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

Joanna Moncrieff, MD
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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.

* * * * *

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 .

36 COMMENTS

  1. Depression is emphatically not an illness, nor is it one single entity. Rather, many vastly different life experiences cause greater or lesser degrees and kinds of depressed feelings for different individuals. It’s amazing that this seemingly obvious awareness escapes so many people… those who naively believe that their feelings of depression are brain diseases that can be treated with a pill.

  2. Hi Joanna,

    If depression is a property of human relations and conduct, how do you explain people who get depressed in the winter and who are helped by a light box?

    This part makes me sad.

    “Instead he makes a plea for these feelings to be understood as legitimate responses to difficult circumstances and an increasingly demanding and destructive society.”

    I think that MIA is an important community and has gotten many things right, but I see this view often expressed as if it is supposed to be obvious. I think it is totally wrong. – Saul

    • Joanna: I was diagnosed with manic depression 1989, which later morphed
      Into bi-polar. I was involuntarily committed, but no one actually shoved the
      pills down my throat, but it became pretty clear to me, either do as you
      are told or be exiled from the human race. I knew nothing of the Mad liberation
      movement, even though I was and am a committed leftist. During this juncture of history, chemical imbalances were the rage in popular culture-think of the Patty Duke Story,’and all the condescension directed at mental patients in cop shows of the time-the poor souls neglected to take their life saving medicine. Now where full circle back to locking up the crazies for their own good, either with more “hospital” beds ‘or outpatient commitment. If I remember correctly, the original threat of the madman was his ability to convince his fellow peasants to revolt-sort of how John Brown was retrospectively recasts a generation after Harper’s Ferry as a “crazy.” Quite a bit different than when I was comforted by stories of Abe Lincoln having been a manic-depressive.

    • Saul,

      Explaining people who get depressed by lack of light is pretty easy. Lack of light can be psychologically and/or biologically depressing and using a light box can help with that problem. That doesn’t mean that human relations and conduct can’t also lead to similar feelings. Depression isn’t one entity; multiple pathways and causes both psychologically/relationally and biologically can lead to experiences of being depressed.

      About this quote,
      “Instead he makes a plea for these feelings to be understood as legitimate responses to difficult circumstances and an increasingly demanding and destructive society.”

      Greenberg isn’t saying that depressed feelings always or only can be understood as responses to difficult circumstances. It seems like you forgot that the essay above also said that Greenberg thought that melancholia could be a form of biological illness-depression (which to me is unproven, but whatever).

      Here are difficult situations which can legitimately lead to feelings of depression:

      – losing a loved one.
      – losing a job.
      – being bullied.
      – being in a warzone.
      – being isolated for whatever reason.
      – being in a car crash.
      – having a miscarriage.
      – not having many friends.
      – being fat and lazy.
      – getting old.
      etc etc etc.

      IF you think it’s “totally wrong” that circumstances like these can lead to feelings of depression… what have you been smoking? That’s pretty out there.

      • I got labeled “paranoid schizoaffective.” People treated me like something subhuman/dangerous/stupid. I got kicked out of college and my mom started abusing me–with encouragement from psychiatry.

        After a year of Hell on earth I wanted to kill myself. Why? It must have been a chemical disorder in my brain. It’s not like “mentally ill” folks have feelings after all, just chemical explosions in our heads. That makes it okay for everyone to treat us like garbage! 😛

    • RE: how do you explain people who get depressed in the winter?

      People used to sleep all winter , before modern lighting / industrialization took place.
      “Economists and bureaucrats who ventured out into the countryside after the Revolution were horrified to find that the work force disappeared between fall and spring. The fields were deserted from Flanders to Provence. Villages and even small towns were silent, with barely a column of smoke to reveal a human presence. As soon as the weather turned cold, people all over France shut themselves away and practiced the forgotten art of doing nothing at all for months on end.” http://www.nytimes.com/2007/11/25/opinion/25robb.html?_r=0

      Otherwise sleep? http://slumberwise.com/science/your-ancestors-didnt-sleep-like-you/

      Other animals hibernate during the winter. https://en.wikipedia.org/wiki/Hibernation

      • “…the forgotten art of doing nothing at all for months on end.”

        Love this. When we go against nature, we are bound to become depressed. Our industrialized, over-achieving, and overly complicated, bureaucratic society has taken us far, far away from ourselves. Doing nothing for months on end is how we can connect to ourselves and to nature, our natural rhythm. That is uplifting, the opposite of depression. It also aligns us mind/body/spirit–the opposite of ‘dissociation.’

        Although in today’s society, we’re kind of in a double bind, here. How can we survive without doing anything other than meditating and communing with nature? How on Earth can this be reconciled?

        • “When we go against nature, we are bound to become depressed.” That’s about the best description of the etiology of depression I’ve ever heard! Our society from our earliest days, even before birth, requires us to do the unnatural, from forcing babies to be born before they’re ready and snatching them away from moms to put them under lights in a box, to encouraging parents to let their babies “cry it out” in another room without responding, to sending kids as young as 6 weeks off to daycare, and later on to a school that has little respect for their developmental needs to explore and create and interact, to requiring adults to work 8 hours every day at something they find little to no meaning in in order to survive, and live under the constant threat that this job will be taken away and they will starve to death and die.

          Depression is a natural reaction to unnatural circumstances. Kinda sums it up.

          • Yes, exactly, we are set up this way from the get go, to struggle against our own nature. Aside from depression, it leads to all sorts of imbalance, distortions of self and reality, and a generally unhealthy society. Adapting has meant dissociating, becoming depressed, consciousness splitting, medicating, denial, dependence, etc.

            How can we not conclude, then, that if we are serious about actually resolving these issues of internal and external splitting, distress, and conflict, our entire social landscape needs to shift radically?

            We need a new way of living. The current one seems to be responsible for what we are calling ‘mental illness.’ I’m looking for pioneers with whom to create a new reality.

  3. I think ‘depression’ has a lot to do with perspective. For one person, losing a job, spouse, and when things fall apart in general, it can lead to depression if we take it all as something we did wrong or something being done to us, etc., and if we deny our emotional response to these things, mostly out of self-judgment, I think.

    But some people know that this is the sign of a transition happening, and, even though these separations and losses do cause pain, in the end, they know the pain is human and temporary, and it will not break them; and they actually can become eventually excited about the prospect of evolving forward, even though it may involve some grief and letting go. That is great change happening, which are passages in life.

    If we swim in our emotions rather than drowning in them, we tend to not get depressed, because everything that happens has some kind of meaning to us, regarding our life path, and is not as random as we might be inclined to believe. That’s what I think, and what works for me, in any event.

    I can get depressed from time to time, if I think too much about the suffering in the world, but it’s always fleeting in favor of all the ways that I’ve used all that I’ve learned along my journey to help create healing and change. That keeps me from sinking altogether into any kind of chronic depression, and in fact, keeps me quite a bit in perpetual joy, which is preferable, to say the least.

    • Alex

      Good response, as usual. I particularly am drawn to the idea of “swimming in our emotions” rather than “drowning” in them. It reminds me of something that Jung wrote about the unconscious, about how shamans swim in the unconscious while others drown in it. I think he made some reference about how drowning in the unconscious is what he would call madness.

      • Oh wow, that’s interesting. I’ve not read much Jung, hadn’t heard this. Rings true, though, about madness and drowning in the unconscious. Change happens through perspective, not by changing what is outside of us. That only comes from our internal changes. Going from drowning to swimming would be a matter of shifting perspective. That changes our worlds, inner and outer.

        • “Change happens through perspective, not by changing what is outside of us. That only comes from our internal changes.”

          I post sayings that I find helpful and thought-provoking outside my office door in the state hospital where I work. I’m posting your statement this afternoon. Thanks-

        • I’m glad you like that quote, Stephen. Ever since I started living by that– which I do, entirely–my process has cleaned up considerably, from complicated and effort-filled to one of simplicity and ease. Much more direct way of manifesting, that’s for sure! And it’s much easier on the mind and body.

          John, you’re right, I really like this perspective. It shows us that we have the tools, internally, to heal any propensity to become depressed over life circumstances. Not being familiar with her work, I checked out the link and read this blurb on Depression: The Way Out of Your Prison (2003):

          “Depression is the experience of a terrible isolation, of being alone in a prison. But by understanding how we build the prison of depression we can dismantle it forever. Dorothy Rowe gives us a way of understanding depression, allowing us to take charge of our lives. She shows it is not an illness requiring drugs but a defence we use to hold ourselves together when we feel our lives falling apart.”

          A defense, I imagine, based on the belief(s) that things will not be ok, that we are losing something or that we have something to fear or feel shame about, followed by what have I done wrong? am I bad? and on and on.

          I believe there are other options as a response to life’s challenges and calamities, antithetical to projecting fear and self-blame. Rather than feeling defensive, worried, fearful, or worse yet, deserving of bad things, we can always choose to take really good care of ourselves, which might include seeking safe and trustworthy support, while, more than anything, seeing where it all leads from moment to moment, as opposed to projecting some big life black hole coming up, which can paralyze us with fear.

          That certainly needn’t be the case, and we do create self-fulfilling prophecies, so I’d take the time to shift beliefs such as these, I think it’s worth doing that kind of internal work, to align with more empowering beliefs about ourselves. Then, life challenges become more interesting rather than something to fear and feel badly about. I think of them as guidance, under any and all circumstances.

          I think what is most depressing is believing that we have no control over our lives, whereas, really, we do. Finding our power is what comes from feeling powerless. We always have the power of perspective, that is inherent in everyone, and on one can take it away from us.

          Although it can be hindered by social programming. So one solution to depression would be to deprogram from false and misleading beliefs that have created the illusions of our society. I think without those filters, we’d have a much clearer picture of reality that wouldn’t be nearly as scary and depressing as the one in which we operate now. That’s my feeling, in any event.

  4. What construct is used to understand the “state” someone spirals into after being carelessly prescribed antidepressants for insomnia
    (caused by a physical problem like a thyroid issue or even a job shift change) or prescribed for “stress urinary incontinence” (like cymbalta trials) or prescribed for hot flashes? These people have indicated no problems, no “issues”, no trauma was part of their lives.
    On the drug, they end up agitated, anxious, suicidal, “depressed”. It has obviously affected their brain? Peter Gotzsche has said, using these drugs “creates” a chemical imbalance, perturbs transmitters, etc.
    So, what is this state considered to be? And, if removing the drug pushes one into a state of “tardive dysphoria” or so-called chronic “treatment resistant” depression, what is to be done? They do not have “issues” to talk therapy out.
    They have been made iatrogenically ill, and now have real “messed up” brain/chemistry/ neurotransmitter short out.
    How does this fit into the scheme of “understanding and treating” so-called depression.
    Even people mildly “depressed” bc of a job loss or a “divorce” are handed antidepressants which hijack and perturb the brain, worsening their state after the job loss or divorce is no longer a concern. This is not a problem in living then.

  5. This is a problem in living where pseudo science for profit is the business plan , government sanctioned titled buffoons preying on the population is the norm , ever ready toxic concoctions from hell or electrical voltage are distributed as medicine , and the wet dream of the powerful , is of a lifetime of unquestioning , complying , non-competing , enslaved multitudes or else .

  6. Your book The Myth Of The Chemical Cure was what woke me up and got me to see psychiatry itself was keeping me sick.

    I was just like WTF that’s how it works. Its not my serotonin ? I was pissed.

    I had one more run in with psychiatry after I screwed up with alcohol and sought detox and when I refused my lobotomy of course they came at me with the injection and state hospital threats. That led me here.

    Bipolar and ADHD … What ever I had insomnia and was screwed up by you quacks.

  7. Saul,

    With all due respect, Dr. Hyman sounds alot like the one size fits all conventional practitioners. Just because someone is an alternative medicine provider doesn’t mean they should be trusted more than the conventional person especially when his operation is quite commercialized.

    I don’t disagree that people with “MH” issues should be automatically checked for various issues. But I am quite skeptical of metal toxicity claims. That sounds just as wild as the bipolar diagnosis’ due to med reactions.

      • Hi Saul,

        Thanks for the information. But just because the Cleveland Clinic has a functional medicine department doesn’t mean it is any more legitimate than their psychiatry department if you catch my drift.

        By the way, I say this as someone who did find the site interesting. I was also curious if they coordinate care with mainstream medical departments. When I looked into going to Cleveland Clinic for other issues, I didn’t sense that occurred so I tend to be skeptical. Of course, I could be wrong.

        Anyway, I haven’t changed my mind on Dr. Hyman.

      • Fred,

        Thanks for the link as I will take a look.

        By the way, the issue is not that mercury toxicity isn’t a serious issue. But it seems just as absurd to blame it for everything under the sun just like it is ridiculous to blame depression for every illness known to humankind.

  8. This blog and discussion regarding the root(s) of depression has really made me think quite a bit about all of this. I know one thing for certain—whether I’m feeling prone to depression vs. feeling good and upbeat can vary quite a bit from moment to moment, depending on around whom I choose to hang around. So I make it a priority now to refine my discernment among people and communities. Made me think of a quote I remember seeing quite a bit back in the day when I was on Facebook:

    “Before you diagnose yourself with depression or low self-esteem, first make sure that you are not, in fact, just surrounding yourself with assholes.” Anonymous

    Then I found this video on YouTube about ‘narcissism’ that really rang true. It’s pretty hard-core and direct, just fyi, might be a trigger for some people, so I wanted to give a heads up. From my experience and so much of what I’ve read on this website alone, this seems quite relevant on many levels, particularly in the struggles with confronting the mental health system/industrial complex–

    https://www.youtube.com/watch?v=XUvmWYWblnc