Manufacturing depression

by Gary Greenberg

  That’s the disease of depression as I saw it then: severe, disabling, and deadly, unrelated to circumstance, resistant to comfort (let alone to treatment)—and, thankfully, rare. Wounded as I was, my suffering—and that of most of my patients—wasn’t even in the same ballpark as theirs, and surely not in the same diagnostic category. Which isn’t to say we weren’t unhappy—after all, why else would we be spending our time and money complaining to therapists about our lives?—just that it didn’t seem to me (or, so far as I know, to them) that we had depression.

  Or so I thought at the time. Now, it could be that I just didn’t want to place myself in the category of the mentally ill; after all, when it comes to those diagnoses, most of us therapists are better at dishing it out than taking it. Or that because I wasn’t looking for depression, I didn’t see it except in the most dramatic cases. If that’s so, then the last twenty years, in which it has become unthinkable for clinicians and laypeople alike not to consider unhappiness as a symptom, constitute a period of unparalleled triumph for public health.

  But it could also be that depression has expanded like Walmart, swallowing up increasing amounts of psychic terrain, and that, also like Walmart, this rapidly replicating diagnosis, no matter how much it helps us, and no matter how economical, is its own kind of plague. It could be that the depression epidemic is not so much the discovery of a long-unrecognized disease but a reconstitution of a broad swath of human experience as illness. Depression is, in this sense, a culturally transmitted disease, the contagion carried not by some microbe or gene, but by an idea transmitted by subtle and not-so-subtle means, including clever direct-to-consumer prescription drug advertising; ruthless drug company dominance of medical education, research, and practice; those dire statistics; state laws ordering insurance companies to pay for the treatment of depression as they would for diabetes or cancer therapies; a new DSM with even more subspecies of depression; and casual conversations with diagnosed and medicated friends. Borne on these vectors and others, the notion has spread that our sorrows, our discontents, our unhappiness, and our hopelessness are the signs of a pervasive disease, until it (the idea, not the disease) has taken up residence in nearly all of us. Twenty years (and a few more bouts of intense unhappiness) after my spell on the floor, I would be very unlikely to feel as I did that day and not conclude that I was probably sick. I resist this thought, but I live under the same climate of opinion as you do, so I must confess that I still don’t know whether that resistance is a mistake.

  I have a couch in my therapy office. People often make nervous jokes about it before seating themselves in one of my chairs. Every once in a while, someone will lie down on it, consciously parodying the Freudian stereotype. These patients might have noticed that the office would be better off without the couch. It’s not only a cliché; it’s also ugly and too big for the space. But it’s an outstanding place to take a nap, which is really why it is there. As long as I can remember, the hand of Morpheus has reached up from the underworld and grabbed me by the neck every afternoon at around two o’clock. He is very hard to resist, so I have never scheduled midafternoon appointments, lest I embarrass myself and infuriate my patient by nodding off in the midst of their travail.

  It turns out that frequent naps—more than half an hour a day, four or more days per week—are a symptom of depression. (There’s no explicit exception for countries, such as Spain, that have siesta schedules, but one imagines that therapists in those places adjust the criteria accordingly.) I did nap more after my first marriage collapsed, although I never kept track. One day during that period, I was awakened from a particularly lovely nap by a phone call from my father. I immediately forgot everything about the conversation other than the way I felt as I fought through my grogginess: anxious to the point of nausea.

  “Dread,” I said to my therapist, whom I happened to be seeing later that day. “Just a feeling of dread and self-loathing. Like there he was working hard, being productive, functioning”—he was calling me from his office, where he spent ten-hour days until he was well into his seventies—“and here I was wasting time, crashed out on the couch in the middle of the day.”

  “Well, what do you think this means?” she asked. I had, I knew, lobbed her a huge hanging curve—all that Oedipal drama captured in a single scene.

  “Maybe nothing. I have to say, it felt, I don’t know, biological.”

  “Biological? You mean, like there are little bugs swimming in your blood or something, making you feel dread?”

  She said this as if it were the most preposterous idea in the world, as if anyone who believed it was either evading the truth or just plain deluded.

  It’s not preposterous anymore. There are many ways to distinguish various depressive states from one another. You could, for instance, listen to the stories I’m telling here and conclude that there are three sorts of depression—the temperamental kind that seems to sum up a considered view of the world as a not-so-happy place, the kind that seems always to have been there and has no particular reason behind it, and the kind that comes on after a setback. Evelyn’s depression is a good example of the first, Ann’s of the second, and, if I have to place myself in a category, mine belongs in the last. And then there are formal distinctions. For example, in the old days, which is to say before the DSM-III, doctors talked about manic-depressive illness, in which patients alternated between those two poles; involutional psychotic reaction, a condition of delusional guilt and self-loathing that came on in middle age; and depressive neurosis, the garden-variety unhappiness that psychoanalysts treated in the Freudian heyday. Whether these distinctions were valuable or not or based on anything other than current fashion is hard to say. But what is clear is that they no longer exist. Sometime in the twenty years since my therapist made fun of me, the “bugs” have gnawed them into so much powder.

  In Against Depression, his sequel to Listening to Prozac, Peter Kramer wrote “Depression is neither more nor less than illness, but illness merely.” Being depressed is not simply a response to circumstance, he argued, although it can be kindled by events in our lives. Neither is it a sign of sensitivity or intelligence or insight, nor a branch of suffering with roots in the social or political world—a despairing apprehension, say, of the world we have made. Nor is it a response to the tragedies inherent to human life—mortality, for instance, and the inevitability of loss. Indeed, he claimed, the failure to grasp the fact that depression is just another disease, just another way our bodies have of betraying us, as purposeless and meaningless as tuberculosis (which, he points out, was once seen as a mark of refinement), is itself a symptom of a widespread and longstanding, but deeply wrongheaded, view: that melancholy signals a profound grasp of the true nature of existence.

  Kramer likened depression to “an occupying government,” one that has apparently colonized our collective consciousness, propagandized us, as it were, into believing that it is more than illness. Under this regime, we don’t understand that when you’re lying on the floor of your study and it feels as if someone has turned up the gravity, you’re in the throes of a disease as frank and indisputable as, say, appendicitis—and that you are just as much at risk as you would be if you ignored that pain in your lower abdomen. Kramer confessed to having fallen prey to this ideology himself—not as a practicing melancholic, but a practicing psychiatrist. He learned this, he wrote, from a patient who, once the drugs had kicked in, chided him for paying too much attention to what her depression might actually mean. But he reeducated himself, and in his book urged the rest of us—doctors and patients alike—to do the same.

  We are on the brink of an epochal shift, Kramer went on—to a time when “the eradication of depression [will] seem unremarkable as a…social goal.” Only one thing stands in the way of achieving that goal, Kramer wrote: ignorance. It takes many forms, but one of them is people like me and the other critics of the depression industry who are, according to Against Depression, unwittingly in thrall to that colonial power an
d who therefore insist on pointing out certain facts. Like, for instance, that the prevalence of depression magically skyrocketed just after the drug industry introduced the SSRIs, that the diagnostic criteria underlying this increase can’t distinguish between grief and depression, and that as a result the diagnosis threatens to swallow everyday sorrows. People who continue to believe these things, as the title of his book implies, must be, wittingly or not, for depression.

  At the risk of sounding like the man who says no when asked if he’s still beating his wife, I’ll tell you that I’m really not on the side of the suffering that afflicted Evelyn and Ann and killed Barbara, the kind that drives people to their knees, or their beds, for months or years at a time. In fact, I’m not in favor of suffering at all. By criticizing the idea of depression as a disease, I’m not wishing anguish upon us. (Nor do I think that we need to safeguard pain against the depression doctors’ attempts to do away with it; something tells me that psychic suffering will never be in short supply.) Pain, psychological and otherwise, is just a brute fact, neither noble nor evil, neither redemption nor scourge. It may play some important evolutionary role—designed, perhaps, to alert us to the fact that something is wrong or to create the necessity for invention—but it’s not hard to imagine a different mechanism fulfilling these functions, one that doesn’t hurt so much.

  The division of the world into forces in favor of and against depression is as false as every other Manichaean scheme. Everyone is against depression, just as everyone is against war and child abuse and global warming. The argument is really over who is depressed, which is to say over whose inner life gets pathologized under the new depression regime and what the depressed people are going to do about it. That’s why it’s important to figure out just what the depression doctors mean by the diagnosis and where that meaning came from: because there are burdens to being declared ill. Unless you are a drug company, in which case the only burden of a widespread illness for which you own the treatment is figuring out what to do with the profits.

  I wish I could tell you that this very lucrative notion about unhappiness has been brought to us by the marketing departments of the big drug companies. That would make convincing you to resist it an easier job. But while I will tell you plenty of stories about shrewd and sometimes questionable corporate behavior, proving that drug companies will do what they have to do in order to sell their product is no more or less illuminating than uncovering gambling in Casablanca. It’s worth noting when the usual suspects behave suspiciously—when, for instance, a website like depressionisreal.org is funded by Big Pharma, but it would be a mistake to see this as evidence that the drug companies are conspiring to change the way we think about ourselves in order to make us dependent on them for our well-being.

  The captains of the pharmaceutical industry are merely doing what they get paid the big bucks to do—to sail their corporate ships expertly on the winds and currents of the times. And the times, with some help from Big Pharma, have delivered them an ideal consumer for their product: someone convinced that unhappiness is a problem for their doctors to treat.

  The history of the invention and production of depression is a strange and elusive kind of secret. Most of what I’m going to expose here isn’t buried in corporate files. It’s as obvious as a commercial for Prozac—or, for that matter, as the fifty thousand copies of Recognizing the Depressed Person that Merck distributed to doctors in 1963 or Symposium in Blues, the compilation album of blues songs that they paid RCA to press and send out three years later with prescribing information for their latest antidepressant inserted up its sleeve. It’s laid out in black and white in the scientific literature, which documents, in addition to all that breathtaking neuroscience, the poor performance of antidepressants and the failure of the serotonin imbalance theory to explain depression. It’s right there in the way that over the last century or so, medicine has shaped a climate in which we feel a bone-deep conviction that disease is something biochemical, that health and illness are scientific categories, and that doctors are dispensers of magic bullets aimed at molecular bad guys. It’s on the front page of the newspaper where stories about America’s drug war stand as daily reminders that we are very confused about taking drugs to change our moods—a confusion that is largely circumvented when we instead take drugs to treat a disease.

  These are the raw materials of depression, and they’ve been assembled in the clear light of day, hidden, like Poe’s purloined letter, in plain sight. I’m going to show you how depression has been manufactured right before your eyes—not in order to deny that depression exists or even that it can, in some cases anyway, rightly be considered a disease that can be cured by drugs, but in order to provide you with another tool to figure out what to do if recalcitrant sadness sets in and sends you to your doctor’s office. Because Peter Kramer is both right and wrong about the climate of opinion—right that psychopharmacology is a sign of a major change in the climate, wrong that it is not worth your time to “ask about the virtues” of the new climate. Once you find out how unhappiness has become an illness to be treated with drugs, and once you grasp that there is a history to your depression that has nothing to do with your biochemistry, you have another choice besides “all in your head” and “all in your brain.” If the idea that depression is a disease is as much a matter of history as it is of science, if it is, in short, a story about our suffering, then you are free to look for other stories, or to tell your own. You are free to arm yourself with information that your doctor might not even know about, to seek alternatives, to resist the regime—or to choose, because it makes sense to you and not because a drug-industry-fattened doctor told you so, to subscribe to that story.

  I’m not going to tell you that I don’t have a dog in this hunt. I’m writing this book in part because I think that the medical industry, regardless of its intentions, has acquired far too much power over our inner lives—the power to name our pain and then sell us the cure one pill at a time. But even though I am a psychotherapist, I don’t think the only alternative is what I sell in my office one hour at a time—although I will point out that it is probably the only profession built on the idea that changing the story we tell about our suffering can relieve it. And I know, through my own experience as both a therapist and, as I’ll detail later, as an officially depressed person, that drugs—although not necessarily the drugs that Pharma is selling—do work. But that doesn’t mean that depression—yours, mine, or anyone else’s—is the disease the depression doctors say it is.

  CHAPTER 2

  JOB VERSUS HIS THERAPISTS

  It is customary for histories of depression to start with Hippocrates, the ancient Greek physician.* There are good reasons for this. In addition to originating the oath by which physicians pledge not to harm or kill or seduce their patients, Hippocrates set Western medicine on its current course by insisting that the doctor’s job was to use his own senses to acquire the actual details of his patients’ suffering. When he told his disciples to seek the truth by examining the phenomenon of the illness itself, Hippocrates was urging them to kick the gods out of the clinic; as Hippocrates said of epilepsy, known in his time as the sacred disease, “it appears to me to be no more divine nor more sacred than other disease, but has a cause from which it originates.” This idea—that illnesses exist in nature and that it is the doctor’s job to find and, if possible, to heal them—is exactly the idea behind most medicine today, including the treatment of depression.

  One of the conditions that Hippocrates took note of looks something like our depression. “Fear and sadness that is prolonged means melancholia,” he wrote, and the melancholic patient, who suffers from an excess of black bile (which is how melancholia translates from the Greek) has an “aversion to food, sleeplessness, irritability, and restlessness.” He is rumored to have cured the king of Macedonia’s melancholia by deducing that he was secretly in love with his recently deceased father’s concubine and prescribing a consummation of his desire (which m
akes you wonder if Hippocrates had heard about Oedipus).

  It’s easy to understand the depression doctors’ eagerness to enlist the father of medicine in support of their contention that depression is a disease. The winners get to write history, after all, so why wouldn’t they claim this patrimony? But even leaving aside for the moment the fact that so much of what Hippocrates and his followers wrote is fanciful at best—for instance, that “it is a deadly symptom…when the patient sleeps constantly with his mouth open” or that lying “with the hands, neck, and legs tossed about in a disorderly manner and naked…indicates aberration of intellect”—you have to wonder why, if depression is such a common disease and Hippocrates such a voluble commentator on a vast range of human suffering, his work on melancholia is so scant. His notes on the subject are scattered throughout his works, and he doesn’t tell us much about it, not even how the problem was related to the other black bile disorders, which ranged from hypersexuality to hemorrhoids (a condition that, unlike melancholia, he devoted an entire book to).

  Hippocrates’ lack of attention to melancholia doesn’t mean that depression isn’t an illness. But to cite Hippocrates as an authority for its existence is a little like citing George Washington as an authority on wooden teeth or cherry tree removal: just because he was a great man who had some interest in the matter, we shouldn’t necessarily privilege his opinion about it. There is, however, an ancient account of depression that is much more robust than Hippocrates’—and much more like our current version of the malady. It’s also much older. In fact, according to one scholar, as soon as people started taking enough notice of themselves to put stylus to clay tablet—in around 5000 B.C., 4,500 years before Hippocrates, in the Mesopotamian society known as Sumer—they wrote down a story about a whopping case. (It would be a mistake to conclude from this ancient lineage that depression, like, say, the common cold, has been with us from the beginning. After all, we know virtually nothing of the inner lives of Homo sapiens for the 200,000 or so years prior to the advent of writing, so its appearance at the dawn of history could just mean that people became despondent as soon as they started paying enough attention to themselves to take notes.) The Sumerian version of this story is in fragments, but the Hebrews eventually incorporated it into their Bible. It has since become one of the Western world’s best-known, if not best-loved, stories.