16,99 €
Mehr erfahren.
- Herausgeber: John Wiley & Sons
- Kategorie: Geisteswissenschaft
- Sprache: Englisch
Depression has colonized the world. Today, more than 300 million of us have been diagnosed as depressed. But 150 years ago, "depression" referred to a mood, not a sickness. Does that mean people weren't sick before, only sad? Of course not. Mental illness is a complex thing, part biological, part social, its definition dependent on time and place. But in the mid-twentieth century, even as European empires were crumbling, new Western clinical models and treatments for mental health spread across the world. In so doing, "depression" began to displace older ideas like "melancholia," the Japanese "utsusho," or the Punjabi "sinking heart" syndrome. Award-winning historian Jonathan Sadowsky tells this global story, chronicling the path-breaking work of psychiatrists and pharmacists, and the intimate sufferings of patients. Revealing the continuity of human distress across time and place, he shows us how different cultures have experienced intense mental anguish, and how they have tried to alleviate it. He reaches an unflinching conclusion: the devastating effects of depression are real. A number of treatments do reduce suffering, but a permanent cure remains elusive. Throughout the history of depression, there have been overzealous promoters of particular approaches, but history shows us that there is no single way to get better that works for everyone. Like successful psychotherapy, history can liberate us from the negative patterns of the past.
Sie lesen das E-Book in den Legimi-Apps auf:
Seitenzahl: 446
Veröffentlichungsjahr: 2020
Ähnliche
CONTENTS
Cover
Endorsements
Dedication
Title Page
Copyright
Preface
Notes
Acknowledgments
1 Depression is a Thing
What Is Depression?
What Makes Something an Illness, Anyway?
So, What About Depression? Is It an Illness?
Do They Have Depression Everywhere?
Is It a Gift?
Mind and Body
Notes
2 Too Dry and too Cold
Melancholy: An Early Modern Epidemic
Melancholia and Depression
A Substance Too Gross Even for Flies: Black Bile in Antiquity
Sickness and Sin: The “Most Oppressive of Demons” in the Middle Ages
An Epidemic of Early Modernity
Trading Places: From Melancholia to Depression in Modernity
Does Stealing Office Supplies Make You an Evil Person? A Note on Guilt
False Choices and Their History
Notes
3 Turned Inward
The “Abrahamic Tradition” in Depression Studies
Alternatives
Carl Jung: Depression as an Opportunity
Psychoanalysis in the Time of The Broken Brain
A Painful Case: The Lessons of Osheroff
Notes
4 A Diagnosis in Ascent
Blurry Borders
A Weak Word Conquers the World
After Meyer: Depression in Ascent
Rating Scales and Therapies: Depression Quantified
The Measure of Efficacy
Who Gets Depression?
Manualization and its Discontents: The DSM Wars
So, Why So Much Depression?
The Drug That Named an Era
Notes
5 “Just Chemical”
Imbalance
Before Antidepressants
Enter the Antidepressants
Books of the Times
Backlash: Clinical Trials and Other Tribulations
Antidepressants Go Global
After Prozac: New Biopsychiatry of Depression
From Brain to Person
Notes
6 Darkness Legible
Mood and Metaphor
The Depression Memoir as Genre and Source
You Don’t Get It
Getting Real
How Did I Get Here?
Seen and Not Seen
The Body and Biology
Gender
In Bed
Taunted by the Beautiful and the Good
Oblivion
Treatments, Recoveries, Damages, and Regrets
Memoir as Manifesto
Notes
Epilogue: Depression’s Past and Future
Sorrow Is Everywhere You Turn
History Against Compulsive Repetition
The Way Forward
Notes
Note on the Historiography
Notes
Partial Bibliography
Index
End User License Agreement
List of Illustrations
Chapter 1
Figure 1
: A (futile) attempt at a comprehensive list of depression symptoms in all context…
Figure 2
: This image was brought in to a class on depression by a Nigerian student. It’s n…
Chapter 2
Figure 3
: This image is usually considered the most iconic representation of melancholia. …
Figure 4
: This Ngram shows the change of frequency in the use of the terms “melancholia” a…
Chapter 3
Figure 5
: Karl Abraham contrasted this painting with others that showed nurturing mothers.…
Chapter 4
Figure 6
: Mark Rothko’s later paintings avoided lush colors. Many wondered if these late p…
Chapter 5
Figure 7
: Prozac: a medicine that named an era. Actress Carrie Fisher, who wrote with wit …
Figure 8
: This schematic gives an idea of how neurotransmitters convey messages between th…
Guide
Cover
Table of Contents
Endorsements
Dedication
Title Page
Copyright
Preface
Acknowledgments
Begin Reading
Epilogue: Depression’s Past and Future
Note on the Historiography
Partial Bibliography
Index
End User License Agreement
Pages
a
b
ii
iii
iv
viii
ix
x
xi
xii
xiii
xiv
xv
xvi
xvii
xviii
xix
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
“If you have depressive tendencies, a loved one with depression or you just feel like shit, then you might enjoy The Empire of Depression: A New History by Jonathan Sadowsky as much as I did. Sadowsky is a medical historian at Case Western and the book follows the black bile through its various iterations – from the Punjabi ‘sinking heart’ to pharmaceutical warfare – with references to the depression of Mark Rothko, Charles Mingus, and Jenny Diski, plus lots of psychiatry gossip.”
Natasha Stallard, The White Review, chosen as a 2021 Book of the Year
“This brilliant and necessary book reveals how the history of depression illuminates psychiatrists’ and society’s engagement with race, sex, and class in a global context. It also engages the question of whether depression is truly a human universal problem or a Western culture-bound syndrome. The answer is complicated: while the neurotransmitter serotonin is found in all people, the experience and meaning of depression vary widely both within and across cultures. Depression presents differently in different communities and carries different stigmas that are socially dependent. Sadowsky treats the subject with his typical sensitivity, nuance, and extraordinary introspection.”
Richard Keller, Professor of the History of Medicine, University of Wisconsin
“What would an updated Anatomy of Melancholy look like? Perhaps something like Jonathan Sadowsky’s The Empire of Depression … Though neither a Galenist nor an Anglican priest, Sadowsky reminds one in many ways of Burton: wry, practical, humane …”
Gregory Hayes, New York Review of Books
“As Jonathan Sadowsky, a professor of the history of medicine at Case Western Reserve University, observes in his fascinating, dense cultural history of the condition, The Empire of Depression, memoirs and first-person testimonies have contributed a great deal to our understanding of depression. The rise of Prozac in the nineties and society’s surging faith in a ‘chemical cure’ ushered in a new generation of depression memoirists, such as William Styron and Elizabeth Wurtzel, who gave shape to our understanding of depression as an illness while also encouraging a broader perspective.”
Sophie McBain, The New Statesman
“We may be grateful to Sadowsky for bringing together such a comprehensive understanding of several literatures, several disciplines. The Empire of Depression is a new history, but it is more than a history that is new. It is a new way of doing history.”
Allen Dyer, Perspectives in Biology and Medicine
“With humour and personal reflexivity, Sadowsky unravels the history of depression in a comprehensive synthesis of a staggering range of sources.
Jacqueline Leckie, Health and History
“[Sadowsky] is an able writer and a careful thinker, as he considers some of the most important questions about depression, past and present.”
Casey Schwartz, Bookforum
“Drawing from literature, medicine, psychology, anthropology, and memoir, Jonathan Sadowsky shows how much the history of depression informs our present understanding of it. This is an immensely readable book which challenges dogmatic opinions about a complex condition which may be ‘hard to manualize’ but, sadly, is also too often politicized.”
Linda Gask, writer and psychiatrist
“Sadowsky deftly guides the reader across history and continents in search of depression’s past, present, and future. Engagingly written, measured in tone, and nuanced in its conclusions, The Empire of Depression never loses sight of the human suffering at the heart of its subject.”
Greg Eghigian, editor of The Routledge History of Madness and Mental Health
Dedication
For Laura, River, and Julia
The Empire of Depression
A New History
Jonathan Sadowsky
polity
Copyright © Jonathan Sadowsky 2023
The right of Jonathan Sadowsky to be identified as Author of this Work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.
First published in 2021 by Polity PressThis paperback edition published in 2023 by Polity Press
Polity Press65 Bridge StreetCambridge CB2 1UR, UK
Polity Press111 River StreetHoboken, NJ 07030, USA
All rights reserved. Except for the quotation of short passages for the purpose of criticism and review, no part of this publication may be reproduced, stored in a retrieval system or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher.
ISBN-13: 978-1-5095-3166-0
A catalogue record for this book is available from the British Library.
Library of Congress Cataloging-in-Publication Data
Names: Sadowsky, Jonathan Hal, author.Title: The empire of depression : a new history / Jonathan Sadowsky.Description: Cambridge, UK ; Medford, MA : Polity Press, 2021. | Series:History of health and illness | Includes bibliographical references and index. | Summary: “How depression colonized the world”-- Provided by publisher.Identifiers: LCCN 2020016685 (print) | LCCN 2020016686 (ebook) | ISBN 9781509531646 (hardback) | ISBN 9781509531660 (epub)Subjects: LCSH: Depression, Mental. | Depression, Mental--History.Classification: LCC RC537 .S293 2020 (print) | LCC RC537 (ebook) | DDC 616.85/27--dc23LC record available at https://lccn.loc.gov/2020016685LC ebook record available at https://lccn.loc.gov/2020016686
The publisher has used its best endeavors to ensure that the URLs for external websites referred to in this book are correct and active at the time of going to press. However, the publisher has no responsibility for the websites and can make no guarantee that a site will remain live or that the content is or will remain appropriate.
Every effort has been made to trace all copyright holders, but if any have been overlooked the publisher will be pleased to include any necessary credits in any subsequent reprint or edition.
For further information on Polity, visit our website:politybooks.com
Preface
When is sorrow sickness?
The writer Virginia Heffernan had a bad break-up. This happens to a lot of people. It can make you sad, sometimes for a long time. At some point, though, Heffernan began to feel that the grief over lost love was overtaken by something else, an illness. Worse, the depression seemed to grow on its own, to become something separate from the grief, disconnected from the break-up.
Trying to understand what was happening, she wondered if her search for happiness was the problem – was she depressed because she expected too much out of life? Or perhaps, she thought (as many people with depression do), she was simply a bad person. Was the depression an excuse for not having a career – was she simply lazy? Not an easy question to answer, because excessive self-criticism is a sign of depression. Was her depression an excuse for laziness? Or was that very question the depression talking?
These puzzles are not new. What happened next, though, is a product of more recent history – and the history of a recent product. Heffernan got a prescription for antidepressants. Sitting on a train, she poured the pills into her hand and looked at them wondering if the chasm she felt in herself could truly be filled by these chemicals.1 A lot of people have been asking this question in recent decades. The question holds a mix of hope and fear. Many feel some relief if the answer is yes. Not only relief from the illness, but also from the torment of doubt over whether they have an illness. If a medicine works, that might reassure that the illness is real. Still, many look at these chemicals with worry, and not just because, like all medicines, they can have unwanted side effects. It can also seem weird that your basic outlook – optimistic or pessimistic, self-hating or self-loving – might be a chemical process. While these questions have grown acute in the antidepressant era, the link of body to mood, of stuff to spirit, has been an enigma for centuries. And nothing arouses the puzzlement as much as the terrible pain on which we paste the label: depression.
This book is about that pain. A pain that isolates, but one always set in a social domain. A pain of soul and body that reminds us how hard it is to say where soul ends and the body begins. A pain found in diverse places and times, changing its features to suit the village where it arrives. A pain that devours hope, and leaches pleasure, ambition, and simple ease. One doctor said there is only one worse illness, rabies.2 Whether he was right or not, few maladies match depression’s super power: to drain life of value, to turn what was golden into mud.
It is also a pain with a history. The history lies in its morphing of form and expression, and in the countless efforts to grasp its origin, meaning, and essence – efforts that are necessary and useful, and yet always fall short. And it lies in the changing ways healers have tried, with incomplete success, to provide relief.
I stress several themes. One is that depression is shaped by history and culture, but that comparisons across time and space are possible, and essential. A second is that we do not have to choose between understandings of depression as biological, psychological, or social. This false choice is a product of recent history. We call depression a “mental illness.” Critics of psychiatry sometimes complain that the problems named by that term are not really illnesses. I am more concerned about the other half of the phrase – they are never just mental. Depression always involves the body. A third is that there is a politics to depression, a politics of inequality. This is another area where some have posed what I think is a false choice, between a “medical” model and a social model. Health, illness, and healing are always set in a social context, and showing that they are does not make them less medical. As I am completing this book, the COVID-19 pandemic is unfolding. In addition to its ravages on human health, it is shining a light on many social problems, including class and race inequality, the inadequacy of the public health and medical insurance systems in many societies, and the bigoted blaming of peoples for illness, a scapegoating that medical historians see resurfacing with dismal predictability. Depression also puts a spotlight on many social problems. It does not cease being a medical problem because of that any more than a virus does. A fourth is the classic historian’s caution against scorning the past. Much of the history of depression is made of efforts by smart and concerned people, doing their best with the knowledge available, to understand and treat it. As in other areas of medicine, some zealots have pushed their favored approach too far. Many others have sounded cautions, seeing the incomplete state of psychiatric knowledge.3
Many books on the history of psychiatry are scathing catalogues of its harms. Psychiatry has harmed a lot of people, through imprisonment, stigmatization, invasive physical treatments, or misguided over-reliance on drugs. Even talk therapy, often assumed to be inherently more humane, can be abusive or harmful. Saying this is not to be against psychiatry. It’s a matter of empirical fact, amply shown by historians of psychiatry. We should not whitewash this history, but we also have to reckon with how psychiatry has helped people. The vast majority of depression patients are voluntary. They return to their doctors because treatment helps them to feel better and live their lives closer to the way they wish. Many people without access to treatment would dearly like it.
I have written with occasional levity. An entirely somber book about depression might be hard to read, or even depressing. There should be no mistaking, though, the seriousness of the subject. Severe depressions can be ruinous, a threat to livelihood, the most precious relationships, and physical health. They can also be directly life-threatening if they lead to suicidal thinking or suicide. Less severe forms can also be painful indeed, and are too often trivialized.
Many historians have recently stressed the newness of the modern concept of depression. The last 120 years have seen vast changes in its meaning and treatment. Whether what we now call “depression” has existed in all times and places in human history is a hard question, and I give it a lot of attention. One part of the question is whether the illness once called “melancholia,” a term that was used from classical antiquity with waning use in the twentieth century, was the same as modern depression. I look at this problem in chapter 2, but to sum up here: no, melancholia and modern depression are not identical. They could not possibly be, because neither has had a fixed, stable meaning. A historical relationship does exist between the two concepts, though. A history of depression that excluded the history of melancholia would be badly incomplete.
Throughout the history of depressive illness, some have noticed, in some cases, a relationship to manic states. Current psychiatry uses the diagnosis of bipolar disorder, formerly known as Manic Depression, to indicate an illness of fluctuating moods, with manic phases alternating with depression. At other times, this has been considered simply one form of melancholia or depression, and sometimes it has been used as the blanket term for all depression. It would be ahistorical to omit any mention of mania or bipolar disorder here, but it will also not be a major focus. Unipolar and bipolar depression overlap, both in symptoms and treatment. Some now believe they are two different kinds of the same illness, others do not. Some even speculate that all the mood disorders and psychoses are related on a spectrum, which could turn out to be hundreds or even thousands of discrete illnesses.4 Some focus is necessary. I am focusing on unipolar depression.
Through history, and also now, many different diagnostic labels have referred to depressed mood. Even within those categories, presentation and experience vary. We might speak of “depressions,” just as some claim schizophrenia is not a unitary condition and prefer the term “the schizophrenias.” I prefer to state the diversity here, and treat it as a given from here on. The unity of these diverse illness descriptions does not come from a core feature one can find in all of them. It comes from their shared inclusion in the centuries of debate about their meaning.5
I look at the history of many treatments. Treatments for depression are often divided into two main types: (1) the physical, or somatic treatments, and (2) the psychological treatments, most of which are talk therapies.6 Both physical and psychological treatments for illnesses of mood have been around for centuries. Current physical treatment is dominated by antidepressant drugs developed in the last 70 years or so. In the middle of twentieth century, the first drugs called antidepressants came into use, most importantly a class of drugs called the tricyclics, and another called monoamine oxidase inhibitors (MAOIs). A bit later the selective serotonin reuptake inhibitors (SSRIs), such as Prozac, fully ushered in the antidepressant era. Also important is electroconvulsive therapy (ECT), invented in Italy in the 1930s. ECT is used on a far smaller number of people, mostly people for whom other treatments have failed. I look at physical treatments, those used widely now, those discarded, and some that may have a promising future, in chapter 5.
The talk therapies are now dominated by two major strands. One is a tradition of depth psychology, also called “dynamic,” or psychology of the unconscious. Depth psychology is based on insight into, and “working through,” inner conflict. A majority of depth psychologists are loosely or strictly Freudian, but some follow other strands, such as the Jungian. Many people are unaware of how much psychoanalytic thought has changed since Freud’s time. I will show these changes in chapter 3. Another major talk therapy is Cognitive-Behavioral Therapy (CBT), which works to correct logical errors in the thoughts of the depressed person, and encourages changes in behavior. Treatments addressed to the thoughts and behaviors of people with depressive illness have been practiced since antiquity (see chapter 2), but they were vigorously thought out and applied in the second half of the twentieth century (see chapter 4). Some talk therapists – possibly most – in practice combine insight, cognitive work, and behavioral advice.
None of these treatments, physical or psychological, lack vigorous critics. I examine the treatments and their critics, and have opinions about them. My job as a historian includes placing developments in context, and weighing evidence carefully; it does not include neutrality or objectivity, if they were possible, which they are not. One opinion I will get to now: sweeping attacks on either physical or psychological treatments are unpersuasive to me. Specific criticisms, of specific physical or talk therapies, can have value. But I am wary of arguments that physical treatment is inherently bad, toxic, or abusive, or that talk therapy is unscientific because it is not biological.7 These judgments are usually driven by unfounded philosophical dogma. Or worse, by turf wars between psychotherapeutic and pharmaceutical clinicians.
Many treatments for depression are effective for many people, even though none are effective for all people, and some people struggle to find a solution that works for them. I am not shy about assessing how well treatments work, or about noting their drawbacks – and they do all have drawbacks. Depression is a monster, and we need an array of weapons to fire on it.
Depression has an “empire” in two senses. First, in Western psychiatry and societies, it became a dominant way of interpreting mental distress, upending other language, in a gradual process that gained powerful momentum starting in the later twentieth century, though it began before then. Second, this linguistic shift then began to spread globally. Older names and conceptions of distress are increasingly competing with the label depression. We will see, however, both that illnesses of great sorrow may not be new to many areas adopting this turn in language, and that older cultural and medical models do not simply give way to new ones, but interact with them in complex ways. One thing this book is not is a long lament on the over-diagnosis of depression, and the turning of life’s normal suffering into a medical problem. Lots of books make this complaint now, and most of them make valid points. The danger of over-diagnosis is real. I give the issue attention, but also some pushback and alternative views. Increasing diagnosis rates of depression in recent decades is a fact, but its cause and meaning are not obvious. There are three possible reasons for it. There could really be more depression. Or, we could be having about as much depression as before, but catching more of it – better detection. A third possibility is diagnostic drift – the relabeling of states that were considered different illness, or not considered illness at all. Two or all three of these possibilities could be at work.
Many laments about the over-diagnosis of depression, and the medicalization of ordinary suffering, are data-poor. They look at widening criteria for diagnosis, or the sheer numbers in treatment, and assume too many people are being diagnosed. They rarely show directly that a lot of people with depression diagnoses do not meet a threshold for real illness – whatever that threshold may be. Greatly increased rates of diagnosis over a short time is grounds to wonder about over-diagnosis, but not, by itself, proof of over-diagnosis.
Psychiatric diagnosis draws a lot of valid criticism. It can stigmatize people and behaviors. It increasingly calls any problem in life a disease. Depression has an unusual status in these debates. With the exception of a few people on the antipsychiatric fringe, most people agree that certain mental disorders, such as severe psychoses, count as illnesses. And many, including many psychiatrists, also believe that we have gone too far in taking normal problems of living and calling them illnesses. In the case of depression, it is a matter of degree. Most people think serious and moderate cases of depression warrant medical treatment. Many also question whether everyone in treatment reaches that threshold. Where should we draw the line? I do not answer this question, but I do hope to show how hard it is, and that it is not as new a question as it might seem. The history of depression is in part a history of the tug-of-war over where the line should fall.
Some argue that depression, or other mental illnesses, are not true medical conditions. They will often point to the lack of a clear physical lesion, or the shifting and imprecise definitions. Fewer say why there needs to be a physical lesion, or a precise and unchanging definition, for something to count as a medical problem. Instead, they treat these measures as self-evident. They are not. Others stress that depression is a social and cultural problem. This is correct, but does not mean depression is not also a medical problem.
Sometimes I look at a major problem or controversy in the science of depression and say the truth is unknown. One job of the humanities is to nurture tolerance of uncertainty. Granting uncertainty is not the same as a cynical nihilism which declares all knowledge bankrupt. Where I think the knowledge about depression is sound, I say so. The social and cultural aspects of depression may yield more certain knowledge than the physical ones, despite progress in understanding the biology over the past century or so.
I have taught a course on depression for years, and I have found that many people who take it are people who have a depression diagnosis, or are wondering if they should have one. Many people who have picked up this book may be in the same situation. The course, I tell students, is not, should not, and cannot be therapeutic, and neither can the book. It will cover debates over whether depression is “really” an illness, and about whether treatments for it are effective. But before we get into the nuances of these debates, I want to say that I think “yes” is the most convincing answer to both questions, as well as the safest. If you feel like you may need help, you should try to get it. Doubting whether you have an illness or not is unlikely to help you feel better. And yes, we have effective treatments for depression, and there is a good chance that one of them can help.
Depression touches a problem all people face.8 We all know sadness, and we all can feel the loss of interest in things, the disturbed sleep, and appetite changes sorrow can cause. Yet most people think that the misery sometimes seems – because of its severity, longevity, or apparent disconnect from reality – like an illness. But when? Other illnesses, probably all, vary in their meaning and appearance across time and cultures. Susan Sontag vividly showed, for example, that tuberculosis and HIV, both caused by known infectious agents, have been shadowed by culture, by metaphors and image associations that influence how they are understood and experienced.9 These associations have a power beyond what science can tell us about the physical effects of disease. Illnesses are always embedded in society and culture, and subject to change according to time and place. Still, few are as changeable as depression.
The plasticity reflects a hard problem: deciding what is a proper reaction to life’s inevitable distress. Most of the world’s religion and philosophy – our accumulated wisdom – assume human life is filled with anguish. As Paul Simon sang in “The Coast,” sorrow is everywhere you turn. But when is sorrow sickness?
Notes
1.
Virginia Heffernan, “A Delicious Placebo,” in Nell Casey,
Unholy Ghost: Writers on Depression
(New York: HarperCollins, 2001).
2.
John Scott Price, “If I Had … Chronic Depressive Illness,”
British Medical Journal
1 (1978) 1200–1. Thanks to Alex Riley for the reference.
3.
I have tried to write as though this could be the only book on depression or mental illness, the only work of medical history, or even the only work of history – the reader has ever picked up. I ask for patience from experts in the field when they see things they already know. The book contains some original research, and I certainly hope original interpretation and ideas. But it is also a work of synthesis. My debts to other scholars in the field are clear in the footnotes and bibliography.
4.
Stephen M. Stahl,
Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications
(4th edn, Cambridge: Cambridge University Press, 2013), 245.
5.
Medical anthropology sometimes distinguishes between “disease,” defined as a state diagnosed by a clinician, and “illness,” defined as the subjective state of feeling ill. This distinction is useful for some purposes, but because the use of the term illness is so widespread in the clinical science and diagnosis of depression, it would bring more confusion than clarity to my discussion. A classic text on the distinction is Arthur Kleinman,
The Illness Narratives
(New York: Basic Books, 1989).
6.
I have elsewhere argued that the division between “physical” and “psychological treatments” is fundamentally flawed. But because it has been so widely believed in, it is hard to write the history without using it. See Jonathan Sadowsky, “Somatic Treatments,” in Greg Eghigian,
The Routledge History of Madness and Mental Health
(New York: Routledge, 2017).
7.
Sadowsky, “Somatic Treatments.”
8.
This paragraph was inspired by an exchange I had with Sloan Mahone at the conference “Global Histories of Psychiatry,” in Groningen, the Netherlands, in November 2018.
9.
Susan Sontag,
Illness as Metaphor and AIDS and Its Metaphors
(New York: Picador, 2001).
Acknowledgments
Thanks to my family above all. My father, for 57 years of support, encouragement, and wisdom. It’s common to think your father is the best man in the world when you are a child, but I still think it now. River Sadowsky, Julia Sadowsky, Nina Sadowsky, and Richard Sadowsky all cheered me on, and cheered me up. My wife, Laura Steinberg, a psychiatrist and psychoanalyst by profession, and a skilled copy editor as well, is my greatest support and best reader.
Three people at Case Western Reserve remain especially vital. Alan Rocke, now retired, continues his unbroken streak of reading everything I write, on this project from the embryonic proposal to the full draft manuscript. Eileen Anderson-Fye, always there for me, helps me in too many ways to list. And no one could ask for a better friend and intellectual partner than Ted Steinberg has been to me.
Two colleagues elsewhere also deserve special mention. David William Cohen, my mentor in graduate school, has left a lasting imprint even as my research focus has diverged from his. My intellectual north star, I still seek him out during his retirement when I need advice on a knotty problem. My interests have grown to overlap with those of my other main inspiration, Liz Lunbeck, a crucial support to me at so many times, and so many ways, over the course of my career.
Thanks to other Case Western Reserve colleagues who helped with the project in various ways: Mark Aulisio, Francesca Brittan, Nese Devenot, Kimberly Emmons, Sue Hinze, Tina Howe, Peter Knox, Andrea Rager, Aviva Rothman, Maddalena Rumor, Catherine Scallen, Renée Sentilles, Maggie Vinter, Ann Warren, and Gillian Weiss.
Also thanks to the many colleagues elsewhere who helped in concrete or less tangible ways: Ana Antic, Hubertus Büschel, Stephen Casper, Carolyn Eastman, Marta Elliott, Jeremy Greene, Matthew Heaton, Vanessa Hildebrand, Nancy Rose Hunt, Sanjeev Jain, Richard Keller, Barron Lerner, Beth Linker, Amy Lutz, Sloan Mahone, Sarah Marks, Elizabeth Mellyn, Emily Mendenhall, Randy Nathenson, Daniel Pine, Hans Pols, Sharon Schwartz, Trysa Shulman-Shy, Nina Studer, and Catherine Sullivan. Elizabeth Durham and Katie Kilroy-Marac get special mention for helpful reading at unconscionably short notice.
I had the help of a number of research assistants at various stages, helping me identify and get sources, and reading drafts. Thanks to Beth Salem, Matthew Yoder, Sufia Bakshi, Riley Simko, Kat Retting, and Sherri Bolcevic. Maia Delegal was especially invaluable down the final stretch of writing.
Two anonymous reviewers read the initial proposal for the book and the book itself, and I owe them a lot. One was more sympathetic to my overall approach than the other, but they were both constructive and thoughtful, and their comments made the book better.
Parts of this book were presented at various conferences and seminars, at: the Department of the History and Sociology of Science at the University of Pennsylvania; the conference “Global Histories of Psychiatry,” Groningen University, The Netherlands, November 2018; the conference “Decolonising Madness,” Birkbeck, University of London, April 2019; a joint meeting of the Carl Jung Institute of Cleveland and the Cleveland Psychoanalytic Center, May 2019; the conference, “Psychiatry as Social Medicine,” The Johns Hopkins University, November 2019; and the Bioethics Work-in-Progress group at CWRU. Thanks to those who commented and inspired in those venues.
Thanks to Meghan Gallagher and Katie Nabors for keeping everything running smoothly, and especially to the amazing Bess Weiss who always goes above and beyond.
Thanks to Bill Claspy, Jen Starkey, and Erin Smith at Kelvin Smith Library, who always made sure I got what I needed.
Thanks to Pascal Porcheron at Polity for his interest, encouragement, and suggestions, and to Ellen MacDonald-Kramer for her help with logistics. I’ve so enjoyed working with this team.
Students in my class on social and cultural aspects of depression have helped me think through many of the issues over the years, but thanks especially to Carolyn Slebodnik, and Tarun Jella. Students in Foundations of Medicine, Society and Culture did the same, but especially, Disha Bhargava, Dami Oshin, Karthik Ravichandran, and Sarah Siddiqui.
“Depression is a thing in which one seems to be dead in life.”10
Notes
10.
These are words of a depression patient quoted in Janis Hunter Jenkins and Norma Cofresi, “The Sociomatic Course of Depression and Trauma: A Cultural Analysis of Suffering and Resilience in the Life of a Puerto Rican Woman,”
Psychosomatic Medicine
60 (1998) 439–47.
1Depression is a Thing
“People who don’t have depression have a lot of difficulty understanding it, but people who have it are also often befuddled by it.”
– Chimamanda Ngozi Adichie1
Imagine a young woman in Philadelphia, a foreign student attending college and far from home for the first time. She is in a phase of sadness, close to despair. She feels isolated, but rebuffs people who invite her to social events. She lacks motivation, letting her room get messier by the day. Is this a case of clinical depression?
Imagine further that the student herself says no, rejects the label of depression when it is suggested by her aunt, a Nigerian doctor who is also a recent immigrant to the United States. She tells her aunt to stop using this American way of naming her distress. She does not have an illness at all, she says. Ifemelu, the main character in Chimamanda Ngozi Adichie’s novel Americanah, believes she is having a normal reaction to her situation. She is poor, her undocumented status has made it hard to find a job, and she is far from loved ones. Who wouldn’t have sadness, maybe some lethargy and social withdrawal? Uju, her aunt, believes she has a real disease, though one not talked about much in Nigeria. Americans, Ifemelu responds, have a disease for everything. Ifemelu’s “symptoms” melt away without much comment once she finds a good job and makes friends.2
The conflict between Ifemelu and Uju might seem to be a new one, peculiar to modern America’s impulse to give medical names to life’s problems. Yet the troubled distinction between depression and normal sadness runs through the history of the ailment. Can the border between the two be drawn sharply? Do they have the same sources, or distinctly different ones?
According to the World Health Organization, depression is now – newly – the single biggest contributor to the global health burden.3 They estimate that there are more than 300 million people worldwide living with depression, with an 18 percent increase between 2005 and 2015. Between 2011 and 2014, about one in nine Americans said they took an antidepressant.4 Many of them took drugs named “antidepressants” for other problems, such as insomnia and pain management, but the diagnosis of depression has swollen massively.
The meaning of the swelling is not obvious, though. Are more people getting depression? If so, what is causing this epidemic? Doctors, though, may simply be diagnosing depression more. If so, are they catching more of the cases that were always there, or changing the norms for diagnosis? Or is the rising currency of the label “depression” influencing how people interpret their mental distress, whether it is profound psychic pain, or moderate unhappiness? How much does the mere presence of antidepressants influence the rates of diagnosis? Counting depression is a vexed project.
The different explanations for rising rates of diagnosis all have smart advocates. Those who think we are having more depression point to alienating or distressing aspects of contemporary life, from wealth inequality and violence, to social isolation brought on by social media.5 Whether the world is any more depressing or alienating than it was 75 to 125 years ago, when the diagnosis was less common, is not obvious, though. We had lower rates of depression diagnosis during the First and Second World Wars, Western imperialism, Jim Crow, and the Holocaust. Early twentieth-century sociology is rife with laments about the alienation of modern, urban societies. The era’s philosophy gave us elaborate arguments that life was absurd and without ultimate purpose.
So perhaps we are not living through an epidemic of depression but of calling things depression. This view usually goes with criticism of the pharmaceutical industry – which certainly does have a financial interest in a broad definition of the illness. As inviting as this argument is, though, consider that before the era of rising diagnosis rates, mental health advocates sought better detection of depression, an illness they thought was under-diagnosed, and a terrible and needless contributor to human misery.6 From their point of view, we are only now finding all the depression they believed was there all along. They were urging more diagnosis before drug companies were making money on blockbuster antidepressants.
Put more systematically: whenever any illness is diagnosed more than before, there are three possibilities. The first is what epidemiologists call “rising true prevalence” – an actual increase in the number of sick people. The second is better detection. If, for example, you use hospital admissions to count the number of people with a sickness, you only count the people who come in to the hospital. You might get a better count if you go door to door in a community. Better detection can also come if doctors and the public grow more aware of the condition, so more patients come into treatment. But what if what you are counting is itself changing? This is the third explanation, diagnostic drift. A diagnosis may be naming distress that before would have been covered by a different illness label, or perhaps not be an illness at all. In debates about mental health, these possibilities are often treated as competitors but two of them, or even all three, could be working in tandem.
Knowing the prevalence of a disease is challenging when its definition is stable and has a clear sign, such as a blood test. With an illness like depression it is even harder. Counting depressions is a vexed project, partly because depression is hard to define.
Depression, in a clinical sense, is a diagnostic term. The prefix “dia” means apart and “gnosis” is knowledge. To diagnose means “to know apart,” to distinguish from something else. Doing this for depression has not proven easy.
What Is Depression?
Many have a loose sense of what clinical depression is – an illness of unusually low mood. That simple definition hides a lot of complexity and change.
Let’s look at Major Depressive Disorder (MDD) in the current Diagnostic and Statistical Manual of Mental Disorders (DSM-5). MDD is the central diagnosis for depressive illness in the current manual, though other illnesses include depressive symptoms. The DSM-5 will not be the last word on what depression is. If the past is any guide, the category of depression will continue to transform. Discontent with MDD has already emerged. Some clinicians and researchers think MDD embraces too many subtypes of depression.7 According to one recent textbook, “no clinician or researcher believes that MDD is a single ‘illness.’”8 More precision might lead to better treatment plans. For now, though, we lack a widely-agreed upon subdivision.9 DSM-5 calls for MDD if five of nine symptoms have been present for a twoweek period. The nine symptoms are:
Depressed mood most of the day, nearly every day.
Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
Significant weight loss when not dieting or weight gain, or decrease or increase in appetite nearly every day.
Change in sleep – sleeping too little or too much
A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
Diminished ability to think or concentrate, or indecisiveness, nearly every day.
Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
One of either of the first two listed symptoms must be present, but none of the rest are required, as long as four others are present. The manual also says that the symptoms must cause significant distress or impairment, and must not be caused by substance abuse, or by another illness.
Time is key. Symptoms have to be lasting for a diagnosis. But the time given is arbitrary. I am not saying that the authors of the manual erred when they set the duration. They had to pick something, or else people could get a diagnosis after being in a bad mood and losing appetite for a few hours because of something the President tweeted. (This happens to me sometimes.) The right length of time, though, cannot be settled scientifically. Future research may refine our knowledge of depression to a point where the amount of time could be settled objectively. I doubt it.
We also frequently ask if the symptoms seem justified by events. Although not a factor in current DSM diagnosis, in much of Western history many definitions of depressive illness have insisted that the distress must be out of proportion to the life situation.10 As early as the time of Hippocrates in Greek antiquity, some said melancholia was present only if the symptoms were not normal reactions to life events. A few centuries later, the physician Aretaeus wrote of melancholic patients being “dull and stern, dejected or unreasonably torpid, without any manifest cause.”11 Freud’s classic work on the subject started with the premise of the difference between normal grief and melancholia without cause. One psychiatrist wrote in 1976 that depression differs from normal sorrow if it “seems exaggerated in relation to the supposed precipitating event.”12 This proportionality criterion – the mood must be out of proportion to the life situation to be called sickness – has had a deep mark on Western concepts of depressive illness, and continues to influence debate, even though it is not now an official part of diagnosis. It also likely influences paths to treatment – people undergoing clearly stressful losses may be slower to conclude they have an illness and need medical attention than people having the same feelings in the absence of those events. Ifemelu reminded Uju that if she was sad, she had reason to be. Ifemelu did not add that such sadness might be depression if her life situation were sunnier. That would, though, seem to save the label from the charge of making every bad feeling an illness. The proportionality criterion often poses challenges in practice, though. The fifth edition of the DSM removed the “bereavement exclusion” from the diagnosis of major depression. In previous editions, the symptoms didn’t count toward a diagnosis if they came during mourning. Some psychiatrists worried that this change to the manual took a normal, if painful, part of life and turned it into an illness.13
Consider heartbreak. Say you were deeply in love with someone who dumped you. You might have five of the nine symptoms above. Both medical and lay opinion usually say that we should not medicate heartbreak. But what if the symptoms last a long time, or become especially severe? If the heartache lasts for years on end, is it then an illness? At what moment does it become so? What if the heartbroken person becomes suicidal? We then might want to intervene medically. But exactly how far short from suicidality is normal enough to be out of the range of medical attention?
The questions lack objective answers. Both the time and proportionality criteria shift with cultural norms, historical moments, and even from person to person.
What Makes Something an Illness, Anyway?
The tacit question in the conversations between Ifemelu and Uju is, what makes anything an illness? How do we decide?
One option, often favored by people who dislike psychiatry, or want to reject a “medical model” is to say a physical lesion must be present. This is appealing. We like to have something we can see. But this is not how most societies have decided on illness states through human history, and it’s arbitrary. Many lesions now known for illnesses were once unknown – was Alzheimer’s disease not an illness before Alzheimer identified the brain pathology? If we someday do find a clearer biological measurement of depression, would depression magically transform into an illness then, after being not an illness now?
Another option is to use illness to refer to atypical states or conditions, but atypical states are not always bad. We would not want to say that someone with unusually high ethical standards has “Excessive Morality Syndrome.” We might, though, if it was causing undue suffering. So perhaps we should add that the condition must cause pain or limitations in daily life. But this could include everything from being left-handed in a world built for right-handed people, or being gay in a society that persecutes gay people. Psychiatry tried labeling being gay as an illness, partly with the hope it would diminish the stigma. The results were terrible.14
Psychiatrist Nancy Andreasen has argued that no one has developed “successful, logical, and non-tautological definitions of … disease, health, physical illness, or mental illness.”15 She’s right.
Attempts to separate “real” from made-up illnesses open a bottomless pit of philosophical debate. Some conditions are easily agreed upon – cancer (an illness), and left-handedness (not an illness), for example. More ambiguous cases can be tough. With agreement, the suffering person gets “the sick role,” with the associated exemptions (such as missing work) and obligations (such as trying to get better). Medical care is appropriate.16 But the agreement is the outcome of a social process. Even when a known physical marker is present, a social process decides whether it is a sign of illness.
People sometimes try to change the social agreements by adding or subtracting illnesses. In an effort at subtraction, libertarian antipsychiatrist Thomas Szasz – a fan of the “physical lesion” yardstick – excluded all of mental illness, and sought to take psychiatry out of medicine. Given how much of human history, all over the world, has seen things like psychotic symptoms, or disabling distress, as signs of illness, Szasz had a lot of success. But just as Szasz was free to question the medical status of mental illness, others were free to re-assert it. They had even more success. A more complete success in subtracting an illness came when gay activists challenged the label of homosexuality as an illness. They were not, they said, suffering from their same-sex attraction. They may have been suffering from lack of social acceptance, but calling their sexuality “illness” was not helping. It did a lot of documented harm.
As for addition, new illness states are being named all the time. I’m surly when I first wake up in the morning. Not an illness, right? But if I want to say I have “Morning Surliness Syndrome (MSS),” I can, and if a lot of people start to agree, then its status as an illness will be a social fact. Others can object, by saying we didn’t always have this newfangled MSS, or asking where is the physical lesion. Ifemelu might say, how American this is, to call something an illness because the culture values morning perkiness. What would matter is how many people I convince, especially if they include doctors and insurers. If a drug could make you more perky in the morning, my success is more likely. This sounds like a fanciful scenario. But it is close to what happened with Erectile Dysfunction.17
If you think social agreement is a bad way to decide on what an illness is, you are free to propose objective criteria. But you will have to get everyone to agree to them. Best of luck!
Psychiatric diagnosis causes more division than those in most areas of medicine. Labels change their meaning, drop out of use entirely, are occasionally revived. The history of psychiatry is strewn with labels with no real clinical purpose, and others that were well-meaning, but failed, attempts to dispel stigma. It is child’s play to show that a DSM diagnosis is a “social construction.” You can teach a class of college freshmen how in under ten minutes. And, psychiatric diagnoses are always to some extent a reduction. Using them can hide context, complexity, and subjective experience. The potential for harm, especially stigma, is always present. These drawbacks are not unique to psychiatry, though. Any diagnosis in medicine can stigmatize, even if stigma is greater for some than others. And any diagnosis is reductive if it draws attention from the larger context. Saying someone has tuberculosis does not reveal the social roots of the medical problem, in poverty or occupation, for example.18 It can also miss cultural context; tuberculosis has had changing meanings and associations.19 As I write, we are vividly seeing the dreadful effects of COVID-19. The virus is exploiting existing social inequalities and inflaming existing stigmas. These social dimensions are not captured by diagnosis alone. They also do not make the illness less real.
Psychiatric diagnosis is fraught, but that does not make it useless. Diagnosis provides a pathway to practical things like treatment and insurance coverage, and can also be comforting.20 A vague sense that something feels bad can be a burden. Naming the feeling as an illness helps people make sense of pain, and can be a first step toward seeing it as a solvable problem. People may feel less alone, to know that their distress is something others know and recognize.
Many people write critiques of the DSM. These critiques often – and I mean really often – call the book psychiatry’s “bible.” By calling it a sacred text, these critics show their irreverence. The analogy is bad, though. Few psychiatrists regard the DSM as sacred, and most recognize its weaknesses.21 Psychiatrists know the DSM fails to capture all the nuances of mental illness.22 Criticism of the DSM is necessary, but not all that contrarian. Perhaps instead of using a manual we should let clinicians use their judgment, based on experience, to make individualized treatment plans. This is what many do anyway, whatever they write on the insurance submission. Much would be lost without some standard manual, though. Clinicians would find it hard to communicate about patients, and research comparing patients would be hard to design. Many patients are dependent on third-party payment, and insurers want a classification system.
