Lisa Harris (lrph) Mon 1 Mar 10 13:54
We are pleased to welcome Gary Greenberg, author of "Manufacturing Depression" to Inkwell.vue. Gary Greenberg is a psychotherapist and journalist from Connecticut. His features and essays have appeared in THe New Yorker, Harper's, Mother Jones, and Rolling Stone, among other magazines. Manufacturing Depression is his third book. He lives with his wife and son and a shifting cast of animals, which right now include a couple of cats, a puppy, and a flock of chickens. Leading our discussion is Katherine Spinner... Katherine Spinner is a Quaker, a knitter, a niece, and aunt and a teacher/caregiver in preschool daycare. Her aunt is in residential care, but her primary commitment is to be present with her and to be on call for her bad days. She has taken most of the anti-depressants which Gary discusses in his book, and hopes to continue to be stable with her current prescription.
Katherine Spinner (spinner) Tue 2 Mar 10 09:36
Gary, your book has several stories, including your own history with depression, the rise of the diagnosis of depression and the increasing use of cognitive therapy to treat depression. (I almost wrote "to treat the disease" then changed my mind.) Now that I'm into your book for the second time, I still can't figure out whether you believe that there is, in some people, an illness that ought to be treated by psychiatry. What about, for instance, post-partum depression? If a new mother had adequate support, so that she could get some rest and some help with daily maintenance work, would that obviate a need for drug treatment? In chapter 4 you quote Kraepelin and Diefendorf on "the mildest form of the depressive states" and say that you would be likely to consider hospitalization for a patient in such a state. Presumably, that hospitalization would include treatment with drugs. Would you suggest that patient go off of drugs once back out in the world and getting psychotherapy? Do you have clients who are taking anti-depressants? If so, do you have any contact with their prescribing physicians?
Gary Greenberg (gberg) Tue 2 Mar 10 16:56
Hi, Katherine. Nice to be here, and I'm looking forward to our conversation. >I still can't figure out whether you believe that there is, in some people, an illness that ought to be treated by psychiatry. That's really two questions: Is depression, at least in some cases, an illness, and ought it to be treated by psychiatry? The first one, not to get too Clintonian about it, depends on what the meaning of "illness" is. I think the working definition of illness, at least of medical illness, is somethign like: a form of suffering that has a biochemical cause, like a bacterium that causes an infection or a cell mutation that causes cancer. I think that by that definition, there may be something like this that explains some cases of depression. There is a form of depression--known variously as melancholia or endogenous depression (as well as some other names)--which seems to have arisen in all human societies at all times since recorded history. One of its characteristics is that it seems unresponsive to the environment and, indeed, unexplained by any of the sufferer's circumstances. It has distinctive physiological signs--handwringing and other kinds of agitation, sleep disturbances, weight gain (or sometimes loss), etc. It runs in families. There are even indications that some of these people, although not all by any means, have biochemical anomalies that in turn have a suggestive relationship to mood--impairments in the endocrine system, reduction in the size of the hippocampus, etc. So all of this adds up, at least in common sense, to the possibility that this form of depression is a classic disease. But there are two problems with this. One is that common sense has been known to be wrong. In 1850 in England, for instance, common sense told doctors that cholera was caused by bad air. The places in the London with the worst cholera, after all, were the places with the worst stink. As we know now, the stink was only an indication of the problem, which lay elsewhere--in the shit-infested water. Waht was missing at that time, in addition to the open-mindedness that John Snow possessed and which allowed him to look at the water supply, was any knowledge of microbes. Obviously, we can't yet know what is missing from our account of the chemical origins of depression, although we can say that if they exist, they're mighty difficult to pin down. The evidence remains largely circumstantial, and there may be no way of finally knowing if the chemical findings are the cause or the effect of the condition. So we need to be very careful about connecting the dots here. The second problem is worse. It is that people with this kind of depression are a very small percentage of the people who can be diagnosed with depression. My book is largely about how these categories came to be conflated, so that we've come to think of demoralization as a disease. The result is a diagnostic scheme that effectively pathologizes something like twenty percent of us. But if you stick with that strain of depression that seems to be a disease in the classic sense, the numbers are much lower, probably lower than ten percent. Which is not an insubstantial number, but hardly the epidemic that various interests would like you to think it is.
Gary Greenberg (gberg) Tue 2 Mar 10 17:03
So that's the first answer--depression may be a disease in the classic sense, but if it is it probably afflicts many fewer people than current epidemiology indicates, and is certainly not the leading cause of disability that the World Health Organization says it is. As to the second question, whether or not psychiatry ought to treat it, if you've read my book you will not be surprised to hear me say that I'm no fan of psychiatry. I'm not sure what psychiatrists ought to treat. But I will say that many psychiatrists are good empiricists. They are careful observers of people's mental suffering and of the effects of drugs upon it. What they are not is people in possession of some highly unified and organized body of knowledge about the human mind, or even the human brain. So a good psychiatrist, someone with some compassion and experience, can, with a little luck, competently treat a depression that will respond to drugs. But so could a good family doc or nurse practitioner or OB-GYN. And not all depressions will respond to drugs, which is where it can get dangerous to be treated by a psychiatrist; most of the psychiatrists I know only know how to give more drugs. They don't know how or when to stop and say, "You don't have what I can cure."
Gary Greenberg (gberg) Tue 2 Mar 10 17:16
AS for the drug question, I'm sure I'll have ample opportunity to elaborate, but just let me say here, I don't have a particular animus against antidepressants (or any other psychoactive drug). I have a problem with the way they have been sold, which is largely by means of creating a disease. If Prozac was sold as a drug that will make you feel better, that will help you get by, that will help you feel like the person you think you ought to be or want to be, rather than as the treatment for a chronic disease, then I probably would have written a book about somethign else.
Scott Underwood (esau) Wed 3 Mar 10 09:29
I haven't read the book, so I'll try to follow along as best I can. (I've also not been treated for depression, but the topic interests me greatly.) Can you say more about cognitive therapy and other nondrug treatments of depression? Given your opinion of psychiatry, is there any value to their body of knowledge, however inconsistent?
Lisa Harris (lrph) Wed 3 Mar 10 11:47
(To our offsite readers, if you'd like to ask Gary a question, please email us at <email@example.com> and we will post your comments for you.)
Lisa Harris (lrph) Wed 3 Mar 10 11:55
Gary, you go into some detail about the diagnostic procedures for depression. The criteria, if I understand correctly, are situational (ie. have you lost interest in usual things, sad mood for 2 weeks). Is there any way to diagnose depression through more mainstream medical testing (for example, blood tests, brain scans, etc)? It would seem that a chemical imbalance could be detected in some way other than talk therapy.
Julie Sherman (julieswn) Wed 3 Mar 10 12:45
Just a comment, having not read the book I was treated successfully for depression with drugs once in my life. Since coming out of that depression I have dealt with cancer and a reoccurence of cancer. I was not depressed during that period of my life and have not had the depression return. There was a huge difference between dealing with depression and dealing with cancer. Depression was worse. I am grateful that I was not dealing with depression while also dealing with cancer. Having said that, I think that we live in a drug-happy culture and we have been taught to rely on drugs to help solve our problems. I am sure if I had asked for it,I would have been happily given drugs for depression while I was dealing with cancer,few to no questions asked. The assumption would have been made that of course I would be depressed while dealing with cancer and the drugs would help.
Gary Greenberg (gberg) Wed 3 Mar 10 12:47
Currently, there is no such test. The closest thing to it is the dexomethasone suppression test, which turn up positive in something like seventy percent of the people with a very severe, and uncommon, form of depression. The biggest reason you most likely haven't heard of that test is that it does the opposite of what drug companies and their doctors want--it creates a small market, and for the wrong drugs. The old-line antidepressants, like imipramine or elavil, are more effective at treating it than SSRIs like Prozac, and the most effective treatment is ECT (shock therapy). The diagnostic procedure is entirely circular. If you have the symptoms yu have the disease, and if you have the disease then you must have the symptoms. The tests use to assess this are blunt instruments. To figure out if you've been in a low mood for two weeks or more, he says, "Have you been in a low mood for two weeks or more?" To find out if you've lost interest in otherwise pleasurable activities, he says, "Have you lost interest in otherwise pleasurable activities?" Add up the yeses, and if there ar emore than five, you're sick. And it doesn't matter why (unless you've been recebtly bereaved, in whcih case you get a two-month exemption). In fact, the whole point of the diagnostic scheme is to take the question of the nature and causes of the illness off the table. THat's why some psychiatrists who didn't like the change, which was implemented in 1980 in the 3rd editikon of the Diagnostic and Statistical Manual, complained that it turned them into clerks. In fact, that was pretty much the point of the exercise.
Gail Williams (gail) Wed 3 Mar 10 16:21
What? It doesn't matter why, unless you've been recently bereaved, in which case you get a two-month exemption, you say! That's contrary to all human cultural knowledge, which grants a year of grief in one tradition after another. What a peculiar state of affairs we have here. If your situation is sad, you have two weeks to snap out if it even if the situation around you does not change. Two months if the love of your life just died. There are times and places where that would not just be unexpected, but actively weird! So how did that change come about?
Gary Greenberg (gberg) Wed 3 Mar 10 17:02
That's an interesting story. It all goes back to the homosexual agenda. In 1973, the American Psychiatric Association was in deep shit. They had just had this huge public battle over where homosexuality was really an illness--a huge embarrassment start to finish, because no matter how they polished the turd, it was obvious to even the most casual observer that psychiatrists didn't agree on the most basic thing doctors need to agree on, which is what a disease is. They tried to cast it as the triumph of science over politics--they had, they said, proven scientifically that homosexuality was not a disease, a proposition that is so logically and scientifically suspect as to be laughable--but the fact was that it was a vote of the membership, after three years of protests and shouting matches and high drama, that deleted homosexuality from the DSM. Even worse, however, was the fact that even when they agreed on what suffering constituted a disease, they couldn't agree on whether or not a given person had the disease. STudy after study showed that psychiatric diagnosis had very low reliability. So for instance, doctors in England were much more likely to diagnose as schizophrenic the same patient (seen on film) that American docs said was manic-depressive. And these were the top docs in their field. It was beginning to seem like psychiatry wasn't real medicine, and now the APA had to justify their belonging in the guild. So this comes down to two problems--reliability (agreeing on diagnosis) and validity (showing that the disease really exists). The second problem is a profound one, especially when it comes to consciousness, because it's hard to say what a disease is without stipulating what normal is, and that is treacherous ground. So they punted that one. The first, however, could be fixed, if only the diagnoses could be rendered as checklists of symptoms. So that's what the APA did--they created a taxonomy of mental suffering, and when it turned out that if you standardize diagnosis, you can indeed achieve high reliability, and then they pretended that by solving the reliabiliyt problem they had also solved the validity problem. (I wish I was overstating the case, but I swear on a stack of my books that this is what happened, and in it are a couple of recent quotes from the head of the National INstitutes of Mental Health, in which he more or less admits that psychiatric diagnosis has near 100 percent reliaability and zero percent validity. He did that, of course, when he was talking to other doctors.) But there was a fly in the ointment. ONe of the people responsible for developing the criteria for depression started interviewing grieving people, and discovered, not surprisingly that many of them met the criteria. So the committee couldn't exactly dismiss her work as nutty, so they did somethign even more clever. They created a workaround--if you have recently been bereaved (and yes, it's two months, regardless of what anyone else says), you're not sick. (It's sort of like the epicycles added by Ptolemaic astronomers to account for why planets weren't wehre they were supposed to be, instead of admitting that the planets didn't really move in circular orbits as Platonic theory insisted they should. Bad science, in other words.) But stay tuned. In the last few years, some researchers have been tugging pretty hard on that bereavement thread, trying to unrvel the whole DSM tapestry. Why only bereavement? they ask. After all, isn't unemployment, divorce, etc., also somethign that normally takes its toll? They did some studies and showed that there was no reason not to include other stressors besides beravement, and wrote a book --"The Loss of Sadness"--which came out as the APA was beginning work on the next edition of the DSM. It was a direct challenge, because it went right to the heart of the whole project, and the way it intentionally ignores context in favor of symptom. (After all, what does it matter if your cancer came from stress or exposure? It's stil the same disease.) The APA pledged to look into this, and last month they unveiled their response. They're droppiong the bereavement exclusion. So starting in 2012, if this all goes as planned, you will once again be sick if you get upset about someone you love dying.
die die must try (debbie) Wed 3 Mar 10 18:30
You are saying that you think homosexuality is a disease? and that there is a homosexual agenda?
Gary Greenberg (gberg) Wed 3 Mar 10 18:44
I'm sorry. That was a joke. The homosexual agenda part, I mean. I won't try to explain the joke. I'll just say I guess it didn't work and apologize for the offense. As to the disease question, no I don't think homosexuality is a disease. I am glad the APA eliminated it from their diagnostic manual. I am not glad that they tried everything they could to cover up the fact that this was a political move--a good one, in my view, but a political one nonetheless. I am also not glad that they responded to the crisis by creating a diagnostic system that even further conceals the political dimensions of psychiatric diagnosis.
Gary Greenberg (gberg) Wed 3 Mar 10 18:47
And I guess I should clarify my remarks about the illogic of the proposition that they had scientifically proven that homosexuality wasn't a disease. That's not to say that it was a bad idea to remove it, only that you can't scientifically (or logically) prove a negation. The reason to remove the diagnosis was that it was unfair and unjust and simply wrong.
die die must try (debbie) Wed 3 Mar 10 18:48
thanks for clarifying - if we were talking in person it would be easier to catch the nuances. It does seem clear that there are many political dimensions - do you think the solution is to just own up to the politicalness - to say something like we are all a product of our time and place and the DSM is also informed by time and place.
Maria Rosales (rosmar) Wed 3 Mar 10 18:49
For the record, I could tell you were being ironic. The rest, I'm still thinking about.
Gary Greenberg (gberg) Wed 3 Mar 10 18:50
>Do you have clients who are taking anti-depressants? If so, do you >have any contact with their prescribing physicians? Yes, many. I sometimes have contact with the docs, but not always. Most antidepressants are prescribed by family docs, and they rarely have time (or inclination) to dig into what might be going on (besides that mythical chemical imbalance).
Gary Greenberg (gberg) Wed 3 Mar 10 18:56
>to say something like we are all a product of our time and place and the DSM is also informed by time and place. That would be a good start. But that would also make the rest of the DSM incoherent, since the idea behind it is that there are mental illnesses in nature, so for the most part they should not vary with time and place. INterestingly, the DSM has a section on "culture-bound disorders," like amok and grisi siknis. The idea here is that psychiatrists are supposed to steeer a wide berth around these problems, resist the temptation to fit them into their diagnostic categories. Once again, as in the bereavement exclusion, the exception proves the rule--that all these diseases are culture-bound. I mean, eating disorders? There's a good book on the way that the DSM's approach to mental illness is changing the way people in other countries understand their own suffering. It's called Crazy Like Us.
Maria Rosales (rosmar) Wed 3 Mar 10 18:57
Nature (and our understanding of nature) varies with time and place.
Gary Greenberg (gberg) Thu 4 Mar 10 03:13
AMen, sister. NOw, if they could only teach that in psychiatrist school.
Steven McGarity (sundog) Thu 4 Mar 10 07:52
Interesting discussion, <gberg> and thank you for bringing your work here. In the healthcare system I have been using the last couple years, the Veterans Administration, one sees a psychiatrist less than anyone else. Their only function I have ever determined is script writing. My psychiatrist right now seems good at that. That was my first introduction really to mental healthcare. I have trouble seeing drugs, or chemicals, as the solution to our problems. I have quite an array of prescriptions - depression, anxiety, sleep, etc. I mean take PTSD as an example. How can trauma be treated as some chemical imbalance in the brain? I do know some people seem more prone to the disorder than others, perhaps that is the genetic effect. I tend to be aligned on the cognitive side. I think therapy, etc. is more productive for dealing with problems like these than writing script for mood maintenance. But then I have a resistance to introducing chemicals into my body. No one seems to have an idea what the side effects are of any given drug. Amazing how the profession has jumped from Freud and Jung to this - irrelevant except for script writing IMHO.
Velma J. Bowen (wren) Thu 4 Mar 10 08:33
I am about halfway through the book, and am fascinated by the history of fashions/trends in diseases and treatments that you have laid out. Fascinated, and no small bit perturbed. I'm also fascinated by the grief timeline coming and going. That strikes me as wrong, in a very fundamental way.
Gary Greenberg (gberg) Thu 4 Mar 10 09:05
>Amazing how the profession has jumped from Freud and Jung to this - irrelevant except for script writing IMHO. Another way the industry has changed is that to the extent that there is therapy, it is not the kind Freud or Jung were interested in. Both of them thought that our psychological lives were endlessly complex and even self-contradictory. Freud was more pessimistic than Jung, to say the least, but neithe of them thought we could know ourselves completely. There are still plenty of therapists thinking this way, but the major movement has been toward cognitive-behavioral therapy, whcih starts with the idea that the mind is the output of the brain, which in turn is a very complex computer that is capable, when it is healthy, of accurately processing information, and of seeing the world as it is. Much as I sometimes wish this were true, I don't. >I'm also fascinated by the grief timeline coming and going. That >strikes me as wrong, in a very fundamental way. yes, indeed. You'd think psychiatrists would at least figure out how bad this looks to the rest of us.
Gary Greenberg (gberg) Thu 4 Mar 10 11:24
>Given your opinion of psychiatry, is there any value to >their body of knowledge, however inconsistent? Sure, there's value in it. There's value in understanding the varieties of human suffering, in ordering and grouping them, and in figuring out how to treat them. There's value in figuring out which drugs can be used to help people feel better. But there is also risk involved. The risk is that psychiatry becomes reductive, that in its zeal to prove its merits as a branch of medicine, it makes claims about human nature based in the rhetoric of science, but not in science itself. That's hubris, and it has implications way beyond the consulting room. There was a time, after the second world war and before the rise of psychopharmacology in the seventies, when psychiatrists, at least some of them, saw their profession as an inescapably political one. Karl & William Menninger, among others, founded the Group for the ADvancement of Psychiatry, which was dedicated to figuring outl, as they put it, "man's transactions with the universe," and especially how social and political institutions could and should be shaped in order to reduce mental suffering. The project wa probably hopelessly utopian, and it had its own problems, but the idea of a profession that was trying to come to grips with how relatedness worked--I think that was a better idea than a profession primarily occupied with the way our brains work.
Mark McDonough (mcdee) Thu 4 Mar 10 11:44
That period produced a great deal of wonderful writing and speculation on what it means to be human.
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