Leah McLaren writes this week that depression might not in fact be a disease: it might be a diagnosis manufactured to allow drug companies to sell more medications to more people. Her arguments are pretty standard among those who question influence of Big Pharma on diagnostic criteria.
In [the view of Gary Greenberg, author of Manufacturing Depression], the game is rigged. As he told me in a phone interview, “the disease was invented to justify the cure.”
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As a clinician he takes issue with the methodology used to determine depression. He points out that answering “yes” to questions like “Have you been feeling depressed lately?” and “Do you ever wonder if life is worth living?” may be evidence that you are a Prozac candidate or simply a natural response to watching the latest news on the BP oil spill.
“With clinical depression, the symptoms justify the disease,” he says. “There’s an infinite regress and no bottom. Don’t forget they used to be able to scientifically ‘diagnose’ homosexuality the same way.”
To some extent, these are important points. Uncontestably, the desire for drug-company profit drives a lot of diagnosis; uncontestably, we live in a culture that prefers quick solutions to complex problems; and uncontestably, there’s a lot of potential danger in defining traits of behaviour or character as medical problems. (I’d recommend Frontline’s documentary, The Medicated Child, for an interesting critical perspective on some of these issues. Or you could read Foucault.)
But there are still major problems with the argument. Let’s take this statement to start:
While Greenberg believes depression is over-diagnosed and anti-depressants are over-prescribed, he sees nothing wrong with experimenting with pharmaceuticals in order to alleviate sadness or mental suffering, which are of course as old as human consciousness itself. He just wishes we would understand that that’s what we’re doing, rather than convincing ourselves we’re suffering from a mental illness and in need of a cure. Such behaviour brings to mind my temperance worker grandmother who used to allow herself a thimble of whisky every night on the grounds that her doctor had prescribed it as “medicine.”
If by “wishes we would understand what we’re doing”, Greenberg means, “wishes we would understand the cultural and economic forces that drive medical practices”, then I’m on board. But if, as McLaren suggests, he means that we should understand that we’re simply dabbling with drugs in a nearly-recreational, physician-endorsed way when we medicate depression or anxiety, then I can’t agree.
There’s plenty of stigma about mental illness and psychiatric medication: talking about medication as something people take because it’s the ‘easy solution’ to problems that everybody has diminishes the courage it takes to seek help when one really needs it. This is the kind of thinking that makes people suffer without medication that they legitimately need, and the kind of thinking that makes people feel like mental health problems should be secret and shameful. They’re not. And if you’ve seen what happens to people who don’t get help they need because of this shame — well, you know why we need to get past this particular stigma.
Second, I am always irritated by discussions of diagnostic criteria that ignore the full list of criteria. In the excerpt above, McLaren focuses on symptoms that, indeed, everybody has from time to time. But not everybody experiences “clinically significant distress or impairment in social, occupational, or other important areas of functioning”. “Clinically significant distress” might sound like a nebulous term — and it probably is an unsatisfactorily flexible term — but it’s a meaningful part of the diagnostic criteria for a lot of mental illnesses. In the hands of a responsible practician, it means that you don’t get diagnosed as having clinical depression when you’re bummed out about current events. And, frankly, the DSM-IV doesn’t require that a patient answer yes to the questions outlined in McLaren’s column: it lists symptoms of pervasive, most-of-the-day, most-days, can’t-eat-or-sleep-properly sadness.
People who have been in the throes of that kind of sadness know how different it is from regular variations in mood. Speaking from experience — the kind of experience that may cause you to dismiss everything I’ve said here — I know that there is a huge qualitative and quantitative difference between the way I feel when I’m anxious in a way that’s part of regular life, and the way that I feel when I’m anxious in a way that means that I need help. The former is unpleasant, but never unbearable; it’s usually focused on a quantifiable concern; and it’s something that I can forget with a bit of distraction. The latter sits very differently in the body: it’s always there, no matter what I do; it’s loud and cold and painful; it wipes out my appetite; it makes me shrink, queasily, from music I love; in public, it means that I use every ounce of my energy in the conscious performance of normalcy. In other words, the former is characterized by the brief appearance of symptoms that might irresponsibly be read as indicating some kind of anxiety disorder, while the latter is characterized by more symptoms, felt more intensely, and crosses into “clinically significant distress”.
It’s a position of enormous privilege to believe that these two things are interchangeable, and it’s irresponsible to speak as if they are. I’m all for cultural criticism of the medical and pharmaceutical establishments, but not when they’re simplistic, badly informed, and unsympathetic to individual experience.
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