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, Bloomsbury: London, 2010; 432 pp: (hbk). 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.

Reference List

(1) Szasz T. The myth of mental illness. American Psycholgist 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 http://www.amazon.co.uk/The-Myth-Chemical-Cure-Psychiatric/dp/0230574327.
(3) Read J, Bentall R. The effectiveness of electroconvulsive therapy: a literature review. Epidemiol Psichiatr Soc 2010 Oct;19(4):333-47 http://www.ncbi.nlm.nih.gov/pubmed/21322506.

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7 thoughts on “A square peg in a round hole: the construction of depression as a disease.

  1. Although being indirect, I think you are assuming judgment: some people suffer and deserve attention and other don’t. Is that right?

  2. On a different but related note Dr Moncreiff, have you come across Dr Bessel van Der Kolk’s book “The body Keeps the Score” I’d be very interested to see you review that.

  3. Pingback: Blogs – between negligence and palaver | Texts, Maps, and Networks

  4. Dear Prof. Moncrief,

    Thank you for a fascinating blog. After having suffered from psychosis, I have become very interested in psychiatry. I have learned a lot from your articles and blogs. I have some questions.

    You write (and seem to agree):

    “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.”

    It might be true that psychiatric labels are, in part, moral judgements. But is it not possible to argue that the same is true for all medical labels (e.g., cancer, Huntington’s)? In describing any disease, it seems natural to always base oneself on some idea of ‘normal’ or ‘good’ functioning.

    This leads me to a second question. Even if it is true that psychiatric labels are, in part, moral judgments, does it follow from this that they cannot refer to brain diseases? I think it is possible to believe that, e.g., the label “Huntington’s disease” is both a moral label and a label that refers to a genetic disorder. Might not something similar be true for psychiatric labels?

    I know you have written a lot about the problems of pinpointing an exact biological cause for psychiatric disorders. I must confess I have not read a lot of this (I am just starting) and I know very little of the field. It may be difficult to pinpoint exact biological causes of psychiatric diseases (I have no idea, I am sure this is a topic of hot debate). But it seems to me to be a very reasonable assumption, supported by general insights from genetics, other biological disciplines, and other medical fields, to believe that there is some biological cause for psychiatric disorders. This is not to say that environmental factors do not play a role, they do (every biologists would agree, genes and environment both influence the development and behaviour of organisms). So to say that biological factors partly cause psychiatric disorders seems to me to be a reasonable assumption guiding future research. I am not sure, but do do you deny that biological factors play a role?

    I know the above is a review of a book not written by yourself. But it prompted me to ask these questions. In any case, I wanted to thank you again for all your writings (both articles and blogs). I will continue reading.

    Thank you,

    H. van den Berg

  5. I just read some other of your posts that address some of the questions I asked (on the genetic basis of Schizophrenia). Now turned to Lewontin.

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