How Everyone Became Depressed (25 page)

The term melancholia itself was not used, yet small groups of researchers not yet in the grip of DSM began to return to such aspects of melancholic depression as slowed thought and movement (“psychomotor slowing”). In 1982 Robert Gibbons and John Davis at the University of Illinois medical school and David Clark of the Rush Presbyterian St. Luke’s Medical Center, all in Chicago, who reanalyzed data on 65 patients previously studied in several Scandinavian centers, said there were two very different kinds of depression: In one type, the patients were at the outset deeply depressed, yet responded well to the TCA antidepressant imipramine. Their symptoms were psychomotor slowing and a loss of interest in sex. In a second group, the depression was less severe at the outset yet responded less well to imipramine; in this group psychomotor slowing and sexual inertness were not important.
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The first group would have been considered melancholic.

Against this background of rising interest in melancholia, both within and without the DSM framework, in 1995 Gordon Parker placed a full-bodied melancholia definitively on the radar and quite outside the DSM framework of major depression, a diagnosis that Parker despised. Parker, then 53 years old, was professor of psychiatry at the University of New South Wales in Sydney (and later director of the Black Dog Institute for Mood Disorders, founded in 2002, its namesake the Churchillian figure of melancholic illness). Parker said that “psychomotor disturbance” was the main characteristic distinguishing melancholia from nonmelancholic depression, meaning mainly that thoughts and actions were slowed, but sometimes speeded up. There were also “endogeneity” symptoms such as insomnia and weight loss that constituted a kind of “mantle” about the core of psychomotor disturbance. He based this conclusion on a careful multivariate analysis of 407 patients at the Mood Disorders Unit of the Prince Henry Hospital, the forerunner of the Black Dog Institute, and this conception of melancholia has had great staying power.
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In 1996 Parker edited a volume on melancholia, arguing that although there are few homogeneous entities in psychiatry, “melancholia is one such entity and capable of being clinically circumscribed.” It was Parker’s achievement to introduce the terms melancholia and nonmelancholia to describe the two depressions, the terms most in vogue today.
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Gordon Parker’s research is of particular interest because it took the emphasis in depression off mood, rather, harkening back to the nervous diagnosis of the nineteenth century. If slowness of thought and movement were the key to depressive illness, the patients’ mood did not matter so much. Daniel Widl öcher, professor of psychiatry at the Salpê tri ère Hospital in Paris, had begun this line of inquiry in 1983 and Parker explicitly built upon it. (In 1983, Widl öcher criticized the conventional wisdom: “Current clinical opinion considers mood change as the primary disturbance, and that retardation is an expression of sadness and loss of interest. According to [the conventional] viewpoint, depression is primarily a painful experience and there is no need to invoke retardation as an independent behavioral pattern.” Widl öcher’s view, by contrast, was that retardation “is a core behavioral pattern.”
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I tis interestingthat Widl öcher was atthe Salpê tri ère, where Charcot once strode the wards, because past memories are being reawakened here. Walter Brown, a long-experienced psychiatrist at Brown University in Providence, Rhode Island, once described the depressed patients who respond well to medication—as compared to the many who do not: “We don’t have good clinical language for characterizing these patients, for articulating the ways in which they differ from those who don’t so clearly require and benefit from medication, but like patients who need ECT, we often know them when we see them. We find them among the melancholic depressed and among the bipolar depressed. The 62-year-old with the now-forgotten involutional melancholia is among them.”
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It was precisely among those veteran clinicians who believe that psychiatry is an art as well as a science that the discipline’s collective memory of melancholia came flooding back.

“Not unexpectedly,” said Barney Carroll, by now chair of psychiatry at Duke University, at a conference in Germany in 1982, apropos DSM’sfailure to differentiate, “These historical themes continue to reassert themselves— they will not simply go away.” “Melancholic, vital, biological endogenomorphic, psychotic, or autonomous: these illnesses probably have a major biological basis.”
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That is why they appeared historically and continue today.

By the dawn of 2000, the field of psychiatry was in tumult. The extent to which rational diagnosis and treatment had been sold out to the pharmaceutical industry was starting to become apparent, and the drafting of a new version of DSM, due in 2013, was the first time in history that a technical issue in psychiatry was followed in the mass media, the subject of prominent articles in the daily press. The field seemed on the cusp of change. In 2006 Michael Alan Taylor at the University of Michigan and Max Fink at the Stony Brook campus of the State University of New York published a major overview of melancholia, essentially reintroducing it to the field. “Melancholia is a severe disorder of mood, often fatal, that has been described for millennia in medical texts and by poets, novelists, and playwrights,” they said. The field had lost sight of it because of DSM-III and because “intrusive actions of the pharmaceutical industry encouraged a weakening of criteria to justify the use of antidepressant drugs in the largest number of persons. The safety and efficacy of the older, no longer patentable agents . . . were maligned through aggressive marketing that relied on unsound industry-sponsored comparison studies. Academic psychiatry went to the highest bidder.”
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Wow! This was a harsh judgment in explaining the eclipse of melancholia, but not necessarily untrue.

Fittingly, it was in Copenhagen in 2006 that a conference considered melancholia “beyond DSM, beyond neurotransmitters.”
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The time had truly arrived to take a second look at the epidemic of depression that DSMand the neurotransmitter doctrine had created, and to attempt to put the field once more on a scientific basis. But there is a difference between talking the talk and walking the walk. Whether the field of psychiatry will shake free and walk toward a substantial reconsideration of its diagnostics and therapeutics remains to be seen.

Whereas melancholia designated a small population of people with life-threatening illness, the diagnosis called simply “depression” was applied to millions. Before DSM-III in 1980, psychiatry had always had two depressions, and now it had only one, and that depression, which began life in 1980 as “major depression,” was a scientific travesty, a poor limp thing of a diagnosis that did not necessarily mean that the patient was sad at all—which is what a depressive mood diagnosis is supposed to convey—but was unhappy, aggrieved, tired, anxious, uncomfortable, or had nothing at all really wrong; the doctor had put her on antidepressants because he or she could think of nothing else to do.

Most depressions—referred to in the literature simply as “depression”— are community depression and not melancholia. And the diagnosis of this type of depression has recently experienced a substantial increase. Between 1985 and 1995, the percentage of office visits to psychiatrists for depression increased from 29.5% to 46.8%. Bipolar disorder rose from 6.1% to 9.1% of the total, making the final amount of depressive illness by 1995 well over half of psychiatric practice. Visits for “other mental disorders” declined from 16.9% of the total to 6.2%, suggesting that depression was becoming a kind of residual category.
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In 1987, three experts on depression noted that “one of every four Americans will suffer from a significant depressive experience in the course of his or her lifetime.”
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The increase continued. Between 1991–1992 and 2001–2002 the prevalence of major depression in a random sample of the U.S. national population more than doubled, up from 3.3% to 7.1%.
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And so depression has become a mass illness. Within a given year, 1 in 10 Americans today will have a mood disorder, the great majority of them major depression.
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Similarly, the consumption of psychotherapeutic medications has more than doubled in a decade, according to the Center for Mental Health Services of the federal government, from 174 million prescriptions in 1996 to 372 million in 2006. Prescriptions for “antidepressants,” a term that can only evoke a smile, rose from 80 million in 1996 to 192 million in 2006.
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In the period 2005–2008, according to the National Center for Health Statistics, 11% of all Americans over 12 years of age took antidepressant medication—1 in 10! And 25% of women aged 40–59 did so.
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Exclamation marks fail. Who can stop this terrible epidemic of depression!

Certain subpopulations, such as late-adolescents, have been hard hit indeed. In 2005–2007, 8.3% of Americans aged 12–17 years had a “major depressive episode” within the previous 12 months—almost 1 in 10 of our teenagers with major depression!
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Here is Kenneth Silk, a psychiatrist with the University of Michigan Health Service, in 2006: “There is a big push now to identify depression on college campuses—MIT, NYU—and big Pharma is putting some $$$ support to these college campus-wide efforts—but some cynics wonder if big Pharma’s enthusiasm for the project has to do with the idea that the more you can identify those students who are depressed, the more antidepressants get prescribed and certainly, having gone back to seeing students myself again (last time I did that was in 1974–1975 at Yale)—we are much more ready to write that Rx today than we were (myself included) 30 years ago.”
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Can anyone doubt that campus depression had vastly increased over those three decades?

It is not just among campus cut-ups but adolescents in general that the consumption of psychiatric drugs has risen so much. An analysis by Medco Health Solutions of prescriptions for psychotropic drugs for some 370,000 adolescents found that the prevalence of adolescent girls taking antipsychotic drugs grew 117% over the period from 2001 to 2006, “whereas boys that age had an increase of 71 percent.” Girls increased their sleep medications by 80% over those years and their medications for hyperactivity by 74%.
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Do these vast increases in the consumption of psychotropic medications stem from a real increase in the incidence of melancholic and nonmelancholic depression? Or are they due to the willingness of doctors to confer the diagnosis or patients’ ardor to demand it? Indeed, one study looking at the onset of depression by birth cohort found that in the younger cohorts, depression began at increasingly earlier ages. This study, however, called upon older adults to recall when their depressive illnesses first began, a chancy business, and later-born cohorts might have had their memories consolidated by the act of taking antidepressants. A meta-analysis of 26 studies of childhood depression by year of birth involving over 60,000 observations on children born between 1965 and 1996 found no increase in depression across birth cohorts. The authors concluded that “If more depressed children are being identified, or are receiving antidepressant medication, this is more likely to be the result of increased sensitivity to a long-standing problem

. . . ” than the result of a real, epidemic-style increase.
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So it seems as though the diagnosis of depression is increasing but not the real illness.
But how many people with the diagnosis of depression are sad? This is the big question. How many of the supposedly depressed patients have a disorder of mood involving sadness, hopelessness, and the other emotions of despair? Raymond Battegay in Basel, one of the founders of psychopharmacology in Switzerland, told David Healy in an interview that “I don’t agree that depressions are mainly mood disorders. Mood is concerned secondarily . . . [Depression] is a disequilibrium of the limbic-hypothalamic-pituitary-adreno-cortical system and, secondarily in most cases, but not in all, mood is affected. What we call masked depressions seem to be the real depressions, since the mood is not visibly affected.”
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(There is more on this below at the discussion of Adalbert Kral and affective equivalents.) These patients are clearly suffering from some kind of nervous disorder, but why call them depressed?
Within an urban medical practice, as many as one patient in five has a diagnosis of major depression.
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Yet in the American population as a whole, only 3.3% of people in a random-sample poll said they are sad “all or most of the time,” according to data from the National Center for Health Statistics.
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This presumably is the core of individuals with a depressive illness. This would be the reality.
But diagnosis is different from reality. Many of those with a diagnosis of depression do not have a low mood: 50% of the Philadelphia patients in the mid-1960s diagnosed with “mild depression” did not have a low mood nor did 25% of those with “moderate depression.”
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In research led by David Healy, a group of 39 patients with depression were given a Quality of Mood Questionnaire and Checklist, and asked to check off what they felt. (The term sadness was explicitly removed from the list.) The words the patients chose most frequently were dispirited (20); sluggish, wretched (19); empty, washed out, awful, bothered, dull (18); listless, tightened up (17); exhausted, gloomy (16); burdened (15); and desolate, powerless, purposeless (14). Healy comments that “It would certainly seem that the words endorsed most frequently in the survey are not the words that people who are simply miserable or unhappy would be likely to offer spontaneously. Dispirited, sluggish, empty, and washed out suggest a somewhat different state from the normal experience of sadness.”
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We are therefore inclined to ask the following: Does this kind of wretchedness really mean low mood? Sadness?
The question is important because sadness is a meaningful term to patients though no longer to clinicians. There was once a German-inspired tradition that sought to differentiate normal sadness from “the sadness of depression,” finding the latter not really sad at all but tired, without hope, inexplicable in origin, and seemingly lasting in duration.
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The following issue arises: Was this “special quality” of the sadness of depression really measuring depression or some other underlying entity?
But today, neither American nor French psychiatry recognizes sadness as a psychiatric concept, for it is not in the main psychiatric dictionaries of those countries.
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Sadness, or Traurigkeit, remains, however, in the main German psychiatric dictionary,
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which is revealing because it was the Germans who founded the field of psychopathology, the exact description of what patients feel and how they behave. The Germans had, therefore, the semantic tools for studying clinical sadness, yet there are no good data that they actually found much of it. “One cannot mistake the base note” in depression, Walter Schulte, director of a German provincial asylum, said in 1961. “It is not sad, but rigidly hard, empty, vacant, indifferent, non-vital, dead, and burned out.” The patients were not sad but were incapable of feeling.
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The bottom line is that when we try to break through the psychiatric short-hand about “depressed mood” and learn what it is that these millions of patients with the diagnosis of depression are actually feeling, we run into something of a semantic stonewall.
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So this is the problem: We have all these patients with the diagnosis of depression. But they are not particularly sad and they have all kinds of other symptoms. What is the point of calling them “depressed”?
It is also interesting that a number of patients who are on antidepressants do not have depression. According to data from the National Ambulatory Medical Care Surveys for 1996, at 59.5% of office visits at which antidepressants were prescribed, there was no psychiatric diagnosis. (This share had risen to 72.7% by 2007.)
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Is this sloppy record-keeping? Among the almost 150,000 patients seen in 39 family medical practices in South Carolina in 1996, 9335 were prescribed antidepressants. Of these 9335, 4022, or 43%, did not have a diagnosis of depression. And a good share of them had already received antidepressants in the past, despite not being depressed.
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Similarly, the Collaborative Psychiatric Epidemiologic Surveys, using national random-sample data, found for the years 2001–2003 that 52% of those taking antidepressants had not had any psychiatric disorder for the past 2 years, and that 26.3% had not had any psychiatric problem on a lifetime basis.
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Such use of “antidepressants,” a term that now belongs in ironic quotation marks, is explicable only as a consequence of the relentless promotion of pharmaceutical products: Whatever ails you must be a depression of some kind because you read it in the media— but the good news is you can be helped with antidepressants.
Lots of people, of course, do get the diagnosis of depression. How confident may we be of the diagnosis in them? The large international differences in the prevalence of depression are not encouraging. At a conference in 1974 Owen Wade, a pharmacologist at the University of Birmingham, said, partly in jest, “Speaking as somebody from a developing country—what is called depression in the United States, is referred to by the British as just ‘a chap being under the weather.’” (Laughter).
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An epidemiological comparison led by Myrna Weissman at Columbia University in 1996 found huge international differences in the lifetime rate of major depression per 100 population, ranging from 1.5% in Taiwan to 16.4% in Paris, France. (The rate in the United States was 5.2% of the population having major depression on a lifetime basis.) For separated and divorced women, the rates ranged from 3.0 per 100 population for Korea to 43.8 per 100 for Paris. (The United States rate of major depression per 100 separated or divorced women was 13.5.)
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These figures demonstrate that in something like the occurrence of depression, culture and society play a large role.
Still, the figures make us wonder. Almost half of the formerly married Parisian women are so sad that they qualify for what, on the face of it, is a serious psychiatric diagnosis? And one American woman in seven who has left her husband behind qualifies? That all these women should be so fragile lacks face validity. Do they have something else?
Calling a depression nonmelancholic is not to trivialize it. Nonmelancholic depression can be a serious illness and can end in suicide. “ . . . The functioning of depressed patients is comparable with or worse than that of patients with major chronic medical conditions,” said a team from the RAND Corporation led by UCLA psychiatrist Kenneth Wells in 1989. “The only chronic conditions having associations with functioning comparable with those of depressive symptoms were current heart conditions.”
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But what kind of an illness is community depression, as opposed to melancholia? Mainly sadness? “I honestly think that depression is a disease of the whole body,” said Columbia psychiatrist Alexander Glassman in an interview in 2003. “There is something going on that’s affecting the whole body.” He noted that depression tended to cause strokes, and that bone metabolism was affected by depression. Kicking off a huge subsequent literature about depression and heart disease, Glassman noted that cardiac mortality was higher. “I gave this lecture at medicine rounds,” he said, “and some ophthalmologist came to me and said, you know, there’s a literature about depression and vascular disease of the eye. I didn’t know about that.”
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So, there is no doubt that depression is real. We are not talking about a latter day version of hysteria. These patients are not just victims of “medicalization,” or the assigning of medical diagnoses to people who are not sick. But these patients with real depression, what do they actually have? If it is a disease of the whole body, maybe they have nervous disease?
Let us look at the components of the nervous syndrome and see how often they occur in patients diagnosed as depressed.
New York psychiatrist James Kocsis saw a number of them out of the corner of his eye as they trudged about the doctors’ offices of Manhattan. We wanted “to show that antidepressant medications worked for these people,” he said in an interview in 2005. “A lot of clinicians didn’t believe they did. They didn’t even believe these people had affective illnesses. They thought they had something else and the patients also believed that. They thought they were misdiagnosed and went to medical clinics and internists who ordered all kinds of X-rays and tests. After getting the results they’d say, ‘I’m sorry there’s nothing wrong with you, it must be in your head.’”
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When such patients reached Kocsis, he put them on TCAs such as amitriptyline and many of them did get better (which demonstrates that not that all these nonsad patients had secret depressions but that tricyclic drugs are effective for the much wider range of illness we have been describing as nervous).
What symptoms do these nervous patients have? A cardinal symptom is fatigue, or weakness. In 1955 psychiatrist Mandel Cohen, a biologically oriented clinician at Harvard who had been exiled to the neurology department by his psychoanalytic colleagues, led a study of the symptoms of 100 manic-depressive patients (the term of the day for serious depression) versus medically-ill patients and healthy controls. What symptoms did they have? Of the depressives 54% reported “weakness,” as opposed to 3% of the healthy controls.
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An analysis of the National Comorbidity Survey of 1990–1992 divided the respondents into subgroups of depression and anxiety and looked at the frequency of various symptoms in each. Here are the findings for “lack of energy”: of those with mild psychological depression, 71.4% lacked energy; psychological anxious depression, 88.8%; somatic depressed anxiety 92.3%; restless somatic depression, 100.0%. (“Low distress,” meaning normals, 22.8%.)
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Thus the depressed population today is certainly fatigued and lacking in energy.
Somatic symptoms were part of the old nervous syndrome. Today, they abound in depression. The Cohen analysis of the manic-depressive patients in Boston found that 49% had headaches (versus 25% of the healthy controls), 77% dyspnea, or labored breathing (versus 3% of controls), and 53% reported paresthesias, or abnormal skin sensations (versus 5% of controls).
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The National Comorbidity Survey did not focus so much upon the somatic side but did ask about “stomach problems,” reported by 79.5% of those with restless somatic depression.
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Again, it sounds as though little has changed since the olden days of nerves.
How about anxiety? Anxiety was certainly part of the nervous syndrome of yore, and flourished in the first half of the twentieth century in the diagnosis mixed anxiety-depression. Anxiety is definitely not lacking among the depressed of today. In the Cassidy study of Boston, 57% of the patients with manic-depressive illness experienced palpitation (versus 10% of healthy controls), or pounding of the heart; 33% had anxiety attacks (versus 5% of controls).
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In a study of the patients with major depression about to enter a drug study at the Massachusetts General Hospital and the New York State Psychiatric Institute, 91% had psychic anxiety at baseline and 68% had somatic anxiety.
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In a World Health Organization (WHO) study in 1996 of almost 5500 primary-care patients in 15 locations worldwide, “Nearly half of the cases of depression and anxiety appeared in the same patients and at the same time.”
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The WHO administrators chose to express the relationship rather oddly because they firmly believed in the doctrine of comorbidity, meaning two separate diseases that just happened to occur in the same patient, such as leukemia and mumps. But it is not surprising that just as in the past, many of their depression patients were also anxious (that half of them were apparently not anxious makes us question the thoroughness of the investigation). Another study of the WHO primary-care patients without a formal psychiatric diagnosis organized by the World Health Organization went ever further: “These findings provide support for the existence of a mixed anxiety-depression category crossing the diagnostic boundaries of current anxiety and depression disorders.”
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To any student of the history of psychiatry this will not come as such big news!
Moreover, the family physicians participating in this WHO study prescribed exactly the same agents for depression and anxiety: Of the patients with recognized depression, 28% got sedatives and 22% got antidepressants; of the anxiety patients, 31% were treated with sedatives and 21% with antidepressant agents.
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Thus, in terms of differential treatments, the doctors themselves saw no differences.
Statistical studies showing a great overlap between depression and anxiety could be recited many times over and it would be tedious to review a long list of them.
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What is interesting is that informal opinion in psychiatry confirms substantially that depression and anxiety are really a single disease. At a meeting of the Psychopharmacological Agents Advisory Committee of the Food and Drug Administration in 1977, under discussion were—what was called at the time—the minor and major tranquilizers. Harold Stevens, a psychiatrist of long experience at St. Elizabeths Hospital in Washington, DC, said, “We have talked glibly about using this for depression and that for anxiety. Actually, there is almost always an intermix, and it is very difficult to identify the purely depressed and the purely anxious.”