Inkwell: Authors and Artists

    
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.
  

    
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?  
  

    
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.
  

    
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."
  

    
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.
  

    
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?
  

    
(To our offsite readers, if you'd like to ask Gary a question, please
email us at <inkwell@well.com> and we will post your comments for you.)
  

    
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.
  

    
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.
  

    
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.
  

    
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?
  

    
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.
  

    

You are saying that you think homosexuality is a disease? and that there is
a homosexual agenda?
  

    
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.
  

    
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.
  

    

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.
  

    
For the record, I could tell you were being ironic.

The rest, I'm still thinking about. 
  

    
>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).
  

    
>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.
  

    
Nature (and our understanding of nature) varies with time and place.
  

    
AMen, sister. NOw, if they could only teach that in psychiatrist
school.
  

    
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.
  

    
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. 
  

    
>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.
  

    
>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.
  

    
That period produced a great deal of wonderful writing and speculation
on what it means to be human.