Authors: Edward Shorter
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Library of Congress Cataloging-in-Publication Data
How everyone became depressed : the rise and fall of the nervous breakdown / Edward Shorter.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-19-994808-6 (alk. paper)
[DNLM: 1. Depressive Disorder. 2. Affective Symptoms. 3. Stress, Psychological. WM 171.5]
1 3 5 7 9 8 6 4 2
Printed in the United States of America on acid-free paper
I should like to thank Tom Ban, Barney Carroll, Max Fink, David Healy, and Gordon Parker for a close intellectual companionship over the years that has made
1 . Introduction 1
2. Nerves asa Problem 7
3. The Rise of Nervous Illness 17
4. Fatigue 31
5. Anxiety 51
6. A Different Kind of Nervous Breakdown—Melancholia 79
7. The Nervous Breakdown 103
8. Paradigm Shift 109
9. Something Wrong with the Label 129
10. Drugs 147
11. The Return of the Two Depressions (and an Anxious Postscript) 163
12. Nerves Redux 185
13. Context 193
Barney Carroll is a large, ruddy Australian psychiatrist who does not suffer fools gladly. In 1968 he figured out that there is a biological marker—a chemical indicator—for the form of serious depression called melancholia. The article in the British Medical Journal in which he announced this finding aroused a certain passing interest. But then several official commissions, staffed by people who had little curiosity about the endocrine system (where Carroll’s test was active), decided that his test, called the dexamethasone suppression test, was not really all that revealing. Carroll, it must be said, did not handle this situation as well as he might have. He became irascible, further alienating people. Psychiatry lost interest in Carroll’s test and went on to decide that there was actually no difference between serious and minor depression, that they were all the same thing. Carroll’s finding passed into oblivion, and the idea that serious depression has a biology of its own became substantially forgotten. Instead, people with emotional issues ended up with the diagnosis of major depression, for which, of course, there was no biological marker. That is the situation in the new millennium: Almost everybody is depressed. This is a scientific travesty. How did it happen?
Take the women that you know. About half of them are depressed. Or at least that is the diagnosis they got when they were put on antidepressants. But depression is a mood disorder. It means the mood is sad, the opposite of euphoria (which would be mania). These women are not necessarily sad, sobbing at home. They go to work, but they are unhappy and uncomfortable; they are somewhat anxious; they are tired; they have various physical pains— and they tend to obsess about the whole business.
How about men? Do they get nervous too? Yes they do, although not in the same proportion as women. Also, men tend to express their dysphoria more by getting into bar fights, in sociopathy, rather than with nervous symptoms. Still, nervousness is a disorder of both sexes, one that is present in all cultures— although the predominant symptom may differ. We have a package here of five symptoms—mild depression, some anxiety, fatigue, somatic pains, and obsessive thinking—and the symptom that is most salient may vary from culture to culture. The depressive component, for example, is played down in Chinese culture.
We have had nervous illness for centuries; it may be a constant in the human condition, and seems to have a significant hereditary component. If your mother was nervous, you may be nervous too. When you are too nervous to function, things ratchet up by a peg and you have a different illness: it is a nervous breakdown. But that term has vanished from medicine, although not from the way we speak.
In medical parlance nervousness has turned into depression and anxiety, although so slowly over so many years that physicians themselves have tended to lose sight of this subtle—but hugely important—linguistic drift. The nervous patients of yesteryear are the depressives of today. That is the bad news, because their basic problem is not really sadness. The good news is that nervousness is treatable,although maybe not with Prozac-style drugs.
By this point I know that some readers, especially psychiatrists and neuroscientists, will themselves have become nervous: Is Shorter proposing to revise this antique term nerves for use in disciplines that pride themselves of being scientifically advanced and future-oriented? I should say at the very beginning that I am not insisting that depression be rebaptized nervousness. There is indeed such a thing as serious depression as an independent entity (melancholia). Rather, I want to show that history offers a template for a much needed rebaptizing of some kind. There is a deeper illness that drives depression and the symptoms of mood. We can call this deeper illness something else, or invent a neologism, but we need to get the discussion off depression and onto this deeper disorder in the brain and body. That is the point.
Edw ardShorter Toronto May 2012
For the past 40 years, the diagnosis of depression has been steadily increasing. The prevalence of serious depression in the middle third of the twentieth century was less than one in a thousand; today, it is measured in the double digits per hundred. In an outpatient medical practice in New York, 18.9% of the patients had a diagnosis of major depression. On a lifetime basis, one American in five will receive a diagnosis of depression. This is a real puzzle.
Given that these millions of patients with purported depression are not necessarily sad and have scads of other symptoms, it is not clear what the basis is for calling them depressed. Maybe they have some other diagnosis?
The extreme form of being very ill was historically the nervous breakdown, involving melancholia, panic, overwhelming fatigue, and bodies that felt and moved like lead. Lesser forms of nervous illness were simply called “nerves.” Were these nervous patients simply depressed? Or is it we who are the nervous?
This is a subject that we as a society have not lost interest in. “Government on the Verge of a Nervous Breakdown” was a page one story on the cable channel MSNBC in 2011, as Congress teetered on the point of passing the controversial deficit reduction plan.
So the nervous breakdown has not gone away after all! Just when psychiatry, with all its talk about depression, thought diseases of the nerves were dead, the concept turns out to be alive and well among the public. Take the HBO comedy-drama “Enlightened”: When Laura Dern, as troubled corporate executive Amy Jellicoe, has a nervous breakdown, every system of her body screams stop! This is way beyond depressed. Then when she returns from a New Age spiritual healing colony in Hawaii “after swimming with the turtles,” everything has been buffed. She’s a “new person.”
People can relate to nerves as a disease of the entire body, whereas depression, in the sense of a sad mood, is a bit of a stretch. Many patients who are called depressed are not sad. And you can have a nervous syndrome without necessarily crying all the time. In fact, in serious depression, mental pain and bodily anguish are the disturbing symptoms, not tristesse in the style of a French romantic movie. Patients complain about the “inability to feel,” not about sad feelings.
The difference between depression and nerves is that depression is considered a mood disorder whereas nerves is a disease of the whole body. Melancholia, for example, the quintessence of the nervous breakdown, reaches deep into the endocrine system, which governs the thyroid and adrenal glands among other organs.
The Japanese have retained this concept of mood disorders as an illness of the entire body far more than we. Junko Kitanaka, in a history of depression in Japan, writes in 2012, “Japanese psychiatrists have continued to combine the technical, neurochemical imageries of depression with familiar cultural idioms that present depression as a generalized illness of both mind and body.” In 2006 one Japanese investigator described depression as a “temporary decline of vital energy” and a “generalized illness of the whole body . . . and the whole person.” The Japanese tend to see what we call depression as “a cold of the heart.” This thinking arose from Japanese notions of neurasthenia earlier in the century.
We Atlantic types are therefore not the first civilization to conceptualize mood disorders as nerves and to surveil the entire body for its symptoms.
Nerves are a kind of package. It includes such common symptoms as mildly depressed mood, anxiety, fatigue, somatic symptoms such as insomnia, and a tendency to obsess about the whole business. These might be considered a nervous syndrome, though physicians in the past did not use that exact term; instead they spoke rather vaguely of nervousness, nervous illness, and the like. Since the 1940s this useful nerve category has been discarded in favor of a disease, considered to be mainly of mood, called “depression.” Today, “depression” has become the disease most commonly diagnosed in medicine. Worldwide, literally hundreds of millions of people are now thought to suffer from depression, or to have a history of it in their past, or the likelihood of another episode in the future, unless they are treated with drugs called “antidepressants.” In the United States, in 2005–2008, according to data from the National Center for Health Statistics, almost a quarter of all women (22.8%) were on antidepressants.
This is an appalling story of scientific error that has resulted in a public that believes itself to be, more or less, depressed.
How could we have been led into this blind alley? In psychiatry, cutting nature at the joints, or coming up with true disease entities, is devilishly difficult. Barney Carroll says, “On ward rounds we direct the attention of medical students to the woman pacing the corridors, wailing, shredding her clothes, appearing unkempt, importuning staff. We tell the students the diagnosis is melancholia. Then we enter another room where a patient is lying mute, inert, with bedsores from immobility and wasting from lack of nutrition. We tell the students again that the diagnosis is melancholia. Not surprisingly, the students are perplexed. So we invent qualifiers. We call these cases agitated depression and retarded depression, respectively. By means of the nominalist fallacy (I name therefore I know) the students are then satisfied.”
What do these patients really have? Patients do not turn up with diagnoses stamped on their foreheads but with collections of symptoms, a story that they relate orally. With a few exceptions, there are no blood tests or biological markers in psychiatry that let us bypass the story and announce “diabetes”! Trying to align these symptoms and signs into diseases is the purpose of “nosology,” or classifying diseases on the basis of cause. And from the beginning, clinicians have been mindful of what they are up against. James Sims, president of the London Medical Society, wrote in 1799 of the “various kinds of alienation of the mind”: “ . . . In distinguishing disorders which have an affinity to each other, there will, in particular cases, be great difficulty; the shades of difference, as they approach, being so very minute, as almost to escape the most experienced mind. Every thing in Nature is a continued chain, without those breaks and intervals which even the accurate describer is obliged to make, in order to keep up due discrimination, and to render himself intelligible.”
Thus, Sims said, we do need to discriminate among distinctive diseases, because, though clinically very close in appearance, they have different responses to treatment and different outcomes. Thus to render ourselves “intelligible”—I love the concept! for otherwise we would be unintelligible—we need to consider the differences among the diseases.
Today, in the study of the different diseases of mood, we have become close to unintelligible. The current classification is a jumble of nondisease entities, created by political infighting within psychiatry, by competitive struggles in the pharmaceutical industry, and by the whimsy of the regulators. Yet this book is not a diatribe. Rather, we want to consider how the majority of illnesses of body, mood, and mind were once understood and how the story has come out today. How everybody has become depressed in other words.
In emphasizing nerves and the whole body rather than just mood, we join a worthy tradition of biological thinking in psychiatry, seeing so-called mental illness as brain disease, not the kind of frank pathological brain lesions studied by neurologists, but disorders of neural biology. Yet impulses from the brain are modified by thought, culture, and society before they turn into behavior. These things have to be kept in balance: the body’s chemistry driving the deep story, the psychoanalysts of the 1930s and 1940s turning the story’s course in certain directions, and the pharmaceutical industry today turning it in others. At a meeting in 1988, Joseph Zubin, a neuroscientist from the University of Pittsburgh, said with the wisdom of his 88 years, “The biological variables we talk about have primarily been wired in through evolution. The psychosocial variables came much later, when culture took over. Cultural transmission is not as efficacious, not as direct, and not as built-in as the biological, yet it presents a very basic underpinning of total behavior, including biological behavior.”
So the churnings of the American Psychiatric Association, the group that produced the radical new reordering of psychiatric diagnosis in 1980 called DSM-III, meaning the third edition of the official Diagnostic and Statistical Manual of psychiatry, will receive equal billing with the disorders of the body’s endocrine axis that seem to twin with melancholia.
The story is driven by the shift from nerves to depression. And the major players are the big-dome German psychiatrists of the late nineteenth century who rather arbitrarily hit on “depression” as preferable to older labels. Then the psychoanalysts, the adherents of Freud’s doctrines, burst on stage in the 1920s; they ditch biological thinking completely, putting neurosis arising in the mind in the center spotlight. Then the analysts, too, fall from grace. After the 1970s, psychiatry, with artful new depression diagnoses at the bowsprit, acquires a kind of mass audience attuned to every fresh diagnostic quiver. And the pharmaceutical industry deftly markets these new diagnoses to the tune of billions of dollars in drug sales. Yet this is a story in which not just vast social tides but ideas make a difference.
In the area of mood disorders, which is to say the gamut of affective styles that runs from euphoria to anxiety and sadness, medical ideas do matter. In the past, the notion of nerves suggested that patients had an illness of the entire body, that spa treatments, for example, could correct. The caress of the healing waters restored equilibrium; the walk at eleven in the spa park before lunch while the band played was calmative. The body was calmed. There were medications such as opium that effectively treated nervous illness and melancholic breakdown as well. Today, with the ubiquity of the diagnosis of depression, we have the idea that low mood and an inability to experience pleasure are our main problems; we see ourselves as having a mood disorder situated solely in the brain and mind that antidepressants can correct. But this is not science; it is pharmaceutical advertising. Meanwhile, the serious, melancholic depressions are missed. The consequence is many suicides that otherwise might have been prevented, and a population taking antidepressants as though they were Tums—and getting all of the side effects and few of the imagined benefits of these medications.