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.