The authors tried to gloss over the issue by conflating reliability and validity. “This communication will present a diagnostic classification validated primarily by follow-up and family studies,” they wrote, as if those follow-up studies could do more than show that people could be reliably grouped by their symptoms—something Kraepelin had already shown, but that didn’t prove anything about whether or not those common qualities constituted a disease.
The team also wrote that their “criteria for establishing diagnostic validity in psychiatric illness have been described elsewhere,” as if others had settled the question. But thirty-five years later, scholars Allan Horwitz and Jerome Wakefield examined those other studies and found that their authors never claimed that they had built a bridge from symptom to disease. One researcher warned that he couldn’t guarantee that his “depressed” patients’ symptoms weren’t the result of some other illness, another concluded his paper by noting that defining “clinical entities by symptom pictures” remained a “serious problem in psychiatry,” and the final source pointed out that in the absence of some theory about what causes depression, it was impossible to sort out the unhappy from the sick. Taken together, Horwitz and Wakefield concluded, “these sources neither justify nor even address the validity of the specific definition” offered by the Feighner criteria. Indeed, the only reason to believe that descriptive psychiatry had solved the validity problem was wishing it was so—which the industry had plenty of incentive to do.
Adopting the Feighner criteria, the DSM-III committee also adopted this wishful thinking. But reality soon intruded. A psychiatrist had discovered that many people who had recently been bereaved met all the Feighner criteria. For all their atheoretical purity, those standards, now incorporated into the DSM, couldn’t even distinguish between the diseased and the merely bereaved. And this psychiatrist, Paula Clayton, wasn’t just some pro-neurotic dead-ender. She was on the faculty of Washington University and a member of the DSM-III Task Force on Affective Disorders.
So when the DSM-III committee were reminded that, according to Clayton, grief was indistinguishable from depression, when, in other words, the validity problem emerged from the avalanche of reliability statistics under which it had been buried, neither she nor the committee should have been terribly surprised. Neither could they simply ignore it, even if they wanted to. A diagnostic manual that turned a person in the throes of grief into a mental patient was a scientific nightmare and a potential public relations disaster. It threatened Spitzer’s strategy of rescuing psychiatry through a return to Kraepelin, to make all the professional blood spilled in the name of reliability a vain sacrifice.
The committee’s response was to solve the public relations problem, if not the scientific one, by establishing a loophole in the definition of MDD—the bereavement exclusion. “A full depressive syndrome,” the DSM-III eventually said, “is a normal reaction to the death of a loved one,” so a recently bereaved person does not have major depression, even if he is depressed. Instead, he is suffering from uncomplicated bereavement, which doctors could still treat if they liked, but, because it was listed in the section of the DSM-III devoted to “conditions not attributable to a mental disorder,” they were unlikely to get reimbursed for. There was good news on this front, however. The exemption was time limited. After two months, uncomplicated bereavement could become major depressive disorder.
It’s not clear why the exclusion expires after two months. There is some statistical evidence that grief begins to wane, on average, about ten weeks or so after a loss, but while this says something about the usual course of mourning, it hardly proves that an unusual course is a disease. Even more important, it’s not clear why bereavement is the only exempt condition, why, for instance, misfortunes like betrayal by a lover or severe financial loss or political upheaval or serious illness—or for that matter a noncatastrophe, the slow accretion of life’s difficulties or a loss of faith in one’s government or simple existential despair kindled by an awareness of mortality—do not also spare people from the rolls of the diseased. If the whole point of the DSM-III was to eliminate considerations of the nature and causes of a condition in favor of pure description, if indeed depression was no more or less than its symptoms, then why was it suddenly, and only in this one case, acceptable to talk about nature and causes?
The scientific answer is that there is no reason. The bereavement exclusion is like the epicycles that Ptolemaic astronomers added to their models of planetary motion—little loops within the orbit of planets that allegedly explained why they showed up in places where Ptolemaic astronomy, with its insistence that heavenly bodies moved in perfect circles, said they shouldn’t be. Epicycles worked on paper, sort of, but they did a much better job at keeping astronomers respectable and their models intact than at describing the actual movements of heavenly bodies; they have come to be known as the epitome of bad science.
Doctors couldn’t ignore Clayton’s findings any more than ancient astronomers could ignore the actual orbits of the planets, but if they had responded by trying to figure out which other setbacks kindled responses indistinguishable from depression, if they generated a list of exemptions, then their diagnoses would have gotten awfully unwieldy and unscientific sounding. Not only that, but people might well have started marching and raising hell about why their particular cause for grief should (or should not) be on the no-diagnosis list. If, on the other hand, the committee had left the winnowing of diseased sadness from healthy sorrow to the judgment of doctors, then the profession would have been back to the bad old days when the circumstances of an individual’s life mattered, when one doctor’s “normal reaction” could be another doctor’s disease. The bereavement exclusion—a single, time-limited exception based in common sense, as if it was just an unfortunate coincidence that bereavement mimicked depression—steered a middle course between these hazards.
Even as a one-time deal, however, the bereavement exclusion doesn’t really work to keep theory, opinion, and judgment out of the clinical picture. It doesn’t, for instance, specify the degree of relationship a patient must have to the deceased in order to qualify. Should a person really be allowed as many days to get over the death of, say, Michael Jackson as that of his own mother? Wouldn’t the diagnosis still require a clinician to make a judgment about just how important those people ought to be to the patient?
The answer, of course, is that the therapist is supposed to do no such thing. If the symptoms are present, and if they are causing trouble for the patient, then it shouldn’t matter if the loved one is a close relative, a celebrity, or even a fictional character whose television show has ended its run. In real life, however, it is hard to imagine that a clinician is going to count the days or consult the family tree as he decides who among the mourning is sick and who is only walking wounded. I haven’t polled my colleagues on this, but I think they do take actual circumstances into consideration when trying to understand and diagnose someone else’s misery. It seems nearly inhuman not to.
I confess that I do.
Not that that makes things any less confusing. Consider my patient Eliza. A couple of years ago, a sheriff called to tell her that her mother had been found in her apartment, dead from a drug overdose. That wasn’t the only momentous news Eliza received that day. Her mother had once, in a druggy fog, mentioned that it was possible that the man whom Eliza had always known as her father, the parent who remained when her mother was on her benders, who had terrified her and cared for her in equal measure, was very likely not her biological father. Eliza’s mother mentioned the other man’s name. Eliza tracked him down on the Internet, and he agreed to a DNA test, which, an e-mail on the day of her mother’s death informed her, was positive.
Eliza showed me a photo of her biological father, taken when she went to meet him. His daughters—four of them now, not three as they had once thought—descended a staircase in front of his large and lovely home. He stood on the landing, above this quartet of pretty blond w
omen, strong and confident and protective. He told Eliza that day that he was terribly sorry that her mother had never informed him of Eliza’s existence, that he would of course have taken care of her, had he only known.
When she talks about her week with her new father, when she recalls her terror of her old father, when she describes her mother’s chaotic life and squalid death, and above all when she remembers the day that her entire history was rewritten, Eliza is often overwhelmed with grief and regret—and with a self-pity that she finds as contemptible as it is inescapable. She has, in other words, at least the requisite five of the current symptoms (the DSM-IV has rearranged the DSM-III’s diagnostic menu a little), they cause her distress, and they have persisted well beyond two months from her bereavement. Nine out of ten doctors (or clerks) would agree that Eliza qualifies.
But is Eliza’s depression really best understood as an illness? Is this a valid way to think of her suffering?
These are exactly the questions that the DSM-III and its successors are designed to avoid. Looking to the symptom itself, and not to what lies behind it, means that it doesn’t matter how Eliza came by her depression any more than it matters if a person with lung cancer smoked three packs a day or never touched a cigarette in his life. There is no difference, except perhaps in degree, between my major depression and Eliza’s and that of someone whose suffering seems entirely unrelated to circumstances. They’re all the same disease, ready to be coded on the insurance form.
Here’s another confession: that is exactly what I did with Eliza—so that I could get paid for seeing her. I didn’t anguish over this decision, and I’ll bet her psychiatrist didn’t either when he billed the insurance company for her visits (which in turn meant that the costs would be covered). Certainly Eliza benefited from her diagnosis, but that’s probably more of a comment about how we define and fund health care than about her actual suffering. She could get the benefit of therapy without a diagnosis, but it’s not clear that her psychiatrist and I could get our benefits that way.
Which is the whole point of turning psychic suffering into mental illness and diagnosis into a bureaucratic function in the first place: to take these questions out of the therapists’ hands and so to eliminate the possibility of the professional embarrassments wrought by Rosenhan or Katz or gay people marching and demanding to be struck from the sick rolls. Erasing reaction, deleting neurosis, overlooking nature and cause, the DSM version of depression realizes its major goal: enhancing the reputation of psychiatry, consolidating its power, turning it into real medicine. Inner life—personal and political—remains important, if it is important at all, only as symptom, only as the evidence that the diagnostic criteria are met, as the raw material for a disease the mental health industry has become expert at churning out.
This may be the most brilliant achievement of the DSM. By adopting and deploying a scientific rhetoric, it has not narrowed the patient pool at all. Instead, it has given increased authority to the pronouncements of people like me—so much so that state and federal governments have determined that insurers must pay for the treatment of depression in the same way they pay for any other illness—and at the same time have given us opportunity to apply the diagnostic criteria as broadly as possible, to turn everyday suffering into a disease. We may have given Blue Cross the “clarity and uniformity of terminology concerning mental diagnoses” that they wanted, but those diagnoses, and especially the diagnosis of depression, have been rendered by doctors for their own use. So everyone can be insane, only now insanity is a real illness, deserving of health care dollars.
This creates a perverse incentive to render diagnoses, which may have something to do with the ever-burgeoning statistics on the prevalence of depression. This in turn has led therapists to do what my Mass General doctors did with me—to tell more patients than they once would have that they are depressed, and to tell them why: because they have this symptom and that, and because those symptoms have lasted for more than two weeks. Which, of course, the patients are primed to hear because a friend has confided that they have been diagnosed in this fashion, or they saw a discussion of depression on Oprah, or because they overheard a conversation at the 7-Eleven. When people are more likely to think of themselves as depressed, to pay attention to certain feelings as symptoms, it’s only a matter of time before those statistics start to rocket skyward and before a doctor says, in a prominent, peer-reviewed medical journal, that “depression in the Western world will affect half the population during their lifetime.”
There are some other perversities that follow on the DSM revolution—notably, that insurance companies are increasingly insisting that treatment go a certain way, that if a patient is to have any therapy at all, it should be cognitive-behavioral therapy, which I’ll tell you about in chapter 13. But the biggest problem with the DSM-III approach to mental illness is that while it hinges on the elimination of theory—which is to say on the elimination of metaphysics, of any kind of preconceived notion of where our suffering comes from or what it means to who we are—it has silently substituted its own metaphysics.
Because there is a theory behind the DSM’s atheoretical approach. If your mental illness isn’t a function of history or culture or geography, if it doesn’t matter whether you got your five symptoms because you were abused and abandoned and then one day bereaved of everything that was familiar or because you show up one day at a clinical trial with a melancholy cultivated through fifty years of absorbing life’s quotidian blows, if it’s not a reaction or a neurosis, if there is nothing behind its symptoms and nothing of psychological or spiritual significance in them, if depression is not, in short, about your transactions with the universe, but only about whether or not you have the signs of the illness, then there is only one thing left for it to be: an internal dysfunction, as stupid and brutal and meaningless as diabetes or cancer. It’s inside you—not in your thoughts and aspirations and dreams, in your fulfillments and frustrations, in your terror or despair or uncomprehending recognition of the irreducible gap between your little life and the infinity of time, not in a flaw in your soul, but in the vast and complex apparatus that gives rise to those thoughts and feelings and apprehensions, and that could just as easily, so it would seem, give rise to others. It’s in your molecules. What matters, when it comes to depression, is matter. The rest is for the poets to worry about.
CHAPTER 12
MAD MEN ON DRUGS
Toward the end of my second visit to Mass General, just before I got my pills, George Papakostas asked me how long it had been since I had felt good for any appreciable time.
“Good?” I asked him.
“Symptom free,” he said.
“For how long?” I asked.
“Thirty days,” he said. “Or more.”
I wanted to remind him that I was a writer, that I counted myself lucky to feel good from the beginning of a sentence to the period. I wanted to ask him if he had ever heard of betrayal, of disappointment, of mortality.
But after having spent nearly two hours cooperating with him, helping him to transmute my messy words into precise data, my inner world into bits as smooth and featureless as Chicken McNuggets, I somehow didn’t feel free to remind him that we hadn’t really agreed that I had symptoms. I’d submitted to his alchemy. I couldn’t just turn myself back into lead.
“I’m sorry,” I said. “But I have no idea what a month of feeling good would feel like.”
I’m sure this only confirmed his diagnosis.
But “thirty days” was ringing in my ears as I left his office with my brown bag full of pills. And much as I wanted to dismiss the very possibility of that symptom-free month, chalk up the idea to a laughably circumscribed view of humankind, much as I wanted to cite the research about depressive realism and to point to Aristotle and Lincoln and the James brothers and other important sad sacks as evidence against the neurochemical reductionism that lay behind this whole enterprise, I had to admit something: thirty days of unbroken conte
ntment, of peace of mind, of resilience and, yes, even of optimism, a month of bright light unfiltered by a black veil—that sounds pretty good. If that was what I’d been missing, if that’s what happens if you take the cure or have been lucky enough to elude the scourge in the first place, if health is happiness in month-long blocks, then suddenly the idea that unhappiness is a curable disease didn’t seem like such a bad one.
I ducked inside a restaurant. I wasn’t hungry, but I ordered a sandwich anyway. And a glass of water. I gulped down my six golden pills. I waited for my month to begin.
Was George Papakostas thinking of the placebo effect when he asked me that question? I don’t think so. But maybe he should have been.
Placebos trouble doctors. There’s too much magic in them and not enough science. They highlight a subject that most physicians would prefer to avoid: that they may not entirely deserve the power that they wield. The word itself, which is Latin for I will please, contains more than a hint of condescension, as if the doctor is merely tossing a pill at whiners, and as if the reason that the placebo effect persists is that people are too credulous (or perhaps too dumb) to get well by virtue of science alone.
So if it weren’t for methodological necessity, researchers would probably forget about the placebo effect. And the game is set up so they can almost do that. They certainly don’t really have to explore or explain or try to harness it, at least not in the laboratory.
Manufacturing depression Page 27