Half a century after Thomas Szasz first declared “there is no such thing as ‘mental illness,’ ” his radical critique of psychiatry is widely viewed as outmoded and simplistic at best, cruelly dogmatic at worst. “The opinion of official American psychiatry,” Szasz writes in the preface to the 50th anniversary edition of The Myth of Mental Illness, “contains the imprimatur of the federal and state governments. There is no legally valid nonmedical approach to ‘mental illness,’ just as there is no such approach to measles or melanoma.…Debate about what counts as mental illness has been replaced by legislation about the medicalization and demedicalization of behavior.”
Yet psychiatry’s lack of scientific rigor is so obvious today that the profession’s leading lights openly complain about it. In a January Wired article about the ongoing revision of the American Psychiatric Association’sDiagnostic and Statistical Manual of Mental Disorders (DSM), Gary Greenberg, a psychotherapist and journalist, recounts an interview with Allen Frances, lead editor of the manual’s current (fourth) edition. “There is no definition of a mental disorder,” Frances tells him. “It’s bullshit. I mean, you just can’t define it.”
Since mental disorders officially exist in the United States only if they are listed in the DSM, which is the bible for mental health professionals and the key to insurance coverage, this is a pretty significant concession. It reinforces Szasz’s point that psychiatrists invent mental illnesses by voting on whether to recognize them. “Old diseases such as homosexuality and hysteria disappear,” he writes, “while new diseases such as gambling and smoking appear, as if to replace them.”
The perils of this approach are evident in Greenberg’s eloquently honest book Manufacturing Depression: The Secret History of a Modern Disease, which questions psychiatrists’ authority to medicalize our moods even as it sympathizes with the suffering of depressed people and describes the author’s own bouts of melancholy. Although his book has a Szaszian title (recalling the heretical psychiatrist’s 1970 book The Manufacture of Madness), Greenberg mentions Szasz only once in passing. Jonathan Metzl, a professor of psychiatry and women’s studies at the University of Michigan, has a bit more to say about Szasz in The Protest Psychosis: How Schizophrenia Became a Black Disease. Metzl implicitly criticizes Szasz and other opponents of forced treatment for inspiring the deinstitutionalization that began in the 1960s, which he says often left former mental patients with “nowhere to go and no one to turn to for help.” Yet by tracking the shifting, politically driven definition of schizophrenia, commonly viewed as the mental disorder most clearly established as a disease, Metzl’s eye-opening book casts doubt on psychiatry’s status as a field of medicine, let alone one with a strong enough basis to justify coercively treating unwilling patients. Together he and Greenberg show that Szasz’s objections to psychiatry’s role in stripping people of their freedom and relieving them of their responsibility, no matter how often they are dismissed as quaint or simpleminded, remain logically and morally compelling.
As Greenberg makes clear in his Wired article and his book, mental disorders are defined by patterns of behavior, without regard to what causes them. By listing these criteria in the DSM, psychiatrists have achieved a high degree of diagnostic agreement, but they simply assume that people who are given the same label have the same underlying problem. In Manufacturing Depression, Greenberg quotes Thomas Insel, director of the National Institute of Mental Health, who told psychiatrists at the American Psychiatric Association’s 2005 convention that the DSM “has 100 percent reliability and zero percent validity.”
In Szasz’s view, this lack of validity is unavoidable, because once a particular pattern of behavior can be confidently ascribed to a physical defect, such as the brain damage caused by advanced syphilis or Alzheimer’s disease, it is no longer considered a psychiatric issue. “Contemporary ‘biological’ psychiatrists tacitly recognized that mental illnesses are not, and cannot be, brain diseases,” he writes in his preface. “Once a putative disease becomes a proven disease, it ceases to be classified as a mental disorder and is reclassified as bodily disease.” If every disorder in the DSM had a clear neurological cause, Szasz says, psychiatry would be indistinguishable from neurology.
Greenberg takes a less categorical stance, skeptical of the DSM enterprise but not quite prepared to give it up entirely. “A new manual based entirely on neuroscience—with biomarkers for every diagnosis, grave or mild—seems decades away, and perhaps impossible to achieve at all,” he writes in Wired. “To account for mental suffering entirely through neuroscience is probably tantamount to explaining the brain in toto, a task to which our scientific tools may never be matched. What the battle over DSM-5 should make clear to all of us…is that psychiatric diagnosis will probably always be laden with uncertainty, that the labels doctors give us for our suffering will forever be at least as much the product of negotiations around a conference table as investigations at a lab bench.”
The example that is the focus of Greenberg’s book, depression, plainly illustrates the arbitrariness of the DSM’s diagnostic criteria. Since everybody gets the blues, psychiatrists need to distinguish between normal sadness and pathological sadness, if only to preserve their own credibility as doctors treating illness. But such line drawing is unavoidably subjective. As Greenberg notes, the official definition of “major depression” excludes people who have experienced the death of a loved one within the previous two months. The American Psychiatric Association (APA) has decreed that 60 days of mourning is appropriate, while 61 is not. Up to the two-month line, you are experiencing normal grief; after that, you are sick.
Not only is the cutoff arbitrary, but so is the decision to count only death as a legitimate excuse for “a period of at least 2 weeks during which there is either depressed mood or a loss of interest or pleasure in nearly all activities.” As Greenberg observes, “It’s not clear why bereavement is the only exempt condition, why, for instance, misfortunes like betrayal by a lover or severe financial loss or political upheaval or serious illness—or for that matter a noncatastrophe, the slow accretion of life’s difficulties or a loss of faith in one’s government or simply existential despair kindled by an awareness of mortality—do not also spare people from the rolls of the diseased.”
Greenberg does not think there is anything necessarily adaptive, redemptive, or ennobling about depression. He recalls his own struggles with it, including “the time I found myself on the floor watching dust specks float through sunbeams for hours (because they happened to be in my line of sight, because looking at anything else or closing my eyes and staring at my own black insides would just take too much effort), racked by some unspecifiable pain, like my whole being was a phantom limb, and thinking about the lady in the Life-Fone pendant ad, the one who has fallen and can’t get up.” He describes clients whose unremitting self-reproach has sucked every bit of pleasure from their lives, who are immobilized by dread and hopelessness.
Yet Greenberg rebels at Prozac apostle Peter Kramer’s confident assertion that “depression is neither more nor less than illness.” He argues that “the medical industry…has acquired far too much power over our inner lives—the power to name our pain and then sell us the cure one pill at a time.” While Greenberg details how pharmaceutical companies have profited from treating depression as “a widespread chronic disease,” he does not claim they foisted this concept on us. The idea appeals to Americans, he suggests, because it gives them permission to take mood-altering substances without running afoul of the principle that Harvard psychiatrist Gerald Klerman called “pharmacological Calvinism”—the belief that “if a drug makes you feel good, it must be morally bad.”
Greenberg agrees that drugs, including psychotherapeutic catalysts such as MDMA (Ecstasy) as well selective serotonin reuptake inhibitors (SSRIs) such as Prozac, can help depressed people feel better. And although he bemoans “the medical industry’s invention of a disease out of our daily troubles and aspirations,” he concedes that pills might be the best choice for some people in some situations. But he emphasizes the crucial role that the placebo effect seems to play in the impact of SSRIs. In clinical trials, drugs like Prozac perform only slightly better than placebos, so slightly that the difference is “not clinically significant,” according to a 2002 review of the evidence by Irving Kirsch, a professor of psychology at the University of Hull, who elaborates on his findings in The Emperor’s New Drugs (Basic Books). The difference is so small that it may be partly or entirely due to expectations primed by the drug’s side effects. These results (along with Greenberg’s own experience as an experimental subject, which he describes) suggest the power of hope, kindled by the rituals of self-improvement, as an antidote to depression.