Major depressive disorder has become the major driver of psychiatry’s social success. It is by far the most common diagnosis found in outpatient treatment. Moreover, its incidence is said to be rising at an explosive rate in recent decades, leading to an “epidemic of depressive disorder” in the population at large but especially among adolescents, college students, and the elderly. The World Health Organization has deemed it, along with heart disease, as among the two most disabling conditions in the modern world. All of these trends have been wonderful news for the pharmaceutical industry, for which anti-depressant medications have proven to be enormously popular treatments over the past thirty years.
Gary Greenberg is a practicing psychotherapist and journalist who wrote two engaging articles for Harper’s on his experiences in a drug trial of anti-depressants. Manufacturing Depression is a major expansion of these pieces, displaying Greenberg’s felicitous and witty writing, skepticism about the widely-heralded view of depression as a “disease,” and ability to penetrate to the heart of complex issues without engaging in polemics. In contrast to the now taken-for-granted idea that depression is a genuine illness that often results from a chemical imbalance, Greenberg speaks of the condition as grounded in the human predicament of betrayals by friends and lovers, disappointments in achieving valued personal and career goals, and coming to terms with the inevitability of death.
For Greenberg, depression is “unhappiness rendered as disease.” He invokes earlier physicians and psychiatrists such as George Beard and Adolph Meyer, who insisted that depression and its sibling nervousness resulted from attempts to adapt to environmental demands. Greenberg provides the reader with an engaging tour of the history of research on depression and anti-depressants, showing how the claims for the biological status of depression and its treatment through drugs have been grossly exaggerated. Pharmaceutical companies, of course, are mainly behind this phenomenon. They are, however, hardly to blame for it because they are doing exactly what they are supposed to do: generate large profits for their companies and employees. Likewise, therapists also act in the interests of their clients who want their therapy paid for and their distress relieved by prescriptions for drug treatments. Despite knowing that their clients are demoralized or worried about their lives rather than suffering from a disease, they say: “I’ll have to tell your insurance company that you have a mental illness.” Depression is the category of “mental illness” that best fits the capacious rang of life problems that clients bring to their therapists.
Greenberg skewers current diagnostic criteria that turn depression into a disease isolated from the life situations and meaning systems of patients. He notes that symptom-based criteria can reliably diagnose illnesses that don’t really exist and have produced a voluminous literature that doesn’t ever mention what being depressed actually feels like. Such criteria situate problems in the language of medicine and science, removing them from social, moral, and religious frameworks that could serve as least equally well to explain the problems at hand.
Greenberg is particularly good at analyzing the history of anti-depressants, which were initially thought to have too limited a market to make them profitable. He provides a wonderful discussion of the similarities of drugs such as LSD and ecstasy to socially approved medications and the efforts of the pharmaceutical industry and psychiatric profession to distance themselves from the uncomfortably close relationship between illegal drugs of abuse and highly profitable anti-depressants. He also astutely scrutinizes the role of the Food and Drug Administration in bringing the SSRIs onto the market, despite the limited evidence of their success. Lest he be accused of focusing too narrowly on the excesses of the drug industry, he is equally adept at skewering the excessive claims of proponents of cognitive behavioral therapy, which in their own way often equal the inflated assertions of the pharmaceutical companies.
Greenberg’s major points will not surprise readers familiar with the writings of David Healy, David Herzberg, Edward Shorter, Andrea Tone, Jerome Wakefield, and me as well as a number of other academics who are skeptical of the depression industry. This book, however, aims at the many millions of citizens who are at risk of having their various life struggles labeled as instances of depressive disorder and receiving anti-depressant medications as the cure for their predicaments. This reviewer can only hope that his appealing and humorous – but deeply serious – narrative will engage the large public that he is trying to reach.
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 may 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.
These wise words should be pasted on the door of every general physician and psychotherapist.
Allan Horwitz, Rutgers University.
Allan Horwitz is a professor of sociology and the author of many books, including Creating Mental Illness (University of Chicago Press 2001), and The Social Control of Mental Illness (new edition) (EWR Press 2002). He last posted on this blog about the latest revision of the Diagnostic and Statistical Manual of the American Psychiatric Association, the DSM-V.