribe in general, unless someone has a definable target symptom and an impairment of function. Even then, I would have no interest in undermining a placebo effect, if it helps! Perhaps I would have been most comfortable with a more balanced approached that challenged psychiatrists to be as sophisticated about prescribing, as possible, and challenged pharmaceutical companies to do the same in regard to marketing and honesty in their claims. Whitfield does prescribe antidepressants for the severely depressed, and he does so judiciously. The bottom line is that if a person is cognitively blunted because of their depression, even if they are mostly functioning in a non-demanding home and work environment, they will not learn well in psychotherapy if they can’t think straight. In my experience, medication can often enough address this specific problem better than talking.

It would have made Dr. Whitfield’s case even more compelling and complete for his patients if he had included more detail on the relationship between Type D attachment patterns of infancy, adverse childhood experience, and the adult Type D attachment profile, available from the Adult Attachment Interview (van Ijzendoorn, 1995). I also believe it would have been more useful to talk about alteration in brain function as a result of childhood trauma rather than to use the more dramatic term: brain damage, a la J. Douglas Bremner (2002). I am sure he is aware that hippocampal size may be shown to change, not change at all, or to recover size, after treatment, in some, but not all studies. Hippocampal change is also seen in schizophrenia, and may be related to traumatic experience in those patients, or may not. Even if studies become conclusive in regard to specific brain changes for specific psychiatric illness it will imply alternative pathways of growth in human brains rather than brain damage. Cocaine use may cause permanent structural brain damage on an intracellular level. It seems more apt to say that childhood trauma causes ingrained functional alterations.

Much of what Charles Whitfield writes is the subject of a therapy long psychoeducational effort that is a routine part of my practice, as I believe is true of most traumatologists. I commend him for putting it in writing so clearly, so that patients can know more about how their minds work, not just psychologically, but neurologically. I think this book would be valuable for some of my patients, the ones who are far enough along in their therapy that they have a hunger for knowledge that outstrips their fear of knowing themselves. If you are going to recommend a book to your patients, whether it is this book or not, I recommend you read it first, so that you can prepare your patients for places in which you might disagree with the author. “The Truth About Depression,” should take a valued space on your bookshelf.

van Ijzendoorn, M. H. (1995). "Adult Attachment Representations, Parental Responsiveness, and Infant Attachment: A Meta-Analysis on the Predictive Validity of the Adult Attachment Interview." Psychological Bulletin 117(3): 387-403.

Bremner , J.D. (2002). Does Stress Damage the Brain? Understanding trauma based disorders from a neurological perspective. Norton, New York