You've Got Your Nerves in My Depression!

A book on the "depression" diagnosis takes its critique in the wrong direction.

How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown, by Edward Shorter, Oxford University Press, 256 pages, $29.95.

A certain type of book claims that the growth in the diagnosis of depression since the 1970s has been misguided. Here are the essential assumptions of such treatises: There is such a thing as real depression, certifiable by objectively measurable biological markers. But for various reasons, depression's occurrence has been inflated and/or conflated with other illnesses, leading to more frequent but inaccurate diagnoses. There has in fact been no growth in real depression; indeed, there cannot be, since there are no grounds to expect that the endogenous sources of real depression would ever increase. We would be happier if society returned to diagnosing real depression.

Edward Shorter's How Everyone Became Depressed is such a book. Shorter, a historian of medicine and psychiatry at the University of Toronto, notes that the incidence of depression began increasing steadily with the dominance of psychoanalysis early in the last century, then took off exponentially in the decade preceding the 1980 edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders. Today Shorter reports, one in five Americans will be diagnosed with depression over their lifetimes. At the same time, other diagnoses have fallen out of favor. Shorter points out that through much of the previous two centuries, the source of emotional distress was identified as "nerves" (as in "nervous breakdown"). A social historian might take a radical view of this shift, arguing that manifestations of distress vary with the social milieu. But Shorter thinks only that the labels have changed as psychiatric terminology and customs have changed, and that "nerves" is a more accurate label for most of what is currently described as depression.

Yet there has also been an exponential jump in other psychiatric diagnoses, such as attention deficit disorder (ADD), first recognized by the American Psychiatric Association in 1980, and bipolar disorder, both of which have exploded among kids and teens. The fact that diagnoses other than depression also have increased dramatically during the last 50 years undercuts Shorter's idea that there has been a simple redistribution of diagnoses from nerves or other psychiatric conditions toward depression and instead indicates a general boom in psychiatric diagnoses.

An even more radical social historian might suggest these conditions are actually increasing in response to a general loss of personal power and the disintegration of social support and community. (Will readers think the idea that one in five Americans is depressed over their lifetimes is a serious overestimate, as Shorter does, or will they consider it a conservative figure?) Although there may well be organic reasons why some people are more susceptible to depression than others, people get depressed due to the circumstances of their lives: their lived experiences and their social environments. Any diagnostic discussion that does not take account of this context is bound to be woefully inadequate.

The idea that psychiatric diagnoses take different forms in different eras is called social constructivism. This idea is very alien in America, where biological determinism holds sway. For instance, widely publicized claims about brain activity associated with addiction suggest that addiction to anything (including gambling and sex as well as cocaine and alcohol) is firmly ensconced in users' brains. The idea that addiction predictably results from a drug's specific effects on brain chemistry also implies that someone in a past era who used drugs or drank a lot of alcohol was an addict, whether or not he was recognized as such at the time.

Because of this mind-set, American historians are prone to finding distinguished addicts and alcoholics (such as Sigmund Freud or Winston Churchill) whose habits were disguised from everyone by their social status and exceptional professional competence. Yet the Diagnostic and Statistical Manual of Mental Disorders, the fifth edition of which is scheduled to be published next month, defines addiction ("substance use disorder") in terms of impaired functioning and not based on dependence symptoms. In other words, historical works such as Howard Markel's An Anatomy of Addiction: Sigmund Freud, William Halsted, and the Miracle Drug Cocaine label as addicts people who not only were not seen as addicts in their time but who also would not qualify as addicted under current diagnostic criteria.

We might hope that a historian would spot the intellectual shortcomings of this reductive perspective. Instead, Shorter (like Markel) doubles down on the biochemical fallacy. Shorter begins with the preposterous claim that an Australian researcher "figured out that there is a biological marker—a chemical indicator—for the form of serious depression called melancholia" but that "several official commissions" rejected this proposition for no good reason. In fact, the idea of a biological marker for depression has been rejected because there is no such thing. As the definitive World Federation of Societies of Biological Psychiatry, a group committed to identifying such markers, declared in its consensus paper on the subject: "no biological markers for major depression are currently available for inclusion in the diagnostic criteria."

Shorter manages to contradict both the social constructivist approach and its opposite, modern psychiatric-genetic research, which is looking for a unifying theory of mental illness. Psychiatric-genetic "discoveries" should be treated with extreme skepticism, since decades of research into markers for mental illness have come up dry. But in a much-ballyhooed study published in The Lancet this year, National Institutes of Health–funded researchers reported finding the same genetic basis for a range of major psychiatric disorders: depression, autism, schizophrenia, ADD, and bipolar disorder (although the reported incidence of the disorders associated with these genes is minor). Such results do not exactly jibe with Shorter's insistence that conditions involving "nerves" or "nervousness," such as ADD, and global or mixed conditions, such as bipolar disorder, are essentially different from "real" depression.

Shorter likewise is not a radical critic of the pharmaco-therapeutized society. His emphasis on distinguishable conditions means he regrets not that people are receiving too many medications but that they are getting the wrong ones. He thus raves about a drug mixture to treat those who are not depressed but "worn out and weary" and who also have anxiety. (Truly depressed people, he assures us, never experience such a combination of problems.) The weary "require stimulation; those who are agitated and preoccupied require sedation," he writes. "Half a century ago the pharmaceutical industry marketed a highly successful combination of barbiturates and amphetamines," which has now, in his view, unfortunately fallen into disuse.

As Shorter promotes such ideas, critics like former New England Journal of Medicine editor Marcia Angell argue that the search for the biological basis of psychiatric conditions has dead-ended and that pharmaceuticals prescribed based on the biochemical model actually increase mental illness. As Angell noted in a New York Review of Books series titled "The Epidemic of Mental Illness: Why?," the introduction of new psychiatric medications never reduces the incidence of the disorders being treated. "The new generation of antipsychotics, such as Risperdal, Zyprexa, and Seroquel, has replaced cholesterol-lowering agents as the top-selling class of drugs in the US," she writes. At the same time, "the use of antipsychotic drugs is associated with shrinkage of the brain, and that effect is directly related to the dose and duration of treatment." The drugs themselves, Angell argues, are causing many of the problems being observed. If this is true—and I think there is a good chance that it is—then Shorter has really missed the boat.

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  • Fist of Etiquette||

    Big Pharm is diagnosing everyone as hyper or depressed? A juvenile probation officer friend of mine constantly rails against how his charges are overmedicated. The brain, especially an adolescent one, is a mystery, so who knows if he's right.

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  • Lord Humungus||

    no shit?

  • Jon Lester||

    Khimki forest dot com. You will care.

  • $park¥||

    If you worked more than 12.5 hours per week just think of what you could have bought!

  • Rich||

    It's Lancia *Stratos*, evie, so I'm calling bullshit on your claim.

  • Jon Lester||

    Funny how quiet Big Pharma's been during the whole gun control debate of the last few months.

  • Rich||

    Yep. A little digging into this aspect of things surfaces some amazing stuff.

  • ||

    How Everyone Became Depressed? Coldplay's mere existence is probably enough to do it

  • ||

    Well shit, not til you mentioned it! Thanks a lot, Furry!

    *begins printing FMLA request form

  • Agile Cyborg||

    People just need more god to avoid the depressions.

  • Fluffy||

    The really funny thing is that an econo-centric way of looking at human activity dissolves most of the various psychological conditions out there into nothingness, once you get past chromosomal disorders with an obvious and visible physical component.

    Depression, anxiety, attention disorders - they all turn into various types of dissatisfaction arising from the gap between our infinite desires and the means at our disposal to satisfy those desires.

    "I can't choose among all these alternative courses of action to satisfy my infinite desires," = attention deficit disorder.

    "My infinite desires are not being satisfied, and this is very discouraging to me," = depression.

    "Oh no, I am running out of time to satisfy my infinite desires, or X might go wrong and get in the way of me satisfying my infinite desires," = anxiety.

    And so forth.

    So the econo-centric way of looking at Man would tell you that attempts to use psychology or pharmacology to get rid of these disorders are doomed to failure, because they are natural outcomes of scarcity. IOW, economists don't expect you to be happy, and psychologists do; to an economist, unhappiness is natural, and happiness is evidence of dysfunction; while for psychologists it's the reverse.

    So who's right?

  • BakedPenguin||

    Which totally ignores problems caused by trauma. PTSD, for one, really doesn't fit that mold.

  • Fluffy||

    "These unpleasant memories come back to me at inopportune moments, and interfere with my pursuit of my infinite desires."

    "Had my infinite desires been satisfied, I'd be remembering that right now, but they weren't, so I'm remembering that time I got my ass kicked instead."

    Or perhaps:

    "While I was deployed, I could satisfy my desire to shoot stuff in a socially-acceptable way, but now that I'm stateside I get really frustrated with being forced to suppress my desire to shoot stuff. It's hard to turn that desire off once you've satisfied it in the past."

  • BakedPenguin||

    Kind of a stretch, I don't think your model can fit mental difficulties that resulted from trauma.

    Your point about psychologists and economists facing different directions in their basic expectations is generally valid, though.

  • Zeb||

    I think that oversimplifies things a bit. It doesn't answer the question of why some people are more effected by these things, for one thing. The fact that different people react so differently to the problems you describe, I think indicates that there is something else at play that varies among individuals.

  • hotsy totsy||

    Nobody literally has infinite desires. Too many to count, maybe, but not infinite.

  • BlueBook||

    "My infinite desires are not being satisfied, and this is very discouraging to me," = depression.

    That's true of some flavors of depression, but others manifest as a severe *lack* of desires.

  • Robert||

    I don't think that accounts at all for the people hearing voices with no correct identifiable source. Or the people who can't move their arms for no identifiable reason. Or the people who have to wash their hands all day when they aren't dirty. Or a load of other things I could mention, but don't because the pink zebra will kick me if he sees them.

  • Baal||

    What ought to be labeled as ADD involves difficulties
    with attention on a much shorter time scale than conscious
    decisions about which high level goal to attend to. It's about
    the ability to execute the intention to attend to something.
    People tend to equate attention with willpower, but a better,
    although very loose, analogy is to the resource allocation
    functions of an operating system kernel. The kernel has to
    decide things like which of contending processes/threads get to
    use which cores, when to flush buffers to disk, when to wake up
    processes after new data has arrived, what's the algorithm for
    pushing data out of each level of cache?. There are a lot of
    functions related to resource management (that's a big part of a
    kernel's job, after all.)

    Similarly, there really is no one kind of "attention." The brain
    has to constantly allocate scare resources, too: where should the
    eye be focused from one fraction of a second to the next ? Which
    visual stimuli should be considered salient enough to pass up for
    higher processing (Or aural or tactile stimuli)? Which bits of
    information get to stay in our extremely limited working memory
    from moment to moment ?

    "Having" ADD should mean you have issues with this kind of lower level control.

  • SusanM||

    I think there's merit in that, but it does ignore that there are real neurochemical imbalances involved in many types of mental illnesses.

    As for over-diagnosing I have "The Da Vinci Rule". Which states that if someone says the maestro had x illness it's become too trendy.

  • Lord Humungus||

    You know who else was depressed?

  • $park¥||

    Giles Corey?

  • ||

    Eeyore?

  • Rich||

    Epi's mother?

  • Lord Humungus||

    every day.

  • ||

    Mad Max?

  • Lord Humungus||

    especially after one of my minions shot his dog.

  • EDG reppin' LBC||

    Kurt Cobain?

  • Marc F Cheney||

    Depressy Depressorson?

  • hotsy totsy||

    Also, I really wonder if there aren't some people who are just..whiney and complaint prone? Others may be simply going through a hard time in life, like an illness or their spouse's infidelity.

  • lap83||

    Depression is a real thing, although I'm not convinced that most people who say they have it actually do. There is a lot of prescription abuse out there.
    The difference between generally feeling down and depression is the difference between a cloudy, rainy day and a sunny day that feels like it's raining. You can't just snap out of depression because your perception of everything has changed.

    That said, it's not hopeless. I have been depressed at least a couple times in the past 10 years. I've never taken medication for it. The key for me has been to realize that I'm depressed so I can start trying to control my thought patterns and my lifestyle. It's something you have to work at.

  • Brian Sorgatz||

    "Shorter manages to contradict both the social constructivist approach and its opposite, modern psychiatric-genetic research, which is looking for a unifying theory of mental illness." (emphasis added)

    Someone has already found a unifying theory of what is misleadingly called "mental illness." Unfortunately, it's not taken seriously because of academia's smug prejudice against temperament typology, which is so often belittled as "no better than astrology." If only David W. Keirsey's sixteenfold division of human personality types were properly respected, then his revolutionary and comprehensive explanation of "mental illness" could be practically applied. In my arrogant opinion, this would finally bring clinical psychology out of the Dark Ages.

  • David Pap....||

    A more particular study shows that white American college-aged women are the nation's most depressed. What does that tell you about allowing Hollywood and snooty professors to influence you?

  • Bill||

    Maybe white American college age men are the problem?

  • DannyHaszard||

    Risperdal reproached.

    Johnson and Johnson are the 'baby care people' and their marketing of Risperdal and other products must be above reproach.
    All the manufacturer's of the SGA (Second generation Antipsychotics) engaged in deceptive promotions and off label marketing.I personally was victimized by Eli Lilly's *viva zyprexa* campaign.
    Fours years of off label prescriptions of Zyprexa for my PTSD gave me life-long diabetes.
    Eli Lilly made $70 billion on Zyprexa!
    --Daniel Haszard 'tell the truth don't be afraid' http://www.zyprexa-victims.com

  • Sevo||

    "Fours years of off label prescriptions of Zyprexa for my PTSD gave me life-long diabetes."

    Uh, cite?

  • lap83||

    I think the best treatment for most mental problems is making yourself useful to others. My evidence comes only from anecdotes and personal experience, but manual labor and service (real service, not "public service") can do wonders. It makes you less self-absorbed.

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