The Phantom Economy   /   Summer 2010   /    Book Reviews

The Ebb and Flow of Depression

The lived experience of depression.

David Healy

Photograph by Ian Keefe via Unsplash.

Responding to Mikkel Borch-Jacobsen’s review in the London Review of Books (11 July 2002) of the French edition of his book, Alain Ehrenberg wrote:

Because my book is not available in English I think I should give an account of what it does say. It is the final volume of a trilogy on contemporary individualism, and addresses two questions: why and how has depression become such an important illness, and what does depression tell us about changing notions of the individual at the end of the 20th century? Two hypotheses are proposed: the first concerns the relationship between depression and the transformation of democratic society since World War Two and holds that there has been a reduced emphasis on guilt and discipline, in favor of a stress on responsibility and personal initiative. Borch- Jacobsen sees this as a proposition that depression is a “simple reflection of changes in society,” but I make clear that social norms do not penetrate people’s heads the way that rain is absorbed by the ground: mediation is necessary. The second hypothesis concerns the role played by depression in the transformation of individual pathologies during the same period: I argue that depression’s prevalence can be attributed to the reduced importance of the notion of “conflict,” which was the basis of ideas of neurosis in the late 19th century.

I also contest the idea that the invention of antidepressants created depression. Such a thesis is a by-product of technological determinism. I distinguish two eras of contemporary depression. The first begins with the invention of ECT—not antidepressants—and ends in the early 1970s. During this period, depression was an appendage of neurosis; psychotropic medications were used as “boosters” for psychotherapy. This paradigm was then rejected, in large part through the development of the Diagnostic and Statistical Manual of Mental Disorders III in the US, but also because of the evolution of the place of depression in psychoanalysis ( the increasing attention paid to narcissistic pathologies). Depression is now used to refer to a whole range of problems, from fatigue to psychotic melancholy.

All three books reviewed here—one by a French sociologist ( Ehrenberg), one by an American psychiatrist  (Hirschbein), and one by an Australian therapist (Stavropoulos)—have a great deal to say about these issues and in particular the lived experience of depression.

Hirshbein’s book might be better titled The Female Experience of Depression in America. She outlines a world where the expectation was that women were defined by their relationship to their husbands and any discontent, such as taking their husbands’ work schedules personally, indicated individual pathology. This was a world that led feminists to label psychiatry as oppressive for suggesting discontent meant women were in need of treatment—that they should adapt to their gender role situation rather than change it. This protest continued through to the 1980s with struggles over the inclusion of Pre-menstrual Dysphoric Disorder (PMDD) and Masochistic Personality Disorder in various iterations of the Diagnostic and Statistical Manual of Mental Disorders (DSM), whose third edition in 1980 was a key moment for concepts of depression.

But somewhat anomalously, as Hirshbein points out, even though depression was linked to femininity, increased attention to depression began in the 1980s to be seen as part of a greater social movement to pay attention to women’s concerns, a key to helping women overcome adversity and advance in society rather than a further instance of oppression. It was perceived as listening to the complaints of women and an alleviation of them with medication rather than an effort to interpret them. As Hirshbein puts it:

Though the message of treatment for depression cut against the primary methods of organization and activism as espoused by the feminist movement in the 1970s, women did not seem to perceive this diagnosis as an expression of patriarchal physician authority. Instead women used the idea of depression as a way to call attention to their changing social circumstances and demanding that their feelings be taken seriously. (117)

Stavropoulos describes a world far from feminist circles, a world in which it would be socially embarrassing for a woman, or anyone for that matter, to mention that she was not coping. But saying she was on Prozac, Paxil, or another SSRI (selective serotonin reuptake inhibitor) would be perfectly acceptable—would be read as evidence of coping. Somehow we all, from high school students up, have internalized the market, and the possibilities of collective action to reverse our problems seem to have melted away as we have done so. There are two experiences here—one seemingly internal but linked to another that stems from the absence of something communal or relational that was there before. This is a world in which if there are communities anymore, they seem to be the communities of people reading magazines or accessing the internet who are faced with recommendations to take the latest medications or get the men in their lives to do so. A world in which the language of feelings has been replaced by a language of chemical descriptors—“my serotonin levels feel low.” So much so that it poses a problem for psychotherapists. Stavropoulos is unusual in engaging with these issues. Many therapists in my experience would now be uncomfortable treating patients who weren’t also on antidepressants.

One of the best indicators of where we seem to be heading lies in the fact that antidepressants are now among the most commonly prescribed drugs in pregnancy and their use continues to grow among women who are ever more reluctant to drink coffee or an occasional glass of wine while pregnant, even though ever more compelling data shows that antidepressants double the rate of birth defects, miscarriages, and terminations in addition to causing other problems.

How do we explain this? It is much more recent than the wider conversion of anxiety into depression that occurred from the 1970s onwards. Is there anything about being pregnant now as opposed to ten years ago that might lead to such an outcome? Modern psychiatry, according to Hirshbein, is persuasive rather than coercive. Ehrenberg resists the idea that depression stems simply from the marketing of antidepressants. Both he and Hirshbein argue depression was there before antidepressants. This is unquestionably true but perhaps misleading nevertheless. Companies and markets rarely invent. As Stavropoulos’s patients bring out, it is much more a case of using and shaping what’s there—especially our own aspirations.

The recent epidemic of juvenile bipolar disorder in America has been astonishing in that there were no precedents for it and it is so out of step with the rest of the world. In contrast to the de novo creation of juvenile bipolar disorder, the turning of the tide of depression, with adults being converted from depression to bipolar disorder—again largely American at present—is more the way companies do business. They turn up the lights on material in the shadows and fade out those whose time is done (patents expired). It is not clear whether the resulting ebbing of depression’s tide or the appearance of depression in pregnant women where it did not seem to exist before poses problems for Ehrenberg’s or Hirshbein’s larger interpretative frameworks.

In Stavropoulos’s case, if she were also treating physical disorders, it would be fascinating to see how she might handle a woman in her 60s on medication for “osteoporosis” who was unwilling for instance to mow the lawn for fear of falling and having a fracture, when mowing the lawn would likely be better for her and make her feel better than taking medication, and what connections she might make between such a woman with the next patient in who complained of depression.

All three books offer fascinating materials on the experience of disorders, especially at times of transition. The question is, do the issues the authors outline so well apply only in the mental health domain and only to depression or can variants be found across health? And if the issues are more extensive, what does this mean? What might the common factors be? One common factor might be the role of measurement technologies, something all authors touch on but don’t consider in depth. There is grist to many mills in these books. There are likely many details in each that readers will quibble with, but it is hard to argue with the common purpose of all three, which is one of attempting to understand why our illnesses take the shape they do. If we understood this, we might be less likely to get ill, or better able to navigate our way through contemporary society.