A Square Peg in a Round Hole: The Construction of Depression as a Disease

This blog is a review of Gary Greenberg’s book, Manufacturing Depression: The Secret History of a Modern Disease. I wrote it originally in 2010, but it was never published. By publishing the review now, I hope it will provide a useful reflection for those who have already read Manufacturing Depression, and an incitement to read the book for those who have not.

In 1960 Thomas Szasz wrote “Mental illness is a myth, whose function is to disguise and render more palatable the bitter pill of moral conflict in human relations.”¹ Like Szasz, Greenberg believes that how we view depression and other human problems is not an empirical, but a philosophical matter. Depression is not something that emanates from, and will eventually be identified, in the brain. It is a property of human relations and conduct. Greenberg follows Szasz in highlighting how designating something as an illness is to make a moral judgement that it is unwanted, that it needs eradicating. Greenberg is not so sure however, that the distress, despair and pessimism that have come to be called depression should be eradicated as if they were a case of pneumonia (even if we are to believe the claims that they can be). Instead he makes a plea for these feelings to be understood as legitimate responses to difficult circumstances and an increasingly demanding and destructive society.

While charting the rise of the modern notion of depression, Manufacturing Depression takes in more or less the whole history of psychiatry in the 20th century and much more. From Job to Kraepelin, through Freud to Meyer, from insulin coma therapy to the rise of the Diagnostic and Statistical Manual (DSM), from Paul Erlich’s earliest magic bullets against syphilis, to the use of LSD and the placebo effect, Greenberg weaves an entertaining and engrossing story about how and why mental disturbance has come to be understood as a brain disease. Some may feel he is a little unfair to Meyer, whose role in Greenberg’s account is to free mental illness from the bonds of Kraepelin, thereby allowing everyone to be potentially mentally ill. But Meyer too was surely trying to give suffering back its meaning in exactly the way that Greenberg wants to do. In fact Greenberg quotes Meyer as repudiating Kraepelin by suggesting that in the search for pathology, the doctor “surrenders his common sense attitude” and fails “to view the abnormal mental trend as a genuine but faulty attempt to meet situations” (cited in Greenberg, P 89).

One of the most valuable parts of the book for me was the account, interwoven throughout the book, of Greenberg’s participation in a randomised controlled trial. Greenberg enrols thinking that his tendency to pessimistic despondency and indecisiveness will be diagnosed as a “minor” depression, but is surprised to find that he is thought to qualify for the part of the trial intended for people with “major depressive disorder”. Greenberg’s description of trying to make his feelings and beliefs fit into the predetermined answers of the rating scales he had to fill in is hilarious in places. Even the trial doctor admits that “you know, this question condenses a lot of areas of life into just a number. It doesn’t work well” (Greenberg, P 130). In this sentence the whole edifice of the supposedly scientific evidence on depression and its treatment collapses. Depression is “diagnosed” and rated using questions which do not come close to capturing the enormous complexity and variety of the feelings and experiences of those who are labelled “depressed”- the concept is a house of cards.

As Greenberg points out, despite the yearnings of biological psychiatrists to identify the neural substrates of our emotions, the diagnosis of depression continues to be based on “symptoms” which, in this context, means how people describe themselves and their problems. But, Greenberg suggests, individuals, and indeed whole societies, can be coached on how to understand their troubles by disease promotion and advertising campaigns. These campaigns supply the language through which people come to describe their difficulties. This language of neurochemical imbalances and serotonin deficiencies, having been supplied directly or indirectly through the activities of pharmaceutical companies, is associated with the suggestion that there is a simple solution in the form of an “antidepressant.” In other words, the modern concept of depression as a brain disorder that has filtered through into ordinary discourse is an incredibly successful, and therefore mostly invisible, marketing device. Antidepressants are the “sacramental pills”  that symbolise this view (Greenberg, P 332).

Despite dedicating most of his book to exposing the medicalisation of suffering, and the subjective nature of psychiatric “conditions”, at a couple of points Greenberg makes the surprising suggestion that some suffering is a real brain disease. He suggests that very severe depression, which used to be called “melancholia,” is a medical disorder treatable with specific and targeted interventions, namely electro-convulsive therapy (ECT) and tricyclic antidepressants. He even suggests that some of his therapy patients might have this real disease, so he is most likely not talking of the sort of people who would traditionally have been diagnosed with “melancholia,” who were mostly elderly and required hospitalisation for severe agitation or retardation, often with psychotic delusions. Importantly, Greenberg never goes into detail about how someone with this real disease is distinguishable from someone with the non-disease. This point potentially undermines Greenberg’s whole argument. If some cases of depression are real diseases, and there is no categorical way of dividing those with the disease from those without, then the tendency to medicalise is understandable and not necessarily particularly concerning. If he had wanted, Greenberg could have found plenty of material to raise questions about the efficacy and specificity of ECT and tricyclic antidepressants ^2,3 and his argument would have been more powerful for encompassing the whole range of suffering currently embraced by the label “depression.”

Overall though, Greenberg’s book tells a convincing story about how the mental health industry, in alliance with the drug companies, has persuaded us we are sick in the head in order to sell its products. The book is carefully researched, with much attention to detail, but Greenberg never pretends to be “objective.” For Greenberg, the quest for objectivity is simply an expression of the mistaken philosophical position that depression resides in the brain. In fact Greenberg follows Foucault in suggesting that psychiatric labels are moral judgements in disguise. Terms like “depression” are loaded with tacit judgements about what is a good, productive and “normal” life.

Greenberg is not shy to draw political conclusions from his analysis. Is it really a coincidence, he wonders, that the Prozac era has also been a period of soaring inequality, fiscal recklessness and wartime atrocities? For Greenberg, one of the worst consequences of the mass medicalisation of suffering and discontent is the way it fosters conformity to a superficial consumerist culture and discourages people from protesting about the nature of the society that we live in. Not everyone will agree with his left leaning conclusions, and they are far from the libertarian politics of Thomas Szasz. Greenberg’s views nevertheless make a welcome contribution to the field of political debate that is opened up by the deconstruction of mental illness, a field which remains as yet largely uncharted.

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References:

1. Szasz T. The Myth of Mental Illness. American Psychologist 1960;15:113-8.
2. Moncrieff J. The Myth of the Chemical Cure: a Critique of Psychiatric Drug Treatment. Basingstoke, Hampshire, UK: Palgrave Macmillan; 2008 .
3. Read J, Bentall R. The Effectiveness of Electroconvulsive Therapy: a Literature Review. Epidemiological Psychiatry Society 2010 Oct;19(4):333-47 .