Manufacturing depression

by Gary Greenberg

  Occasionally, this discussion ends our relationship—something I usually find out when the patient calls back to cancel or just doesn’t show up for the next appointment. A few of these ex-patients have been generous enough to tell me, when I asked, that my behavior seemed, well, a little unusual to them. They may have expected me to make mountains, but not out of that molehill. My doing so made them uneasy—not in a let’s-talk-about-this way, but in a get-me-the-hell-away-from-this-nut way. I can’t blame them for this. They were undoubtedly correct in their assessment that they couldn’t work well with me.

  That’s why I don’t try to explain to these people that if the whole point of therapy is not to take anything for granted and to make explicit what would prefer to stay invisible, then it doesn’t really make sense to hide the truth of what we—my patient and me—are doing when it comes to the insurance companies. Why make bad faith central to a relationship that is supposed to be the antidote to that?

  That used to be my main justification for bringing the business of diagnosis to the foreground of therapy, if only briefly, and to exercise some due diligence when it comes to giving and receiving labels. And I still believe it, but my clinical trial experience taught me another reason to do it: being told that you are mentally ill can really mess with your head.

  That may seem like a reason not to have the diagnosis discussion, to just let the medical-industrial complex chug along unremarked and get to the real work at hand. But even if such a distinction can be drawn, the truth is bound to emerge. Maybe the insurance company will ask for details about what is wrong with the patient, or will refuse to pay for further treatment unless the patient seeks medication, or, as happened to me the very first time I was in therapy, a patient will catch a glimpse of his statement and realize that there is a diagnosis code on it. If you are in therapy, sooner or later, implicitly or explicitly, it is inevitable that you will figure out that you have become a mental patient. And you should be prepared for what that might mean.

  I certainly should have been prepared. By the time I showed up at Mass General, I’d been doling out the labels for a long time—and not thoughtlessly. Like many people who went to college in the 1970s, I had read Erving Goffman and Michel Foucault, sociologists who had pointed out the inescapable ideological dimension of diagnostic labeling. Identifying people as depressives or schizophrenics, they suggested, was a way to exert power over them, to stifle dissent and impose conformity to a particular way of being human. Sometimes, as in the case of a person shut up in a mental hospital or forced to undergo a lobotomy, the exercise of power was obvious and brutal.

  But more often, especially according to Foucault, the label doesn’t function to put a person in his place so much as it gives him the language to put himself there. People are, in this view, socially constructed, and the power of a diagnosis is that it changes the way people understand and identify and treat themselves. For theorists like Foucault, this is a crucial, and perhaps the central, problem of modern life: that the power to tell us what kind of life we ought to live, and what kind of people we ought to be, could be wielded not directly but diffusely, not through force but through culture, not by jackbooted thugs but by experts. Tell people what they ought to want, help them to think that they are freely choosing, and you’ve gotten around any resistance they might have to being told what to do. Power exercised this way is invisible and in some ways even more dangerous than the kind that is obvious. The power that hides in the plain light of day can fashion people in its own image without their even knowing it.

  Those experts include doctors. For a psychiatrist to say that you have the disease of depression is to tell you not only about your health, but also about who you are, what is wrong with your life and how it should be set right, and who you would be if only you were healthy. In making these pronouncements, the doctor draws on the authority of science, which presumably has no stake in the outcome. He couches his judgments in the language of sickness and health rather than sin and virtue, which means that he is cloaking his morality, even from himself, in science.

  It’s easy enough to see the way this happens in a case like Sheila’s. She was a woman in her midthirties, married with three children, who came to see me in the midst of a crisis. She’d fallen in love with a man who wasn’t her husband. He lived far away, but they were in constant contact by phone and e-mail and had arranged a tryst. She was, she said, standing on a precipice, as terrified as she was excited, but there was no doubt she was going to leap.

  Which she did, with the predictable results: a blissful weekend, a redoubled attraction, more e-mail and phone contact, a longer trail of incriminating evidence for a husband made suspicious by her sudden preoccupation, the inevitable discovery and confrontation, fifteen years of marriage reduced in a moment of cyber carelessness to a smoking heap of anguish and recrimination. Within a few weeks, she was beside herself with anxiety and guilt, sleepless and without appetite, unable to conceive of a way forward that didn’t destroy either her family or herself, flirting with thoughts of suicide.

  Sheila had been on antidepressants before—when, a few years before her affair, she had found herself interested in another man, this one a local friend. The drugs had been helpful, she told me. While on them, she had refrained from acting on her attraction and her discontent with her husband dissipated. She was considering taking them again, but she wondered if that was a good idea. Perhaps, she told me, her time on the drugs had only postponed the inevitable. Her husband was the kind of man who inspected the home every day when he returned from work and presented her with a checklist of the flaws in her homemaking, a right he claimed as part of his role as head of a Christian household. While taking antidepressants, she had found it easier to go along with this regime, but since she’d stopped—just before she’d struck up her affair—she had come to see her unhappiness differently.

  Her compliance wasn’t strictly a pharmacological effect, she said. “When you think you’re sick—you know, really sick,” she told me, “you don’t have to pay attention to those feelings. They’re not real, they’re just part of the sickness, and that was a good thing then. It calmed me down and it gave me a reason to stay. There’s a part of me that wants to go back there, but there’s a part of me that’s afraid that that’s exactly what will happen. I’ll end up back there, where I can be the good little Christian wife.”

  I know Sheila’s psychiatrist. He’s a secular Jew who has no interest in promoting fundamentalist Christianity or preserving a bad marriage for the sake of the institution or otherwise duping a patient into thinking that her unhappiness is the symptom of an illness rather than the indication that something is wrong with her life. He just wants to reduce his patients’ suffering, to prevent suicide, to treat their illness. He’d be the first person to say that her circumstances bear exploration, and he would no doubt urge a patient to use her drug-induced relief to do just that. I am also sure he didn’t give Sheila the depression-is-a-disease-like-diabetes talk. He didn’t have to. To receive the prescription from a doctor and then to take the drug every day and then feel the difference—that’s enough to give a person pause, to make her wonder if everything she thought about herself and the world she occupied was wrong, just another symptom of the illness that the drug is evidently treating.

  That, at any rate, is what happened to me during my clinical trial. Even before the doctors started to tell me I was getting better, the idea that depression was a malfunction in my brain was working on me like a worm. When I woke up in the middle of the night in a cold sweat or craved my afternoon nap, when I found myself frustrated by my shortcomings or deflated by the seeming impossibility of getting done what I wanted to get done, when I felt sorry for myself and for all of us for having to live in such a broken world, I wondered if indeed I’d been suffering from an illness all along. I began to notice how physical the experience was, how it made my legs feel shaky and my chest feel tight, as if a snake were wrapping itself around me and choking the l
ife out of me. I also began to see that the items on the tests, stupid as they were, corresponded to my experience; I may not have accepted that these were symptoms, but I couldn’t deny that those sensations, the sleepiness and the lack of appetite and the sadness and the guilt and the indecision, all occurred together. I began, in short, to wonder if depression had colonized my consciousness in exactly the way that Peter Kramer described, fooling me into thinking that it wasn’t a disease. I wondered if all those unacknowledged (and untreated) legislators of mankind had manufactured me as the kind of person who would mistake neurochemical noise for existential signal, if I should let myself be remanufactured—not by the drugs, but by the idea behind the drugs, by the label. And I wondered if I shouldn’t just bag the fish oil and go to my doctor and get the real thing.

  I hated to admit that I was thinking this way. I didn’t want the depression doctors to be right. I didn’t want to be mentally ill, but even more I didn’t want their authority over who we are, over what it means to be human, to be legitimate. That’s the problem with science. When it’s right, it’s right. It’s a big comedown to discover, for instance, that the earth is not at the center of the universe. Or, for that matter, to see a CT scan of your abdomen and realize that your inflamed appendix doesn’t really care what you were planning to do today. This is probably another reason why some patients run for the hills when I suggest that we collaborate on their diagnosis. They know that science can’t be a democracy.

  And this is where my resistance to the idea of my own mental illness gains some purchase and my native orneriness finds some comfort. Because it turns out that when it comes to the depression and the other diagnoses into which psychiatrists carve up the landscape of psychic suffering, science (or perhaps I should say “science”) is much more of a democracy than you might think. Underneath its placid surface, its dispassionate description of diseases and their symptoms, is a history of heated battles—“fevered polemical discussions,” in the words of one of DSM’s main authors—that nearly tore the profession apart and were settled in the most humble of democratic ways: at the ballot box.

  I may have given you the impression that psychiatry’s march toward scientific respectability in the 1950s and 1960s was sure and steady. But even as the drugs were flooding the market and the statisticians were figuring out how to please the regulators and the doctors were claiming that they were hot on the trail of the twisted molecules that caused depression, most psychiatrists, glad as they were to prescribe the drugs their neuroscience-minded colleagues were inventing, were still tending to people’s psyches, treating conditions like depressive neurosis and helping their patients understand how their personal histories, their past traumas had shaped their current suffering—or, as psychiatrist Karl Menninger once put it, “what [was] behind the symptom.”

  Karl Menninger and his brother William, a psychiatrist who had served as a general in World War II, were at the forefront of a postwar psychiatry that was confronted with an unavoidable question. Soldiers who had gone off to war as healthy, well-adjusted people had often returned in a devastated condition. “We must attempt to explain how the observed maladjustment came about and what the meaning of this sudden eccentricity or desperate or aggressive outburst is,” Karl Menninger wrote. The answer, said his brother, was not to be found in the internal disease process implied by a classification scheme like Kraepelin’s, but rather in “the force of factors in the environment which supported or disrupted the individual.” This view dovetailed with Adolf Meyer’s contention that psychological problems were reactions to life stresses and with the Freudian notion that the psyche was a dynamic organ whose balance could be upset by trauma. This synthesis was enshrined in the first DSM, which came out in 1952, and in which nearly all mental illnesses were named as reactions: schizophrenic reaction, depressive reaction, anxiety reaction, and so on.

  The biopsychosocial model, as this something-for-everyone approach came to be known, seems as obvious and unobjectionable as any other ecumenical view. It’s even lucrative; as we have seen, if mental illness is the result of collisions between the complex and demanding modern world and the psyche, then virtually anyone could be insane. But it required taking an approach to the question of what constituted mental illness that was hard to reconcile with scientific medicine and its carving up of the world into disease entities. It created a natural tension between therapy-oriented psychiatrists like the Menningers and biological psychiatrists like Roland Kuhn.

  “Instead of putting so much emphasis on different kinds…of illness,” Karl Menninger wrote in 1963, “we propose to think of all forms of mental illness as being essentially the same in quality and differing quantitatively.” There was no discrete boundary between mental illness and mental health, let alone among mental illnesses. To say that the whole world was insane was only to say that we were all vulnerable to psychic suffering, each of us in different ways and measures, and that what was important was not what disease we had but what troubles our lives had visited upon us and how we had reacted.

  The clinician’s focus, according to this model, should not be only on the individual patient. The Group for the Advancement of Psychiatry, an influential organization founded in 1946 by William Menninger, among others, sought to practice prevention psychiatry, in which the social conditions that could make people mentally ill were as much a focus as the individual patient. GAP advocated for an education that taught psychiatrists to take “an objective critical attitude on a broad perspective of Man in transaction with his universe.” Psychiatrists could then weigh in on the psychological dimensions of the important political arguments of the day, give a scientific answer to the question of whether one policy or another was better or worse for our mental health.

  Unless, that is, they didn’t even know what mental health and illness were.

  Even before the Rosenhan study about being sane in insane places was published in 1973, psychiatrists and, increasingly, the public had begun to wonder about that. The troubles began in 1949, when psychologist Philip Ash showed that psychiatrists presented with exactly the same information about the same patient agreed on a diagnosis only about 20 percent of the time. By 1962, published studies indicated that at their best psychiatrists reached the same diagnosis in a dismal 42 percent of cases.

  Some defenders of the industry pointed out that the studies used transcripts or summaries of cases, and that the problem might be in the relative distance of the doctors from the subject. So in 1964, a team led by Martin Katz, a National Institutes of Health psychiatrist, showed films of diagnostic interviews to panels of psychiatrists and asked them to make a diagnosis. Even then, they couldn’t agree on the broadest of distinctions—whether or not a given patient was psychotic or neurotic—let alone on what variety of mental illness he or she was suffering with. No matter how disturbed the patient seemed, no matter who was conducting the interview, no matter how experienced or august the psychiatrists on the panels, the doctors came up evenly divided.

  Katz even tried manipulating how much information he gave the doctors. He had a film of a “clearly depressed” woman in her fifties who, because she had had a manic episode, seemed to have an obvious case of manic-depressive psychosis. He showed one group of psychiatrists a version of the movie in which her history of mania was edited out. Those doctors came up evenly divided about whether she was psychotic or neurotically or involutionally depressed. When he showed the whole movie to the other group, despite what he thought would be a slam-dunk for a manic-depression diagnosis, the vote was again split; even when they were telegraphed the desired answer, only half the psychiatrists got it right.

  The bad news was compounded when Katz showed the interview to a group of British doctors. Only one thought the patient was psychotic, seven that she was neurotic, nineteen went with personality disorder, and four split their tickets, voting for mixed diagnosis. This study, along with others that specifically investigated schizophrenia and manic-depressive illness, helped to expla
in a mystery brewing since the late 1950s, when epidemiological studies showed that manic depression was much more common in Great Britain than schizophrenia, while the reverse was true in the United States. It turned out that the diagnostic problem wasn’t a result of, say, the differing genetic stocks of the two countries or their different approaches to childrearing. It wasn’t in the patients at all, but in the doctors. Something in their educations, their training, perhaps even their countries’ differing cultures made transatlantic psychiatry a profession divided by a common language.

  The difficulty that doctors had agreeing on the meaning of the words they were using not only worried them; it made them feel inadequate. “There is a terrible sense of shame among psychiatrists,” one of them wrote, “always wanting to show that our diagnoses are as good as the scientific ones used in real medicine.” They might have kept their shame in the closet, however, had it not been for some of their colleagues who were tired of remaining in a closet of their own. In 1970, gay psychiatrists began to object loudly to the fact that their sexual orientation was considered a mental illness. Emboldened by the activism (and by the sexual revolution) of the sixties, they disrupted APA meetings around the country, picketing and protesting, sitting in to demand that homosexuality be deleted from the DSM, then in its second edition. At one annual meeting, a masked man appeared at a panel discussion and announced that he was both gay and a psychiatrist and that there were at least two hundred others like him at the convention. Donnybrooks like this could not help but attract widespread media attention.