What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (18 page)

More common than manic-depression—probably ten to twenty times as common—is unipolar depression. This is the disorder that so many of us know well. It springs from the pain and loss that are inevitable parts of being creatures who think about the future. We don’t get the jobs we want. Our stocks go down. We get rejected by people we love. Our spouses die. We give bad lectures and write books that flop. We age. When such losses occur, what happens next is regular and predictable: We feel sad and helpless. We become passive and lethargic. We believe our prospects are bleak and that we lack the talent to make them brighter. We don’t do our work well, and we may not even show up. The zest goes out of activities we used to enjoy, and we lose our interest in food, company, sex. We can’t sleep.

But after a while, by one of nature’s benevolent mysteries, we start to improve. Mild forms of this depression (called
normal
depression) are extremely common. I have repeatedly found that at any given moment, approximately 25 percent of us are going through an episode of mild depression.

There is sharp disagreement about whether unipolar depression (a certified disorder) and normal depression are related. I believe they are the same thing, differing only in the number of symptoms and their severity. One person may be diagnosed as having unipolar depression and be labeled a patient, while another with just the same symptoms may be held to be suffering from acute symptoms of normal depression and not be a patient. The distinction between these two diagnoses is shallow, often no more than a matter of how readily a person will seek therapy, or whether his insurance policy covers unipolar depression, or how comfortably he can bear the stigma of being labeled a patient.

My view differs radically from prevailing medical opinion, which holds that unipolar depression is an illness and that normal depression is simply passing demoralization of no clinical interest. This view is the dominant one in spite of strong evidence that unipolar depression is just severe normal depression. No one has established the kind of distinction between the two that has been established between, for instance, dwarfs and short normal people—a qualitative distinction.

Most crucial, I feel, is that normal depression and unipolar depression are recognized in exactly the same way: Both involve negative change in thought, mood, behavior, and the body.

Epidemic

It is very important to know that this kind of depression is rampant today and that its usual victim is a woman.

In the late 1970s, under the leadership of the visionary biological psychiatrist Gerald Klerman, the United States government sponsored two major studies of mental illnesses; the findings were startling. In the first, 9,500 people were randomly picked as a cross section of adult Americans. Each was given the same diagnostic interview that a troubled patient who walks into a knowledgeable professional’s office would get.

Because such a large number of adults of different ages were interviewed, the study gave an unprecedented picture of mental illness over many years and made it possible to trace the changes that had taken place over the twentieth century.
³
One of the most striking changes was in the lifetime prevalence of depression, that is, the percentage of the population that has had it at least once. Obviously, the older you are, the more chance you have to get the disorder. The lifetime prevalence of broken legs, for instance, goes up with age, since the older you are, the more opportunities you have to break a leg.

It was expected that the earlier in the century a person was born, the higher would be the person’s lifetime prevalence for depression—that is, the more episodes of depression she would have had. Someone born in 1920 would have had more chances to suffer depression than someone born in 1960. Before the statisticians looked at the findings, they would have stated confidently that if you were twenty-five years old at the time you were interviewed for the study—which meant that you were born around 1955—there was, say, about a 6 percent chance that you had had at least one episode of severe depression, and that if you were between twenty-five and forty-four years old, your risk of depression would have climbed—say, to about 9 percent—as any sensible cumulative statistic should.

When the statisticians actually looked at the findings, though, they saw something odd. The findings showed that the people born around 1925 hadn’t suffered much depression; not 9 percent but only 4 percent had had an episode. And when the statisticians looked at the findings for people born even earlier—before World War I—they found something even odder: Again, the lifetime prevalence had not climbed; in fact, it had nosedived to a mere 1 percent. This meant that people born in the second half of the century were ten times likelier to suffer depression than people born in the first half.

One study, however—even one as well done as this—does not entitle scientists to shout “epidemic.” Fortunately, another major study was done at the same time. This time, the people were not randomly selected; they were chosen because they had close relatives who had been hospitalized for depression.
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Again, the findings turned expectations upside down. They showed a strong increase in depression over the course of the century—again, more than ten to one. For instance, when the women of the World War I generation were thirty (the age women born during the Korean War now were), only 3 percent of them had ever suffered a severe depression, while by the time the women born during the Korean War period had turned thirty, 60 percent of them had had an episode of depression—a twentyfold difference. The statistics for the men in the study showed the same surprising reversal. Though the men suffered only about half as much depression as the women (a crucial fact I’ll discuss in a moment), they also displayed the same strong percentage increase over the decades.

Not only is severe depression much more common now; it also attacks its victims much earlier in their lives. If you were born in the 1930s and at any point thereafter had a depressed relative, your own first depression, if you had one, would strike between the ages of thirty and thirty-five, on average. If you were born in 1956, your first depression would strike between twenty and twenty-five—ten years sooner. Since severe depression recurs in about half of those who have had it once, the extra ten years of exposure to depression amounts to an ocean of tears.
⁵

This trend toward more depression at a younger age continues into the 1990s. Dr. Peter Lewinsohn of the Oregon Research Institute recently interviewed 1,710 adolescents, half born between 1968 and 1971, the other half born between 1972 and 1974. The older ones have an alarming rate of depression: By the time they were fourteen, 4.5 percent had had a full-blown episode of depression. The younger ones were even worse off: By fourteen, 7.2 percent had had an episode. It is shocking that Americans, on average, may be victims of unprecedented psychological misery in a nation with unprecedented prosperity, world power, and material well-being.
⁶

In any case, this is enough to warrant shouting “epidemic.”

Women and Men

Study after study has found that across the twentieth century, depression strikes women more often than men.
⁷
The ratio is now two to one.

Is it because women are perhaps more willing to go to therapy than men and thus show up more frequently in the statistics? No. The same preponderance shows up in door-to-door surveys.

Is it because women are more willing to talk openly about their troubles? Probably not. The two-to-one ratio manifests itself in both public and anonymous conditions.

Is it because women tend to have worse jobs and less money than men do? No. The ratio stays at two to one even when groups of women and men are matched for the same jobs and the same income: Rich women have twice as much depression as rich men, and unemployed women twice as much as unemployed men.

Is it some sort of biological difference that produces more depression? There may be some biological differences that contribute, but probably not enough to make for a two-to-one ratio. Studies of premenstrual and postpartum emotion show that while hormones do affect depression, their effect isn’t nearly big enough to create so large a disparity.

Is it a genetic difference? Careful studies of how much depression occurs among the sons versus the daughters of male and female depressives show that there is substantial depression among the sons of male depressives. Considering the way chromosomes are passed from father to son and from mother to daughter, there is too much male depression in this study for it to be true that genetics causes the lopsided sex ratio. While there is some evidence of a genetic contribution to depression, genetics probably does not cause the lopsided sex ratio.

Is it sex-role pressure? Probably not. There
are
more conflicting demands on women than on men in modern life, and a woman nowadays not only has the traditional role of mother and wife but often must hold down a job as well. This extra demand could produce more strain than ever before and therefore more depression. Sounds plausible, yet like many ideologically congenial theories, this one dashes against the rocks of fact. On average, working wives are less, not more, depressed than wives who do not work outside the home. So sex-role explanations do not seem to account for the female preponderance.

This leaves three plausible explanations:

The first is
learned helplessness
. In our society, it is argued, women receive abundant experience with helplessness over the whole of their lives. Boys’ behavior is lauded or criticized by their parents and their teachers, while girls’ is often ignored. Boys are trained for self-reliance and activity, girls for passivity and dependence. When they grow up, women find themselves in a culture that deprecates the role of wife and mother. If a woman turns to the world of work, she finds her achievements given less credit than men’s. When she speaks in a meeting, she gets more bored nods than a man would. If despite all this she manages to excel and is promoted to a position of power, she is seen as being out of place. Learned helplessness manifests itself at every turn, and learned helplessness reliably produces depression.
⁸

The second explanation of why women are more depressed than men involves
rumination
. This theory says that when trouble strikes, men act, whereas women think. She gets fired from her job and she tries to figure out why; she broods and she relives the event over and over. A man, upon getting fired, goes out and gets drunk, beats someone up, or otherwise distracts himself from thinking about it. He may even go right out and look for another job, without bothering to think through what went wrong. If depression is a disorder of thinking, rumination stokes it. The tendency to analyze feeds right into it; the tendency to act breaks it up—at least in the short run.

In fact, depression itself sets off rumination more in women than in men. When we find ourselves depressed, what do we do? Women try to figure out where the depression came from. Men play basketball or head for the office to work in order to distract themselves. It is a fascinating fact that men have more alcoholism and drug abuse than women do, perhaps even enough for us to be able to say: Men drink, women get depressed. Women, ruminating about the source of the depression, will only get more depressed, whereas men, by taking action, may cut depression off at the knees.

The rumination view might explain the depression epidemic as a whole, as well as the lopsided sex ratio. We now live in an age of rationality and self-consciousness. We are encouraged to take our problems more seriously and analyze them endlessly rather than act. Since depression is amplified by negative thinking, more depression might well be the result.
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The third possible explanation is the
pursuit of thinness
. To a much greater extent than men, women in our society have been caught up in the notion that being very thin is beautiful. The thin ideal is biologically almost impossible to achieve, however. If you are one of the majority—constantly to achieve the ideal—you are set up for depression. Either you will fail to keep the extra pounds from coming back, like 95 percent of women (and then failure and frequent reminders that you are “too fat” will depress you), or you will succeed and become a walking anorexic, starving constantly (see
chapter 12
) and suffering one of the major side effects of starvation—depression.

Around the world, every culture that has the thin ideal has more depression in women and also has eating disorders. All cultures that do not have the thin ideal do not have eating disorders, and they do not have more women depressed than men.
¹⁰

In a study of several hundred seventh-graders I participated in, we tried to predict which girls, as they came into puberty, would be at risk for depression. We found discontent with developing body shape to be a major risk factor. When boys go through puberty, they become more muscled and more like the “ideal” man. But when girls go through puberty, they develop soft fat, which fashion dictates is unsightly. They have been brainwashed into thinking that voluptuous is ugly. Before puberty, boys are more depressed than girls, but as puberty sets in, the girls become more depressed.
¹¹

So there are three factors that make women more depressed than men: more training in helplessness, more rumination, and the vain pursuit of thinness. These are all changeable. Changing the thin ideal is largely a matter of changing societal practices. Changing rumination and changing the indoctrination of girls into helplessness is a matter of changing childrearing and of therapy.