Should we think of our unhappiness as a disease? And take antidepressants to treat it? • Two new books on depression — among the most thoughtful ever written for a lay audience — offer a resounding "No, and No."
Gary Greenberg's Manufacturing Depression: The Secret History of a Modern Disease is a blistering, rambling, entertaining attack on the biomedical disease model of depression. It's the story of how advertising, pharmaceutical companies and psychiatrists packaged unhappiness as a medical disease to be treated with antidepressants. With nearly 30 million Americans taking antidepressants at a $10 billion yearly cost, Greenberg is up against Goliath, armed with a slingshot, careful research and clever one-liners.
Manufacturing Depression is a subversive mix of personal memoir, case histories (Greenberg is a practicing therapist), intellectual and business history, and guerrilla journalism (he shows up for a clinical trial as a patient).
His narrative is digression at its best. Among its detours are germ theory, the transformation of German synthetic dye companies into pharmaceutical industry titans and the turf wars among psychiatrists, psychologists and neurologists over what mental illness is and who gets to diagnose and treat it.
Along the way, Greenberg marshals several different cases against the biomedical model.
There's the historical case. The disease model was not inevitable, but resulted from the confluence of big pharma and late 20th century cultural needs. He delights in the irony that earlier discredited treatments such as insulin coma therapy and lobotomy raised expectations for heroic psychiatric cures, setting the stage for magic pharmaceutical bullets.
There's the scientific case. Greenberg articulates the differences between depression and other bona fide diseases like cancer, diabetes or flu. Unlike those conditions, there remains no reliable biological marker of depression, nor a validated theory of the biology that produces its symptoms. He covers the sequence of failed attempts to establish a biological basis of depression, from black bile to serotonin.
There's the clinical case. Greenberg notes that the medications don't work well enough to be considered magic bullets (more on that in a moment).
Finally, and dearest to Greenberg, there's the humanist case. He objects that psychiatric diagnosis is a one-size-fits-all checklist — and that the resulting diagnoses stunt how psychological suffering is experienced and expressed. He objects to how the biomedical model treats consciousness as "merely the steam rising off the amino-acid-rich neurochemical soup that roils in dumb silence in your head."
As a psychotherapist, he questions how the disease model replaces the potentially redemptive power of self-exploration. He worries that if we call our misery a disease, we won't try to fashion our past and present troubles into a coherent narrative. He worries that calling pessimism the symptom of an illness will lead us to turn over our discontents to the medical industry. If our feelings of pessimism are "an ally at a time of crisis" perhaps we shouldn't surrender our autonomy.
This isn't your father's antipsychiatry, railing against the "chemical straitjacket" and drugs that rot your brain. Greenberg is a thoughtful and charming skeptic who has nothing against using psychiatric drugs to change feeling or perception, just as long as you don't call it treating a disease.
If Greenberg is dizzying and dazzling in his critique, Irving Kirsch is measured and laserlike in focus. Kirsch is an expert in statistics and in clinical trial methodology. His book, The Emperor's New Drugs: Exploding the Antidepressant Myth, dismantles the case for antidepressants as a pharmacologically effective treatment.
The book's cornerstone is a careful analysis of a vast database of drug company data. Using the Freedom of Information Act, Kirsch managed to get the data that drug companies had sent to the FDA in the process of getting their medications approved.
His argument boils down to three points. First, nearly all the benefit of antidepressants can be attributed to the placebo effect. When the data are all arrayed, Kirsch finds common antidepressants barely beat dummy pills. More than half of the clinical trials sponsored by the pharmaceutical companies showed no significant difference at all between drug and placebo. As important, the benefit of medication over placebo is not clinically meaningful. The overall advantage is about 1.8 points on the 51-point scale used to gauge severity of depression (through questions about mood, sleep habits and the like). This isn't much.
Second, when antidepressants do beat placebos in clinical trials, it is actually another version of the placebo effect. Though clinical trials are supposed to be double-blind (neither patient nor evaluator knows who's getting drug and who's getting placebo), patients in clinical trials can often figure out when they are receiving the investigational drug because they experience pronounced side effects. Knowledge that you may be receiving a potential cure enhances the placebo effect.
Third, pharmaceutical companies and the FDA are being intellectually dishonest. The pharmaceutical companies are given wide latitude concerning which clinical trials they want to publish and which data they want to include. This is important because many clinical trials yield negative findings (no differences between drug and dummy pills). If a drug company does 10 trials and only two support the efficacy of the drug, they can elect to publish only those two. The FDA does not compel disclosure of the unsuccessful trials. This almost guarantees doctors (and the public) will have inflated perceptions about the drugs' efficacy.
Kirsch writes for grownups. His clear, nontechnical prose does not shy away from complex, controversial findings (such as different explanations for the power of placebos). Kirsch loves data. When he is speculating beyond the data, he says so. When he concludes psychotherapies provide depression treatments that are just as effective in the short run and more cost effective in the long run than antidepressants, many will be convinced.
Ironically, Kirsch's matter-of-fact argument for the power of the placebo effect may ultimately undermine the clinical effect of antidepressants. If we lose faith that they work, they won't work.
The sober Kirsch and the lyrical Greenberg pack a powerful one-two punch against psychiatric and pharmaceutical orthodoxy. They aren't touring together. Maybe they should.
Jonathan Rottenberg is an associate professor in the psychology department at the University of South Florida, where he directs the Mood and Emotion Laboratory.