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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.
See also:
(HTM) Do You Still Believe in the Chemical Imbalance Theory of Mental Illness?
# 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.
(TXT) Equity of outcome @Wikipedia
I have heard of these ideas before. See the intro section of the
following log entry.
(DIR) 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-
(TXT) detail: gopher://gopherpedia.com/0/Gary_Greenberg_(psychologist)
LOC: RC537 .G722
tags: book,health,non-fiction,science
title: Manufacturing Depression
# Tags
(DIR) book
(DIR) health
(DIR) non-fiction
(DIR) science