'Manufacturing Depression': Are Doctors Overprescribing Antidepressants to the Tune of $10 Billion a Year for Drug Companies?
Is depression manufactured? Two decades after the introduction of antidepressants, it’s become commonplace to assume that our sadness can be explained in terms of a disease called depression. The National Institute of Mental Health estimates more than 14 million Americans suffer from major depression every year and more than three million suffer from minor depression. Some 30 million Americans take antidepressants at a cost of over $10 billion a year.
My next guest argues while depression can be debilitating, it’s also been largely manufactured by doctors and drug companies as a medical condition with a biological cause that can be treated with prescription medication. Psychotherapist and writer Gary Greenberg participated in a clinical trial for antidepressant medication and found that more often than not the drugs failed to outperform placebos. His latest book is a scientific, medical, historical and cultural exploration of the antidepressant revolution here in the United States. It’s called Manufacturing Depression: The Secret History of a Modern Disease.
AMY GOODMAN: Tell us about the trial you went through.
Gary Greenberg: I enrolled in a trial at Mass General Hospital, intending, actually, to enroll in a trial for minor depression. But the tests that I took showed that I had major depression. And the trial was a trial of fish oil versus placebo, which meant that I was taking omega-3 fatty acids or a placebo, I didn’t know which.
AG: And what happened?
GG: What happened was that I returned to Mass General every other week for two months, and I was given the same battery of tests over and over again. And as the time went on, I appeared to be getting better on the tests that were being used to measure my depression. At the end of the trial, I asked if I could be told if I was on the placebo or the drug, and they told me no, but since it was the next to the last day of the trial, I still had some pills left. I sent them off to a lab, and it turned out I was on the placebo.
AG: What did you think?
GG: I thought that was really interesting. And I thought that it was more interesting that the doctors really assumed that I was on the drug. The way I know that is because after the trial was over, they offered me what’s called an open label trial, where I would get what I knew to be, in this case, fish oil, which is standard for clinical trials. If they think the subject was on the drug, they offer them the drug after the trial is over, even if they have no way of knowing.
AG: So, talk about your overall thesis in this book, Manufacturing Depression, two decades after exactly what?
GG: It’s two decades after Prozac was introduced, which saw an explosion of two things: one of them is sales of antidepressants in the Prozac generation, and the other is the rates of diagnosis of depression. And in the book, what I’m trying to do is to show how these two things go together and how, in many respects, the drugs came first, and how this was something that has grown historically. For at least 150 years we’ve been heading in this direction.
And basically what the book is about is why it even makes sense at this point for people who are unhappy to even think about the possibility that they have a mental illness. And in the book, I’m mostly interested to say that our concern probably shouldn’t be so much with the drugs themselves as the meaning that we have for why we’re taking the drugs, which I believe shapes our response to the drugs, and that what really we should be paying attention to is how easily people are diagnosed with mental illnesses, as opposed to given other explanations or opportunities for themselves to explain why they might be suffering.
AG: Go on with that.
GG: Well, people get diagnosed largely by their family doctors, and sometimes only implicitly. In other words, you go to your doctor and you have some complaints about sleeplessness or nervousness or unhappiness or demoralization, and the doctor will give you a prescription often for Prozac, after asking some intelligent questions, or some other antidepressant besides Prozac. And he may not say, you know, “You are depressed.” He may just give you the drug. But you’ve seen enough on TV in ads and heard enough to know what the deal is. You don’t need the weatherman to know which way that wind blows. Or he does tell you that you’re depressed and explains to you that it’s a biochemical imbalance. And so, when you take the drug, if you feel better, then indeed you—that confirms that you were sick in the first place. And I’m not sure that it’s necessary to do that in order to take—get whatever benefits there are of these drugs.
AG: Today we’re seeing a major recession—jobs, unemployment. People can get very depressed. What happens? What do you think should happen? How should this be dealt with?
GG: Well, I don’t know that we’re that far off. I mean, there’s no reason people shouldn’t confide in their doctors or their therapists about how unhappy they are, but to be told that you have a biochemical illness is automatically to distract your attention from those kinds of conditions that you just mentioned. In fact, I think that the American Psychiatric Association is going to move even farther away from any kind of consideration of causes that come from the outside. In their next edition of the DSM, they’re eliminating—at least they’re planning—
AG: Explain the DSM.
GG: The DSM is the Diagnostic and Statistical Manual of diagnosis. It lists the diagnoses of official mental illnesses. Right now, if you’re simply suffering from bereavement—somebody dies—you can’t be diagnosed as depressed, unless your unhappiness lasts for more than two months. In the next edition, they may remove even that as an exception to the diagnosis of depression. And so—
AG: And remove what?
GG: The bereavement exception. So, in other words, if you’re bereaved now, you meet all the criteria for depression, but you can’t be diagnosed, because you were bereaved. Research shows that bereavement isn’t any different from other psychosocial stressors, like unemployment, like divorce. So, rather than grapple with that, the American Psychiatric Association seems to be moving in the direction of simply eliminating the exception. So what I’m getting at is that it’s very difficult in the context of a doctor’s visit, because doctors aren’t trained to do this, to talk with people about how their world might be at least part of why they’re demoralized.
AG: And then, take that a step further.
GG: If people then are encouraged to think of external circumstances, then they may be more empowered to take action. They may be more ready to consider the possibility that what they need to do is engage somewhere in the politics of their world. They may be ready to tell their own story about what depression is about, rather than the biomedical story.
The definition of depression has been changing since it was first introduced as a medical concept, which was about a little more than a hundred years ago. But the most radical changes have occurred after 1973, when the American Psychiatric Association had suffered a series of embarrassments, including, particularly, the discovery suddenly that homosexuality really wasn’t a disease. And they were forced to grapple with the fact that they—not only were there questions about whether their diseases really were diseases, but doctors couldn’t agree on the same patient what disease that patient had. And so they went to a system of diagnosis that’s purely a checklist. If you meet the criteria, then, regardless of your circumstances, you have the disease. And that’s how depression works.
And so, over time what’s happened is that the diagnosis has gotten increasingly detached from any sense of where it might come from, either within the psyche, as Freud would talk about, or from external circumstances, as more politically minded psychologists would talk about. And that, of course, goes hand in hand with the idea that it’s a biochemical illness, because if it’s not being caused by your external circumstances and it’s not being caused by some, you know, childhood trauma, then what’s left? In must be being caused by something inside your brain. And it’s become a brain disease.
AG: What role do pharmaceutical companies play in this?
GG: Pharmaceutical companies have been very eager to jump on that bandwagon. In fact, in many respects, they’ve originated that idea, or at least spread it through the culture like a virus. Since about 1960, the drug industry has been actively engaged in trying to help first doctors and now patients —believe that demoralization is really a mental illness.
They’ve done it through very clever marketing. For instance, they distributed 50,000 copies of a book called Recognizing the Depressed Patient to prominent doctors back in the early 1960s, in which the biochemical argument was made for the first time, in the almost entire absence of any findings that supported it. It was like a myth that was being given to the doctors to pass along to their patients, like viral marketing. Now with TV direct to consumer ads, every time there’s an advertisement for Prozac, it’s also an advertisement for the idea that depression is a disease. And I think that’s obviously very beneficial to the drug companies.
AG: At the end of your book, your final chapter is 'The Magnificence of Normal.' What does that mean?
GG: In my book I try to grapple with the possibility that there might be something redemptive about large groups of people thinking of themselves as sick, as is what’s happening right now, if 20 percent of the population is depressed. And I visited with some people who take that line. Unfortunately, what they do with their collective action is they decide to treat themselves as chronically ill people and to demand better drugs and to demand nothing but the restoration of normalcy in what they consider to be their brain illness.
Now, I don’t mean to criticize people who are really struggling to just get by every day, but for most of us, the idea that the normal is what’s magnificent is a problem, because it gives very little room for challenging or questioning the status quo. So, in the end, we can see that this idea that depression is a biochemical illness, no matter how the intentions or what the intentions were, which were probably good intentions, it doesn’t matter, because that idea is going to favor the status quo no matter what we do, if there’s not built into it some understanding of the way our engagements with the world contribute to the way that we’re unhappy.
AG: What about antidepressants in children?
GG: don’t know much about antidepressants in children, except I know that it’s a science experiment that everybody’s involved in right now that nobody has actually been asked to consent to. We don’t really understand how Prozac works in grownups. We know that if you put it into the system, you get a better mood out of the system after—in many cases. But with children, we have no idea what constantly tweaking their brain metabolism—we don’t know what the effects of that are going to be on a brain that’s still developing. So, while there may be situations in which it can be valuable, I think that we’re moving very, very fast, considering we know very little about how the drugs work in the brain and we know very little about the developing brain. So you put those two things together, that’s a lot of ignorance.
AG: Gary Greenberg, you’re a psychotherapist. You have been through trials yourself. But when you were researching Manufacturing Depression: The Secret History of a Modern Disease, what most surprised you?
GG: The thing that most surprised me was to discover just how easily ferreted out this history is. I mean, if you sit down and you look at the way medicine has developed for the last 150 years, while you probably couldn’t have predicted it from 1850, looking back, it’s a complex history, but it’s a very clear line from the first discovery of magic-bullet drugs in the late 19th century and the idea that our diseases—our suffering can be understood as medical diseases, to the idea that this kind of suffering can be understood as a biomedical disease. The book was really hard to write, don’t get me wrong. I earned my money. But it was really also a surprisingly straight line. It was how easily or quickly things fell into place to show that history.
I think that that’s important for people who might read the book, because when you read it, you see how you’ve really arrived on a wave that’s been building for 150 years. When you get to your doctor’s office and he starts to talk to you about your depression, you’re really at the end of a long line of events, that if you know about them, they really change the way that whole experience goes and the way you understand what your demoralization is about and the way you understand being told that you’re depressed.