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# 2021-12-19 - Manufacturing Depression by Gary Greenberg | |
When i was in high school, i learned about lead plumbing in Rome. I | |
learned that it caused a lot of illness, including mental illness. | |
So the Romans were literally crazy for using lead plumbing. My | |
teacher told us that some day, our descendants would think similar | |
things about us. "Why oh why did they ever think that SUCH-AND-SUCH | |
was at all a good idea?" | |
Manufacturing Depression documents modern-day "Romans" with a "throw | |
caution to the wind" approach to neurological plumbing. | |
A friend recommended a related book, "Anatomy of an Epidemic" by | |
Robert Whitaker. | |
Another relevant book is "Plato Not Prozac" by Lou Marinoff. | |
# Chapter 1 | |
This is a powerful and compelling idea: if you are unhappy in a | |
certain way, then you are suffering from a brain illness, no | |
different in principle from any other illness. This idea has become | |
part of the way we think about ourselves. | |
This is the sense in which depression has been manufactured--not as | |
an illness, but as an idea about our suffering, its source, and its | |
relief, about who we are that we suffer in this way and who we will | |
be when we are cured. Without this idea, the antidepressant market | |
is too small to bother about. With it, the antidepressant market is | |
virtually unlimited. | |
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... | |
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. | |
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 [the false dichotomy of] "all in your head" | |
and "all in your brain." | |
# Chapter 2 | |
Your sadness doesn't become depression until it has settled in for a | |
while--officially, according to the DSM, for two weeks. After two | |
weeks, it seems, your dejection is at risk of becoming a fixed and | |
tragic view that is not only unpleasant but also nearly taboo in a | |
society dedicated to the pursuit of happiness... | |
The arbitrary nature of fortune, the near certainty that unbidden | |
catastrophe will visit each of our lives, the inevitability of | |
mortality, a nature that is more generous with pain than with | |
pleasure, in short, all the stacked-deck calculus of human | |
existence--these are challenges to optimism if not outright | |
invitations to pessimism, and that's before we even consider what a | |
hash we've made of both civilization and nature. But I don't with to | |
mount a broadside against optimism or, Kramer forbid, more | |
legislation for pessimism. Instead, I want to point out that the | |
depression doctors have done exactly what Eliphaz and company did. | |
Psychology may have replaced theology, but pathology is still the | |
point: for Kramer no less than for Eliphaz, pessimism is evidence of | |
interior disturbance. | |
I don't want to overstate this, I'm not worried that antidepressants | |
will turn us into mind-numbed, smiley-faced zombies. The drugs | |
aren't that effective, at least not yet. But I do think we need to | |
pay attention to our feelings of demoralization. Pessimism can be an | |
ally at a time of crisis, and I think we're living in one right now. | |
Regardless of whether or not the drugs work, to call pessimism the | |
symptom of an illness and then to turn our discontents over to the | |
medical industry is to surrender perhaps the most important portion | |
of our autonomy: the ability to look around and say, as Job might | |
have said, "This is outrageous. Something must be done." | |
For religious people--in Job's time as well as in ours--the solution | |
to the problem he represents is to relinquish the expectation that | |
human sensibilities can grasp the sense of life and replace it with a | |
conviction that there is a divine, if inscrutable, plan behind our | |
suffering. Job's pessimism and outrage, in this view, dissolve when | |
he gives up that expectation. His suffering over the unfairness of | |
his life is transformed into faith in a God whose justice surpasses | |
understanding and whose mercy can soothe his grief. | |
And just as Eliphaz and his colleagues overstepped with Job, so too | |
the depression doctors, and their drug company sponsors, have | |
overstepped with us. They don't know any better than you and I what | |
life is for or how we are supposed to feel about it. | |
# Chapter 3 | |
The promise of a boundless future that originated with the | |
Enlightenment and began to come to fruition in the Industrial | |
Revolution has perhaps no better expression than in the birth of | |
scientific medicine. | |
But that promise also created a temptation, one that eventually would | |
prove irresistible. To the manufacturers of drugs, diseases are | |
markets. The continued growth and success of the pharmaceutical | |
industry depends on a proliferation of those markets. It was only a | |
matter of time before doctors and drug companies started to improve | |
upon nature in yet another way: by creating the diseases for which | |
their potions are the cures. | |
# Chapter 4 | |
It's not hard to understand why diagnosis doesn't work that way | |
anymore. Reaching that kind of conclusion requires open-ended | |
conversation and liberal interpretation, which would be very hard to | |
map onto a troubleshooting chart. That's an inefficient process, and | |
it would yield an unscientific result. The difficulties raised by | |
this approach to diagnosis reached a crisis point in the early 1970s. | |
In addition to the Rosenhan study, psychiatrists were confronted | |
with research that showed that they often disagreed about what mental | |
illness a given person had. Diagnostic trends varied from country to | |
country, from city to city, even from hospital to hospital, and | |
diagnoses began to seem much more like folk stories than medical | |
categories. Even worse for the industry's credibility, in 1972, | |
after years of subjecting homosexuals to all manner of "treatment," | |
the American Psychiatric Association voted homosexuality out of the | |
DSM. Developments like these seemed to indicate that psychiatrists | |
didn't know how to define mental illness to begin with. That kind of | |
confusion could have been very bad for business. | |
So just a few years before Prozac came along, psychiatrists turned to | |
what they called a descriptive nosology. In a development I'll | |
describe in detail later on, they came out with an entirely revamped | |
DSM, one that focused not on personalities or causes of mental | |
illness but on lists of symptoms like the one that my doctor was | |
using to diagnose me. These lists featured more or less objective | |
criteria--duration of unhappiness, changes in weight, length of | |
sleep. They were designed to meet statistical standards like | |
interrater reliability, which made them much more friendly to the | |
quantitative tests and measures that we equate with science. And | |
they worked. It turns out that if you standardize the questions you | |
ask, you will come up with standardized answers. Or, to put this | |
another way, if you go into the interview looking for what you | |
already know, then you are very likely to see it. | |
The trick with the descriptive approach to diagnosis is to keep your | |
eye on the loose-leaf notebook and not on the patient. | |
If this approach seems a little unsophisticated, a little primitive, | |
and a little inhumane, there's a reason for that. When the APA | |
turned to a descriptive nomenclature, they weren't exactly making an | |
innovation. In fact, they were turning back nearly a century, to a | |
nearly forgotten diagnostic system developed by Emil Kraepelin, a | |
German doctor who was much more interested in weeding out the | |
mentally ill than in curing them. Resurrecting Emil Kraepelin's | |
system, psychiatrists also dusted off his solution to the problem | |
that William James had noted: act as if there is science behind your | |
nosology, and eventually the name of the disease will seem to be an | |
explanation of everything. | |
The problem, as Kraepelin saw it, was that the only source of | |
psychological information about insanity was the patient, and the | |
patient was, well, insane. So, he concluded, "we cannot afford to | |
pay much attention to the patient's account of his experiences." | |
Neither did he think that it was a good idea to indulge in "poetic | |
interpretation of the patient's mental process. This we call | |
empathy," he said, warning that a science-minded doctor employed it | |
only at his [or her] own peril. | |
"Trying to understand another human being's emotional life is fraught | |
with potential error. This is true in healthy people and much more | |
so in sick ones. "Intuition" is indispensable in the fields of human | |
relations and poetic creativity, but it can lead to gross | |
self-deception in research." | |
Likewise, the point of a taxonomy of insanity was to figure out what | |
to do WITH the patient, not FOR the patient. | |
# Chapter 5 | |
Meyer wasn't merely modifying Kraepelin or reinterpreting his | |
statistics. He was repudiating the German master, reversing his | |
dictum to ignore the patient and eschew empathy in favor of a | |
psychiatry that listened, and listened carefully, to the actual | |
experience of his patient. "There is no advantage," he told his | |
fellow doctors, in merely looking for "'symptoms' of set 'disease | |
entities' that would allow us to dump all the facts of each case | |
under ONE TERM OR HEADING" [emphasis original]. Searching for | |
pathology, a doctor "surrenders his commonsense attitude" and fails | |
"to view the abnormal mental trend as a genuine but faulty attempt to | |
meet situations, an attempt worthy of being analyzed as we would | |
analyze the blundering of a distracted pupil, or the panic of a | |
frightened person, or the bumbling of one who reacts poorly in trying | |
to meet an unusual situation." | |
It took Meyer only a few years from the time he arrived in America to | |
figure out something important about his adopted country. "The | |
public here believe in drugs," he wrote to the governor of Illinois | |
in 1895, "and consider prescription as the aim and end of medical | |
skill." Americans, that is, wanted their doctors to DO SOMETHING for | |
them. That was the last thing that psychiatrists, with their | |
life-sentence diagnoses, could offer. | |
It's not hard to see why neurasthenia was such a hit and the | |
neurologists who purveyed the cures so successful. The diagnosis | |
gave a name to anxiety about the dizzying pace of change even as it | |
reassured patients that as soon as their nervous system caught up, | |
the disease would remit and all would be well--not to mention that | |
their illness was a sign of superior refinement. ... psychiatry was | |
languishing. By World War I, according to historian Edward Shorter, | |
it had "become marginal to the mainstream of medicine." It was left | |
to Adolf Meyer to reclaim the everyday psychological suffering of | |
Americans for his profession, and he did it in part by making | |
depression less like insanity--and more like neurasthenia. | |
... they could be cured--but only if the psychiatrist did exactly | |
what Kraepelin warned against: listened with empathy, interpret, and | |
pay attention to the patients' experience. Psychiatrists, in other | |
words, should offer patients exactly what Freud and Charcot and some | |
other European neurologists had recently begun to offer: | |
psychotherapy. | |
Meyer's efforts intersected with another development in early 20th | |
century America. Men like John Watson and Sigmund Freud's nephew | |
Edward Bernays were teaching manufacturers how to use mass media to | |
sell their products. Their efforts were informed by psychological | |
knowledge. | |
Which is exactly what Meyer accomplished. Lowering the bar for entry | |
into the psychiatrist's office, he gave his profession unique and | |
privileged access to the average citizen, the one whose life wasn't | |
as happy or productive or fulfilled as he thought it should be. | |
Meyer claimed that cure could be found in the one resource that | |
everyone, especially every American, had: a life story. This | |
democratization of mental suffering was enhanced by other | |
developments in American life, notably the mental hygiene movement, | |
spearheaded by activist (and former asylum patient) Clifford Beers, | |
that made "mental health" a subject of polite conversation. People | |
could now talk about their "life problems" without fear that they | |
would be carried away to the loony bin. They could be depressed | |
without being insane and they could be cured. | |
# Chapter 6 | |
The biggest weakness in Freudian theory--and perhaps the major factor | |
in its fall from grace--is that it is, as philosophers of science | |
like Karl Popper would put it, non-falsifiable and therefore not | |
subject to scientific testing. Psychoanalysis is a self-contained | |
system, its basic tenets impossible to verify. | |
But a funny thing happened to learned-helplessness theory. | |
Cognitivists predicted that depressed people would be significantly | |
more likely than non-depressed people to blame themselves when things | |
go wrong. In 1979, a couple of psychologists, Lauren Alloy and Lyn | |
Abramson, decided to check out this hypothesis. They set up a series | |
of studies revolving around a green light and a button. In the first | |
experiment, subjects were told to push the button and decide whether | |
or not it made the green light come on, a condition that was | |
controlled by the experimenter. Over and over again, the depressed | |
people were better than their normal peers at assessing their role in | |
the light's status. | |
Then Alloy and Abramson introduced money into the equation. They | |
gave some subjects five dollars and told them that they'd lose money | |
every time the green light failed to light. They gave other subjects | |
no money but told them that they'd get money if the light came on. | |
What they didn't tell them was that the button was completely | |
irrelevant and that everyone who started with money was going home | |
broke, while everyone who started with nothing was going to win five | |
bucks. Then they asked them to estimate the extent to which they | |
were responsible for their fortunes--a task which depressed people | |
excelled. And when the experimenters started to give subjects | |
control over the light, the nondepressed people turned out to think | |
that they deserved to win but not to lose regardless of the actual | |
facts. Depressed people, in the meantime, continued to be superior | |
at figuring out their role in events. The experimenters concluded | |
that "depressed people are 'sadder but wider' ... Non-depressed | |
people succumb to cognitive illusions that enable them to see both | |
themselves and their environment with a rosy glow." | |
Alloy and Abramson noted that depressive realism, as this phenomenon | |
came to be called--and, by the way, this work has never been refuted: | |
cognitive theory, as we will see in later chapters, chugs along as if | |
it never happened--raises a "crucial question": Does "depression | |
itself [lead] people to be realistic, or [are] realistic people more | |
vulnerable to depression than other people?" | |
What was bothering me about the tests wasn't only that they seemed | |
inane and puny compared to what they were trying to measure. It was | |
also their logic--or their lack of it. It's the burden the | |
depression doctors took on when they revived Kraepelin: you have to | |
assume that the patient is depressed in order for his [or her] | |
feelings to be considered symptoms, but the symptoms are the only | |
evidence of the depression. Wondering if "life is empty" or "if it's | |
worth living," may be, as the QIDS insists it is, a thought of | |
suicide or death--but only if you're depressed. Otherwise, it's just | |
a common, if disturbing, thought. To logicians, this is known as | |
assuming your conclusion as your premise, or begging the question. | |
# Chapter 7 | |
The really scary part is that none of the shock doctors had any idea, | |
at least any scientific data, of why their treatments worked. | |
Cerletti didn't even try to explain it. | |
That's why when Sakel noticed (or says he noticed; he was known for | |
revising his autobiography to suit his needs) that depressions seemed | |
to lift in patients who had convulsions while being insulinized, or | |
when Cerletti concluded that he was getting better results with | |
depressed patients than with schizophrenics, or when an American | |
doctor wrote that he was using Metrazol to cure depressions, or when | |
Philadelphia psychiatrists reported that 70 to 85 percent of their | |
depressed patients were recovering (and none of their schizophrenics) | |
after electroshock therapy, or when a controlled study in 1945 found | |
that 80 percent of ECT-treated depressives improved and their average | |
length of hospitalization was cut from twenty-one months to five | |
months, or when suicide rates among the depressed who received ECT | |
decreased dramatically, and all the while shock treatment's effect on | |
schizophrenia, the disease it was theoretically supposed to cure, | |
proved more and more disappointing--when all this happened, | |
psychiatrists were happy to skip the theorizing and get on with the | |
treating. Not of schizophrenia, of course, but of depression. | |
Those 80 percent improvement rates, by the way, are way better than | |
anything that any antidepressant, no matter how cooked the books, has | |
delivered, and they have been replicated often. But before you | |
wonder why ECT is not the treatment of choice, you have to remember | |
one thing: these depressives were very sick. They had AFFECTIVE | |
PSYCHOSES, which meant that they were immobilized, delusional, | |
nonfunctional--much as you would want people to be before you start | |
shocking them into convulsions. | |
It's not that doctors didn't try to use their methods on the walking | |
wounded. Unhappy people can be every bit as desperate as disabled | |
people. But the shock doctors discovered that, as Luthar Kalinowsky, | |
one of ECT's major proponents and the man who did the most to spread | |
it in the United States, put it, "the results [with neurotics] are as | |
a whole disappointing"--adding that especially if the patients were | |
anxious as well as depressed, ECT was not indicated. | |
If anyone was worried about the irrationality of all this therapeutic | |
exuberance--other than the analysts whose livings it threatened--they | |
weren't saying. But then again, the guinea pigs in this experiment | |
were terribly sick, which made it easier to justify desperate | |
measures taken on their behalf. Had the shock doctors' methods been | |
less extreme and unpretty, had they been, say, gaily colored pills | |
with friendlier names than ELECTROSHOCK THERAPY, remedies that just | |
tweaked consciousness a little bit, that could be taken in the | |
privacy of one's own home, that had only a few side effects, and that | |
were held out to cure a disease afflicting 20 percent of the | |
population, there might have been a little more worry. In this | |
sense, the depression doctors are in infinite historical debt to the | |
shock doctors. They softened up the market for them, getting people | |
used to the idea that doctors could mess with their heads even if | |
they didn't know exactly what they were doing. | |
Kraepelin had in effect issued a promissory note: eventually, he | |
promised, an explanation would emerge that would validate his | |
taxonomy; on that assurance, the taxonomy, which SOUNDED scientific, | |
should be accepted now. The shock doctors realized that so long as | |
they did something dramatic to a patient's body, so long as what they | |
did was plausibly biological, and so long as they got results, they | |
could further claim that they had proved what they were still only | |
assuming. They could have the capital without even making the | |
promise. They also identified the market: not schizophrenia, which | |
often remained unaffected by their treatments, and which rendered its | |
victims nearly inhuman, but depression. | |
# Chapter 9 | |
For instance, among the clinical impairments listed in the DSM are | |
LEGAL ISSUES, which means that after 1986, when it was made illegal, | |
MDMA use could earn a diagnosis the way that it previously could not. | |
The DSM, committed to neutrality, can't comment on the political or | |
social dimensions of this symptom. Instead, it can only refer to a | |
patent's run-in with the law as a health problem--as if the only | |
reason to break the drug laws is that you are mentally ill. | |
Similarly, if you get arrested for drunk driving, the DSM is going to | |
diagnose your difficulty as substance abuse rather than the | |
misfortune of living in a country where mass transit barely exists | |
and where the focus on individual responsibility is so great that | |
lawmakers don't even bother trying to require cars to be impossible | |
to start if a driver is intoxicated. | |
Antidepressants (which interestingly, are not listed as possible | |
drugs of abuse in the DSM, despite the fact that they cause both | |
withdrawal syndromes and dependence) are not only, chemically | |
speaking, the spawn of LSD, one of the most notorious recreational | |
drugs ever to come down the pike. They also, as you'll see shortly, | |
owe their entire existence to the fact that people taking drugs for | |
conditions other than depression--tuberculosis, allergies, | |
schizophrenia--suddenly and unexpectedly felt a whole lot better. | |
Or, as we drug abuses say, they got high. | |
If you're a psychiatrist or a drug company, this uncomfortable | |
closeness places a great premium on dividing up the territory, on | |
separating your chemicals from theirs, on making sure that yours are | |
medicine and theirs are drugs, that you are treating illness while | |
they are abusing substances. | |
On the one hand, Americans have always enjoyed a good buzz. Even the | |
Puritans, the same people who once outlawed the celebration of | |
Christmas on the grounds that it was sacrilegious, kept their larders | |
stocked with rum and ale. Indeed, while John Winthrop was giving his | |
shipboard sermons about a life of hard work consecrated to God, | |
barrels of booze were rolling around in the hold and one of his | |
shipmates was no doubt figuring out where to put the pubs in the City | |
upon a Hill. | |
On the other hand, Americans have also always been suspicious of | |
getting high. They once amended the Constitution to outlaw drinking | |
and currently spend something like $14 billion a year on a "war" to | |
keep the country drug free and to round up those who would cheat in | |
the pursuit of happiness. | |
But there is a third hand, which becomes obvious when you realize | |
that $14 billion is only a little more than the national expenditure | |
on antidepressants, and if you throw in tranquilizers like Valium and | |
the uncountable volume of opioid analgesics like Vicodin that are | |
used long after the pain from surgery wears off, you've dwarfed the | |
war-on-some-drugs budget by an order of magnitude. Apparently, some | |
ways of getting high are acceptable after all. | |
# Chapter 10 | |
As nonsense goes, however, placebo effects are pretty impressive. | |
Patients taking those ancient remedies--poisonous and inert | |
alike--routinely got better. In part, that was because so many | |
illnesses remit on their own, and the potion's reputation was only | |
coincidence trumped up by post hoc reasoning--superstition, in short. | |
But after years of giving placebos in virtually every clinical | |
trial, it is now a matter of scientific fact that there's more to | |
these cures than nature running its course. People given a pill, any | |
pill, will do better than those for whom nothing is done. | |
Researchers have figured out how to allow for this in their | |
calculations: a drug's effect is the treatment group's response minus | |
the placebo group's. But despite the fact that placebos are without | |
a doubt the most widely studied medical treatment in human history, | |
and the hidden subject of every placebo-controlled trial, scientists | |
haven't figured out why they work. In part, that's because science | |
in general has a hard time grappling with irrationality, with cases | |
that blur the bright line between sense and nonsense. But science, | |
at least the variety of science bought and paid for by corporations | |
like drug companies, also has a hard time getting interested in sugar | |
pills--which, after all, can't be patented. | |
It is, however, much less than what the drug companies claim. You | |
wouldn't know it from a Prozac ad that the drugs have failed almost | |
half of their tests, or that even their successes are well short of | |
miraculous. But then again when the FDA says a drug is | |
scientifically proven to treat a disease, its manufacturer is well | |
within its rights to take that ball and run with it; that is what the | |
United States government has issued it a license to do. Especially | |
if the company's best marketing strategy is to sell not only the drug | |
but the disease that it treats, and if its best proof for the | |
existence of the disease is the effect of the drug, then getting this | |
approval is an enormous boon. | |
You wouldn't know this from reading the scientific literature, | |
either. Of those thirty-eight trials considered successful by the | |
FDA, thirty-six were published in professional journals. Only | |
fourteen of the unsuccessful trials saw print, however. And, | |
according to a team of reviewers, the papers reporting eleven of | |
those studies were written in such a way as to convey a "positive | |
outcome," despite what the FDA said. A doctor reading every paper | |
published would therefore be correct to conclude that 94 percent of | |
antidepressant trials were successful. | |
That seemingly innocuous phrase--"substantial evidence"--contained a | |
huge break for drug companies. Lawmakers had considered a different | |
standard--the PREPONDERANCE OF EVIDENCE. The difference, as one | |
senator put it, was that to require only substantial proof meant that | |
a drug could be deemed effective "even though there may be | |
preponderant evidence to the contrary based on equally reliable | |
studies." Especially after the FDA determined that two independent | |
trials with statistically significant results in favor of the drug | |
constituted substantial evidence, this meant that a drug up for | |
approval could have as many do-overs as a drug company wanted to pay | |
for. So long as the research eventually yielded evidence of | |
efficacy, the failures would remain off the books. This is why | |
antidepressants have been approved even though so many studies have | |
shown them to be ineffective. | |
# Chapter 11 | |
... this is a crucial, and perhaps the central, problem of modern | |
life: that the power to tell us what kind of life we ought to live, | |
and what kind of people we ought to be, could be wielded not directly | |
but diffusely, not through force but through culture... Tell people | |
what they ought to want, help them think that they are freely | |
choosing, and you've gotten around any resistance they might have had | |
to being told what to do. Power exercised in this way is invisible | |
and in some ways even more dangers than the kind that is obvious. | |
The power that hides in the plain light of day can fashion people in | |
its own image without their even knowing it. | |
Those experts include doctors. For a psychiatrist to say that you | |
have the disease of depression is to tell you not only about your | |
health, but also about who you are, what is wrong with your life and | |
how it should be set right, and who you would be if only you were | |
healthy. In making these pronouncements, the doctor draws on the | |
authority of science, which presumably has no stake in the outcome. | |
He [or she] couches his [or her] judgments in the language of sickness | |
This study, along with others that specifically investigated | |
schizophrenia and manic-depressive illness, helped to explain a | |
mystery brewing since the late 1950s, when epidemiological studies | |
showed that manic depression was much more common in Great Britain | |
than schizophrenia, while the reverse was true in the United States. | |
It turned out that the diagnostic problem wasn't a result of, say, | |
the differing genetic stocks of the two countries or their different | |
approaches to childrearing. It wasn't in the patients at all, but in | |
the doctors. Something in their education, their training, perhaps | |
even their countries' differing cultures made transatlantic | |
psychiatry a profession divided by a common language. | |
After bruising and embarrassingly public bureaucratically battles, | |
the protesters got what they wanted. In April 1973, an APA committee | |
recommended deleting homosexuality from the DSM... In 1974, after a | |
rearguard action had forced a referendum, a majority (58 percent) of | |
the voting membership ratified the decision. This may have been the | |
first time in history that a disease was eradicated at the ballot box. | |
The solution was obvious. If you want reliability, in other words, | |
you have to stick with observation; a mental illness is no more or | |
less than the group of symptoms that a careful observer has noted to | |
occur together. | |
But that was exactly the committee's intent--to prune the taxonomic | |
tree of its less reliable branches, of which neurosis, weight down | |
with the Freudian idea of a dynamic inner world, was perhaps the most | |
rotten. | |
And in April 1979... after the APA's assembly elected to approve the | |
DSM-III, the APA's board of trustees once again voted on the | |
existence of diseases. This time the stroke of their pen didn't | |
eliminate a single illness but rather a whole class of them, even as | |
it created some fifty more that hadn't previously existed. But these | |
were new and improved diseases, the kind that could be reliably | |
diagnosed without recourse to theoretical notions about how the mind | |
works. | |
The DSM-III was a huge hit. Purged of theory, of any pretense to | |
saving the world, and of any claim to know how the mind worked or | |
what caused mental illness, the book was invaluable to psychiatrists' | |
attempt to secure their place in "real medicine." Thanks to the | |
descriptive approach, there would no longer be any question about who | |
[received which diagnosis]. Nine out of ten doctors using the | |
criteria agreed on diagnoses, a spectacular improvement over the old | |
days of theory-laden nosology. | |
The authors tried to gloss over the issue by conflating reliability | |
and validity. | |
So when the DSM-III committee were reminded that, according to | |
Clayton, grief was indistinguishable from depression, when, in other | |
words, the validity problem emerged from the avalanche of reliability | |
statistics under which it had been buried, neither she nor the | |
committee should have been terribly surprised. Neither could they | |
simply ignore it, even if they wanted to. | |
The committee's response was to solve the public relations problem, | |
if not the scientific one, by establishing a loophole in the | |
definition of MDD--the bereavement exclusion. | |
The scientific answer is that there is no reason. The bereavement | |
exclusion is like the epicycles that Ptolemaic astronomers added to | |
their models of planetary motion--little loops within the orbit of | |
the planets that allegedly explained why they showed up in the places | |
where Ptolemaic astronomy, with its insistence that heavenly bodies | |
moved in perfect circles, said they shouldn't be. Epicycles worked | |
on paper, sort of, but they did a much better job at keeping | |
astronomers respectable and their models intact than at describing | |
the actual movements of heavenly bodies; they have come to be known | |
as the epitome of bad science. | |
Which is the whole point of turning psychic suffering into mental | |
illness and diagnosis into a bureaucratic function in the first | |
place: to take these questions out of the therapists' hands and so to | |
eliminate the possibility of professional embarrassments wrought by | |
Rosenhan or Katz or gay people marching and demanding to be struck | |
from the sick rolls. Erasing reaction, deleting neurosis, | |
overlooking nature and cause, the DSM version of depression realizes | |
its major goal: enhancing the reputation of psychiatry, consolidating | |
its power, turning it into real medicine. Inner life--personal and | |
political--remains important, if it is important at all, only as | |
symptom, only as the evidence that the diagnostic criteria are met, | |
as the raw material for a disease the mental health industry has | |
become expert at churning out. | |
This may be the most brilliant achievement of the DSM. By adopting | |
and deploying a scientific rhetoric, it has not narrowed the patient | |
pool at all. Instead, it has given increased authority to the | |
pronouncements of people like me--so much so that state and federal | |
governments have determined that insurers must pay for the treatment | |
of depression in the same way they pay for any other illness--and at | |
the same time have given us opportunity to apply the diagnostic | |
criteria as broadly as possible, to turn everyday suffering into a | |
disease. | |
This creates a perverse incentive to render diagnoses, which may have | |
something to do with the ever-burgeoning statistics on the prevalence | |
of depression. | |
Because there is a theory behind the DSM's atheoretical approach. | |
It's in your molecules. What matters, when it comes to depression, | |
is matter. The rest is for the poets to worry about. | |
# Chapter 12 | |
But the real boon to the drug industry was not so much the drugs | |
themselves as the emergence of a vast new market: people whose | |
suffering wasn't bad enough to warrant a visit to a psychiatrist's | |
office but who would confess it to their family doctor and then | |
gladly take Miltown or Valium. | |
Take some Valium or Miltown (which is still available in a slightly | |
modified formulation called Soma...) and, if you're like most people, | |
you'll immediately see why they more or less sell themselves: they | |
make you feel pretty darned good. Take some imipramine, on the other | |
hand, and you most likely won't feel any immediate effects, except | |
maybe some jitteriness or dry mouth. So it's no wonder that while | |
Valium sales were soaring to the stratosphere, amitriptyline | |
(Elavil), Merck's entry into the tricyclic antidepressant market was | |
down in the dumps. | |
To a marketing executive, the problem was straightforward: doctors | |
weren't making the connection between the problem and the solution | |
because the problem had not yet been properly named. | |
But the doctor's first duty, Ayd emphasized, was "to explain to the | |
patient the nature of his illness in understandable terms." This was | |
also the tricky part. "Depressed people are very suggestible," he | |
wrote, "and an inept comment can do irreparable harm." To prevent | |
this, Ayd provided a script for the fledgling doctor to use in | |
breaking the news, one that uses the patient's suggestibility for | |
better ends: | |
You have an illness called depression. It is very common. Everyone | |
who has it feels just as you do. What is happening is real. It does | |
not mean you have a serious physical disease or that you are losing | |
your mind. Your symptoms have a physical basis. | |
Not only do the [SSRI] drugs perform poorly in trials, but while they | |
do bind to serotonin receptors at higher rates than they bind to | |
other receptors, and at higher concentrations than the tricyclics do, | |
they by no means bind ONLY to serotonin sites. They are active all | |
over the brain, so while they may not cause as many side effects as | |
the tricyclics, they still cause so much discomfort that there is a | |
cottage industry devoted to reducing nonadherence among SSRI takers. | |
Patients, researchers have found, were reluctant to take psychiatric | |
drugs in the first place, and when they start feeling jittery and | |
agitated, or when they can't sleep and have upsetting dreams when | |
they do, or when they get constipated or nauseated, or when they hear | |
about the reports linking antidepressants to suicide and violence, | |
and above all else, when they find that they suddenly can't reach | |
orgasm or don't want sex at all, they often just stop. Indeed, | |
nearly 70 percent of people stop taking antidepressants within the | |
first month. | |
None of this is a secret anymore, if it ever was. The data used by | |
the FDA to approve the drugs, including the ones in which the drugs | |
didn't work, are in the public domain. The agency also knew that | |
reports linking SSRIs to the increased risk of suicide and violent | |
behavior had begun to surface within a year of Prozac's emergence on | |
the market. Still, by 2006, antidepressants had become the most | |
commonly prescribed class of drugs in the United States, at an annual | |
cost of $13.5 billion. | |
This dramatic success depends on the old tricks--downplaying side | |
effects and overstating efficacy in marketing campaigns directed at | |
prescribers. But it also hinges, at least sometimes, on outright | |
lies. Psychologist Glen Spielmans and his team analyzed a group of | |
ads from leading psychiatric and general medical journals. They | |
discovered that in more than one third of the cases, the sources | |
cited in the ads failed to verify the claim they were supposed to | |
support. And that's when the companies bothered to mention a source. | |
Fully half of the time, they didn't even do that--or they cited a | |
source that couldn't be obtained. When Spielmans asked Wyeth for the | |
data cited in an Effexor ad, the company responded, "Unfortunately, | |
our internal policies do not allow for distribution of unpublished | |
data." As Spielmans pointed out, this is ironic given the tag line | |
of the ad: "See depression, see the data, see a difference." | |
When a couple of researchers pointed out to the FDA that, according | |
to Essential Psychopharmacology, a standard medical textbook, "there | |
is no clear and convincing evidence that monoamine deficiency | |
accounts for depression," the FDA wrote back to say that this was an | |
"interesting issue," but that "these statements are used in an | |
attempt to describe the putative mechanisms of neurotransmitter | |
action(s) to the fraction of the public that functions at no higher | |
than a 6th grade reading level." The alleged stupidity of the | |
citizenry, in other words, justified the drug companies' lying to | |
them. | |
But what matters above all else about Kravitz's study is... Because | |
in real life, none of those SPs was actually depressed... Yet 60 | |
percent of them got a diagnosis, and nearly 45 percent of them got | |
drugs. Try faking a case of diabetes. I don't care how good an | |
actor you are or how well informed. Unless you brought a real | |
diabetic's urine with you, or your doctor is criminally incompetent, | |
you are not going to go home with a prescription for insulin. | |
... it wasn't my idea to compare depression to diabetes in the first | |
place. That was the drug companies' brainchild, as in "Depression | |
doesn't mean you have something wrong with your character. It | |
doesn't mean you aren't strong enough emotionally. It is a real | |
medical condition, like diabetes or arthritis"--which is what you | |
learn when you go to the Myths and Facts page on Pfizer's zoloft.com | |
website. Or prozac.com's version: "Like other illness such as | |
diabetes... depression is a real illness with real causes." | |
It's easy to see why the depression doctors want to make that | |
comparison. Diabetes provides a classic magic-bullet scenario: your | |
pancreas stops producing insulin (or, in the case of type 2 diabetes, | |
your cells lose their ability to absorb insulin), and the deficiency | |
is treated with regular medication. No one would be ignorant or | |
insensitive enough to suggest that your illness is related to your | |
character or emotional strength. No one would blame the victim or | |
imply that a diabetic is weak for taking his [or her] medicine. A | |
depressed person who thinks of himself [or herself] in this way, in | |
other words, is a loyal patient for life. | |
But doctors don't have to convince their diabetic patients that they | |
have a "real illness." The symptoms generally speak for themselves. | |
A diabetes doctor... doesn't have to talk about chemical imbalances | |
that he [or she] knows aren't really the problem or contend with | |
package inserts that say, in plain black and white, that the drug | |
makers have no idea why their drug works. | |
And above all else, the diabetes doctor doesn't have to tell the | |
patient that he [or she] is getting better. | |
# Chapter 13 | |
Beck based his therapy [CBT] in part on behavior therapy and in part | |
on the cognitive science that was then emerging at the intersection | |
of linguistics, philosophy, and computer science. In cognitive | |
therapy, he explained, "therapist and patient work together to | |
identify the patient's distorted cognitions, which are derived from | |
his dysfunctional beliefs. These cognitions and beliefs are | |
subjected to empirical testing. In addition, through the assignment | |
of behavioral tasks, the patient learns to master problems and | |
situations which he previously considered insuperable, and | |
consequently, he learns to realign his thinking with reality." | |
[This sounds like command-and-control self-torture similar to | |
Landmark Forum.] | |
Cognitive Therapy [the book] was a hit with my students. After the | |
maddening uncertainties of psychoanalysis, the quasi-fascism of | |
behavior-modification, and the touchy-feely vagueness of | |
existential-humanistic therapy, they really appreciated Beck's bullet | |
lists, her step-by-step instructions and verbatim scripts and | |
you-can-do-this-too optimism. And above all, they liked her rational | |
approach, her implicit reassurance that we were equipped to make | |
sense of our lives. | |
Therapeutic outcomes are dependent in part on allegiance effects, on | |
the extent to which a therapist believes in what he [or she] is doing | |
and conveys this confidence to his [or her] patient. So a claim to | |
be in possession of a universal method is good for a therapist's | |
business. | |
... one fact, documented in clinical trials and endorsed by the | |
mental health industry and government alike: that when it comes to | |
depression, cognitive therapy gets results. Empirically validated | |
results, results that give psychologists a place at the depression | |
feeding trough, that both capitalize on and strengthen depression's | |
status as a bona fide disease, and that warrants cognitive therapy's | |
inclusion in the American Psychiatric Association's standards of | |
care--which means that by not practicing it with anyone who is | |
depressed, [by paying attention to the person and their dreams and | |
stories], one may be guilty of malpractice. | |
Because it never went to trial, Osheroff v. Chestnut Lodge didn't | |
establish any official legal precedents. Its impact on the | |
profession was nonetheless profound. According to Edwin Shorter, | |
"The case left the strong impression that treating major psychiatric | |
illnesses with psychoanalysis alone constituted malpractice... Any | |
clinician who henceforth treated patients as Chestnut Lodge had Dr. | |
Osheroff ran the risk of incurring heavy penalties." Not only that, | |
Shorter says, but psychiatrists, chilled by the outcome, began to | |
abandon their notebooks and couches for prescription pads and more | |
traditional office furniture, creating a vacuum that was filled by | |
the psychologists and social workers and other non-physician | |
therapists. Sixty years after they had wrested psychoanalysis from | |
Sigmund Freud, doctors evidently could barely wait to hand it back | |
over to the lay analysts. | |
Luborski also determined that there was nothing specific to a given | |
therapy that accounted for its success. Luborski suggested an | |
explanation: "The different forms of psychotherapy have major common | |
elements--a helping relationship with a therapist... along with the | |
other related, non-specific effects such as suggestion and abreaction | |
[Freudian jargon for emotional catharsis]." These common | |
elements--nonspecific factors--accounted for therapy's success. | |
The conclusion is inescapable: to the extent that therapy succeeds, | |
it's due not to the particular help that's offered, but rather to the | |
fact that something is offered in the first place, and by a person | |
whom the patient expects, and believes, will help. Therapy, no less | |
than [antidepressant] drugs, works by the placebo effect. | |
This shouldn't be a surprise. To the extend that it is understood, | |
the placebo effect seems to be the result of a patient's entering | |
into a caring relationship with a healer, which is a much more | |
explicit feature of psychotherapy than of general medicine. | |
[This is basically the "dodo bird hypothesis" named after the dodo | |
bird in Alice's Adventures in Wonderland. | |
Equity of outcome @Wikipedia | |
I have heard of these ideas before. See the intro section of the | |
following log entry. | |
Focusing by Eugene Gendlin | |
] | |
It's not an accident that more than 90 percent of EST trials focus on | |
cognitive therapy. From the beginning, even before the DSM-III's | |
clinical-trial-friendly symptom lists, Aaron Beck had set out to | |
create a therapy whose effects on depression could be validated | |
scientifically. He did this by developing his theory that depression | |
is caused by dysfunctional thoughts and core beliefs--and a treatment | |
targeted directly at those causes, one that could be broken down into | |
specific modules, whose performance could in turn be evaluated by | |
reviewing tapes of sessions and scoring them on the Cognitive | |
Therapist Rating Scale. Beck also developed a test--the Beck | |
Depression Inventory (BDI)--to measure the outcome. If you think | |
there's a circular logic at work here, not to mention a conflict of | |
interest, you're probably right. But it's no worse than what Max | |
Hamilton did when he fashioned his test to meet the needs of his drug | |
company patrons. Besides, it's easy to overlook such matters when | |
the theory allows cognitive therapists to claim that they are | |
attacking the psychological mechanisms of depression in the same | |
precise way that antidepressants attack neurotransmitter imbalances. | |
This impression was only strengthened over the next 15 years as | |
researchers replicated the finding that Cognitive Therapy was as good | |
as or better than drug treatment and added studies testing it against | |
no therapy at all (other than an intake interview and placing the | |
subject on a waiting list), and even against other therapies. As the | |
findings mounted, professional and public opinion followed. Gerald | |
Klerman's dream of government regulation of therapy hasn't yet come | |
true, but a therapist not using cognitive therapy for depression | |
would find himself [or herself] on the margins of his [or her] | |
profession. | |
Dig into the clinical trials that give Cognitive Therapy its | |
stranglehold on depression treatment, however, and its claim to the | |
status as the most effective therapy begins to seem less than | |
scientific. | |
Cognitive therapists don't only claim that their treatment works; | |
they also assert that it is superior to therapies that haven't been | |
tested. This is another advantage of adopting the [model used by the | |
drug companies]; according to the logic of clinical trials, absence | |
of evidence is evidence of absence. That's why Steven Hollon, an | |
early collaborator with Aaron Beck and a leader in the field, can get | |
away with writing that the fact that "empirically supported therapies | |
are still not widely practiced... [means] that many patients do not | |
have access to adequate treatments"--as if it had already been proved | |
that the only adequate treatments are empirically supported therapies. | |
The remedy is to compare two kinds of therapy that differ only in | |
their specific interventions. But most forms of psychotherapy | |
weren't designed to be manualized--not to mention that the people who | |
practice them aren't leading the charge to measure therapy outcomes. | |
It has been left to cognitive therapists to invent their competition, | |
with the predictable results. One study, for instance, pitted | |
cognitive therapy against "supportive counseling"--a therapy made up | |
by the researchers for their trial--as a treatment for rape victims. | |
The subjects in the supportive counseling group were given | |
"unconditional support," taught a "general problem solving | |
technique," but "immediately redirected to focus on current daily | |
problems if discussions of the assault occurred." It's not | |
surprising that the patients who couldn't talk about their assault | |
didn't fare as well as the patients who could (and who were getting | |
cognitive therapy), but that does cast doubt on the conclusion that | |
cognitive therapy should take home the prizes. Proving that a bona | |
fide therapy provided by someone who believes in it, who is | |
inculcated with its values and traditions, works better than an | |
ersatz therapy, implemented by someone who doesn't think it is going | |
to work, may only show, as one critic put it, "that something | |
intended to be effective works better than something intended to be | |
ineffective." | |
This is why critics object to another statistical procedure common to | |
clinical trials: excluding from the bottom line the subjects who | |
don't complete the study, people who presumably didn't feel that | |
confidence or loyalty. Rather than counting them as failures, most | |
studies simply treat dropouts as if they never enrolled in the first | |
place, which, mathematically speaking, makes the treatment look | |
stronger than it would otherwise. And the numbers also exclude those | |
people who were not allowed into the study because their case wasn't | |
diagnostically pure enough--a move that allows researchers to improve | |
their numbers by cherry-picking the patients most likely to benefit | |
from their treatment. | |
Researchers can study the effect of these and other methodological | |
problems by using meta-analysis, a statistical technique that allows | |
them to determine the mean of means, or, in layman's language, what | |
all the studies lumped together say about a particular factor--even | |
one that the original scientists didn't necessarily intend to | |
examine. So, for instance, two independent groups of researchers | |
have used meta-analysis to factor out the advantages that cognitive | |
therapy has when it goes up against treatments intended to fail. | |
They scoured the literature for studies in which all treatment groups | |
were given bona fide therapies. After crunching the numbers, they | |
came to the conclusion that when the competition was fair, there was | |
no difference in the effectiveness of the treatments. | |
But there is one set of numbers that bears particular weight: | |
findings generated by a group of loyal cognitive therapists. The | |
team, lead by prominent cognitivists Neil Jacobsen and Keith Dobson, | |
set out to investigate Beck's pivotal claim that his therapy has | |
active ingredients that target the psychological cause of depression. | |
Jacobsen and Dobson wanted to determine whether some of those | |
ingredients could be effective in isolation from the | |
others--presumably because this might make an even more efficient | |
therapy. They separated patients into three groups--one that | |
received cognitive therapy according to Beck's manual, one that was | |
given only the component in the manual directed toward behavioral | |
activation (using activity schedules and other interventions to get | |
patients into contact with sources of positive reinforcement), and | |
one that got the modules that focused on coping skills, and in | |
particular, on assessing and restructuring automatic negative | |
thoughts. The experimenters, all of them seasoned cognitive | |
therapists, had an average of fifteen years' clinical experience, had | |
spent a year training for this study, and were closely supervised by | |
Dobson. And at the end of the twenty-week study, to everyone's | |
surprise, there was no difference between the groups. Everyone | |
benefited equally, just as the "dodo bird hypothesis" would predict. | |
Other studies, like one in which two cognitive therapists discovered | |
that most improvement in cognitive therapy occurs in the first few | |
sessions and before the introduction of cognitive restructuring | |
techniques, strengthen the finding that to the extend that cognitive | |
therapy works for depression, it is not because its specific | |
ingredients act on specific pathologies. Instead, according to the | |
meta-analysts, cognitive therapy's success depends largely on the | |
therapeutic alliance, therapist empathy, the allegiance of the | |
therapist to his [or her] technique, and the expectations of the | |
patient--the same nonspecific factors that Aaron Beck intended to | |
eliminate in the first place. "HOW therapy is conducted is more | |
important," as one researcher put it, "than WHAT therapy is | |
conducted." As it does in drug therapies for depression, the placebo | |
effect deserves most of the prizes. | |
But in real life, the prizes go to Cognitive Therapy, especially the | |
prizes doled out by insurance companies. | |
But Cognitive Therapy is very clear about who we will be when we are | |
cured: smoothly functioning processors of information, resilient | |
navigators of life's ebbs and flows who can "take off those tinted | |
lenses and see the world for what it really is," as Leslie Sokol | |
exhorted us... | |
After four and a half days in this airless room, I still haven't | |
accepted the idea that the world really is a place that offers up | |
nothing I can't handle, if only I can restructure my negative | |
thoughts and shed my self-doubt, that when I repair the glitches in | |
my software, I will finally be able to make it. Instead, I'm chafing | |
against Beck's and Sokol's relentless can-do optimism, weary of their | |
talk of coping skills, their agendas and strategies, their paperwork. | |
Their model of life as a series of challenges to be managed | |
efficiently is as bland and disappointing as this suburban office | |
building. It just doesn't do justice to the perversity of our nature | |
or to the seemingly limitless tragedy on which it feeds. | |
And here is another way that Cognitive Therapy helps us understand | |
depression's wild success in the marketplace of ideas about us. | |
Because to be told that depression is a disease is to be reassured | |
that when we are discouraged, we are not really sick at heart. We | |
are just plain sick. Which means we can get better. We don't have | |
to look [too closely beyond the surface.] We don't have to be | |
worried that pursuing happiness the way we do is also pursuing | |
destruction. We can be healed. We can get our minds to work the way | |
they are "supposed" to. And then we can get back to business. | |
# Chapter 14 | |
The method [Cognitive Therapy] didn't prove itself ineffective but | |
the conditions of its effectiveness, its dependence on our very | |
peculiar societal arrangements and on the corporatism that has come | |
to dominate our self-understanding, were unmistakable. I got a | |
glimpse of the finishing room in the depression factory, the place | |
where the last touches are put on the gleaming new self. | |
[Reminds me of the song On The Outside by Information Society. Below | |
is an excerpt from the lyrics.] | |
> So now they've grown up in these | |
> Brilliantly beautiful sterile communities | |
> Floating like sleepers through the | |
> Flowers and emptiness, the boring futility | |
> | |
> So now they're educated | |
> 12 years of chains and lost opportunities | |
> What they have learned is how to | |
> Jump when the bell rings and fear the breakdown | |
> | |
> See the pain inflicted and | |
> See the vein restricted and | |
> See the pain inside | |
> Caressed, unfolded, delivered | |
> | |
> To the outside | |
> | |
> It's known that nothing can be done | |
> There's just no room for the unconverted | |
> It's known that anything is possible | |
> But there's nothing worth doing here | |
> | |
> See the forgotten sun and | |
> See the forsaken ones and | |
> See them driving cars | |
> As big as they are, as fast as they'll go | |
> | |
> See the eyes turned in and | |
> See cigarette-burnt skin and | |
> See self-loathing love | |
> Assume, turned up, and used | |
"The DSM-IV... has 100 percent reliability and zero percent | |
validity," Thomas Insel, the director of the National Institute of | |
Mental Health told psychiatrists gathered for the APA's annual | |
meeting in 2005. | |
"Brain imaging in clinical practice is the next major advance in | |
psychiatry. Trial-and-error diagnosis will move to an era where we | |
understand the underlying biology of mental disorders. We are going | |
to have to use neuroimaging to begin to identify the systems' | |
pathology that is distributed in each of these disorders and think of | |
imaging as a biomarker for mental illness... We need to develop | |
biomarkers, including brain imaging, to develop the validity of these | |
disorders. We need to develop treatments that go after core | |
pathology, understood by imaging. The end game is to get to an era | |
of individualized care." | |
Materialism may arise out of the wish to be rid of metaphysics, of | |
something that simply can't be explained by science, of a doubt that | |
can only be resolved by faith, but when it crosses the line into | |
fundamentalism, it turns into a metaphysics of its own. | |
And when that metaphysics [of materialist fundamentalism] purports to | |
explain our inner lives--as it most surely does when doctors tell us | |
our depression is a disease of the brain--it has profound | |
implications. | |
All I really have is belief. That's all the manufacturers of | |
depression have too, and as much as I wish they would admit this or | |
at least not so ruthlessly exploit their claim to be on the side of | |
the facts and the facts alone, much as I think their failure to do so | |
is just plain bad faith, I can't deny the attractions of their | |
conviction. They are on the side of progress and optimism and I am | |
on the side of.. what? Of suffering? Of some ancient, outmoded idea | |
about the necessity of storytelling, the incapability of tragedy, the | |
uniqueness of consciousness, the importance of meaning? | |
I once talked to Donald Klein, the Columbia psychopharmacologist, | |
about the placebo effect. Or I should say, I tried to talk to him. | |
He wouldn't engage in the subject. "For the same reason that I don't | |
debate creationists," he told me. | |
# Chapter 15 | |
Whatever else you do, don't let the depression doctors make you sick. | |
This is harder to do than it sounds. Because you have to grant the | |
brilliance, the irresistible narrative power of the story they have | |
manufactured. | |
Reiger went on to point out that the dire estimates of mental illness | |
in the population--in any one year, using DSM criteria, something | |
like 30 percent of Americans qualify for one diagnosis or | |
another--raise some red flags even without the critics. For | |
instance, he wrote, the mental health treatment system is in no way | |
prepared to treat the 100 million patients forecast to meet the | |
criteria every year. This embarrassment of riches could be a public | |
relations disaster. | |
Fink is not the first doctor to propose cortisol tests to verify | |
depression, and they are compatible with our neurochemical theories, | |
which see depression as a stress reaction gone amok. But not without | |
a cost--market share. But that's not the only reason that the | |
depression industry is not beating a path to Max Fink's door. It's | |
also because Fink, who in his late eighties, is one of the world's | |
leading proponents (and practitioners) of electroconvulsive therapy, | |
which is a highly effective treatment for melancholia--as doctors | |
have known since the 1940s. But while doctors continue to provide | |
ECT, very quietly, it's hard to imagine who is going to pay for | |
clinical trials for a device that lost its patent protection long | |
ago, and which has such a terrible reputation. | |
It's probably an oversimplification to say that depression as we have | |
come to know it has been manufactured in order to maintain a Maginot | |
line between recreational drugs and antidepressants. On the other | |
hand, you have to marvel at how well the diagnosis protects the | |
pharmaceutical companies from the bad reputations of their | |
illegitimate siblings. | |
But as dishonest as this evasion-by-renaming is--and it is really | |
dishonest--it does accomplish one good thing. It is hard to imagine | |
that so many people would avail themselves of whatever relief | |
antidepressants offer if the drugs were officially considered | |
addictive. Neither would regulators long tolerate an addictive drug | |
if it weren't a cure for illness. As long as we live under a | |
pharmacological Calvinist regime, calling depression a disease is | |
perhaps the best way to get drugs into the mouths of the people. | |
I suppose I'll never know whose story is the right one. But I know | |
what mine is, and I'm sticking to it for now. The greatest injustice | |
that Eliphaz and his friends inflicted on Job was that they refused | |
to let him have his version of events. That's what the depression | |
doctors want to do to you. | |
Call your sorrow a disease or don't. Take drugs or don't. See a | |
therapist or don't. But whatever you do, when life drives you to | |
your knees, which it is bound to do, which maybe it is meant to do, | |
don't settle for being sick in the brain. Remember that's just a | |
story. You can tell your own story about your discontents, and my | |
guess is that it will be better than the one that the depression | |
doctors have manufactured. | |
author: Greenberg, Gary, 1957 June 9- | |
detail: gopher://gopherpedia.com/0/Gary_Greenberg_(psychologist) | |
LOC: RC537 .G722 | |
tags: book,health,non-fiction,science | |
title: Manufacturing Depression | |
# Tags | |
book | |
health | |
non-fiction | |
science |