|The real money always lay not in convincing sick people they were ill, but well people they were sick|
Throughout the 1990s, the UK Royal College of Psychiatrists and Royal College of General Practitioners, enabled generously by the pharmaceutical industry, campaigned to educate clinicians and the public about depression and its treatment. The Defeat Depression campaign was pithily encapsulated in the slogan: “Depression. Treat it. Defeat it.” Today depression is so overdiagnosed, that a recent study found that over 60% of those diagnosed did not meet the diagnostic criteria for a major depressive episode, rising to over 90% of those over the age of 65. A recent article in the BMJ claims that the DSM-5, by expanding the definition of depressive illness to include reactions to bereavement, will further erode the concept of normal sadness, leading to more people incorrectly diagnosed and treated for depression. If not depressive illness, what are we experiencing? The answer: social suffering.
The changing face of depression
From 1992 to 1996, the Royal Colleges of General Practitioners and Psychiatrists led the Defeat Depression campaign, to raise public awareness of depression as a medical illness, and to educate professionals to diagnose and treat it. A UK survey of public attitudes at the time found that 85% believed counseling to be effective but were against antidepressants, and almost 80% believed antidepressants were addictive. By 2003, traces of metabolites of the antidepressant Prozac would be found in the water supply. By 2012, 50 million antidepressant prescriptions were issued in England alone, with 1 in 6 people in some areas using antidepressants. This is despite the number of people suffering from depressive illness at any one time staying roughly stable at about 6%. How did this sea-change occur? So successful was the public education campaign and other sources of information, that many people have now come to believe that depression is caused by a chemical imbalance in the brain that is corrected by antidepressants. As the sociologist Nikolas Rose notes, we have come to recode our moods in terms of neurotransmitters, and identity in what he calls ‘the neurochemical self’. In addition, primary care doctors who bear the brunt of the endemic minor misery were heavily pushed into screening for depression, and reimbursed on quality measures including documenting depression scores of self-report rating scales like the PHQ-9. The result was an increase in new antidepressant prescriptions throughout the 1990s. This was coupled with the lack of availability of psychological treatments, with waiting lists in some areas as long as two years.
Although the detection of hitherto unnoticed individuals who suffered extreme mental anguish explain some of the rise in depression diagnoses and antidepressant prescriptions, in the early 2000s something strange happened. In the UK at least, the number of new prescriptions for antidepressants weren’t increasing, but the overall number of prescriptions were. That is to say, it wasn’t that more and more people were being prescribed antidepressants, it was that those who were on them continued. Depressive illness, once thought of as a temporary aberration, sometimes chronic and lifelong, was becoming more chronic. It is likely that antidepressants themselves may have played some role in this. There is some suggestion that some individuals on long-term antidepressant use will become depressed as a result of the chemical changes occurring in their brain, the so-called tardive dysphoria syndrome. Part of this is likely psychological too – in the narrative of chemical imbalances, taking antidepressants is just like insulin for diabetes. If you stop taking your antidepressant won’t your chemical imbalance come back? Further, by locating the source of distress inside a broken brain or twisted molecules we have disempowered individuals to take charge of their lives. The reality is, as I discussed previously, the notion that depression or any mental illness is caused by chemical balances is an oversimplification at best and a myth at worst. That is not to say there is no biological basis to depressive states, but this despair cannot be meaningfully reduced to aberrant brain chemistry.
The currency of depression
Today the word depression provides a currency of validation. When we see a doctor feeling deflated, tired, sleepless, joyless, or sad, a diagnosis of depression is like a badge of honor for the wounded warrior, it confers recognition that we have suffered so. There is something reassuring to hear an ‘expert’ tell us they know what is wrong and they know how to help. When you feel like you are drowning, a prescription for a pill, is like a lifeline that keeps you afloat. And even though you know the reasons you feel so terrible, which you are constantly reminded of, it becomes convenient to believe that something as simple as a chemical imbalance is at the root of it all. Even if you realize that the remedy may be in deeper psychological work, having more money, a better relationship, a better economy, better behaved children, a sense of self-worth, or even taking better care of yourself, those things are unavailable or not forthcoming. We make do with what’s on offer. And what’s on offer is antidepressants.
Incidentally, whilst states of despair and misery have existed throughout time and space, depression only has currency in the West in recent times. In China whilst the same syndrome of major depressive disorder is recognizable, it has no cultural cachet. Instead the diagnosis of neurasthenia is made. In Zimbabwe, anxious and depressive ruminations are captured by the term ‘kifungisisi’ (which is included in the DSM-5) which means 'thinking too much'. In Somalia, there is no linguistic concept of depression. The closest thing is ‘Qu’lub’ which translates as ‘the feelings a camel has when its friend dies’. In Latvia, the term “nervi” or damaged nerves captured the endemic suffering following the fall of the Soviet Union. Depression is as much a cultural concept as it is a biological one.
Whither Social Suffering?
In the anthropological literature, there is a concept that describes the misery that individuals experience in contexts where they are powerless, where things have no prospect of improvement, and the feelings are entirely understandable. The concept is that of social suffering. In the medical and psychiatric literature, little attention has been paid to this concept, yet it afflicts the majority in large parts of the world who are indeed the inhabitants of unstable and uncertain sociopolitical landscapes. Although this term is often applied to those in developing countries, it seems apt to describe many patients in the developed world as afflicted by social suffering too.
It is not surprising that psychiatrists have neglected social suffering. There isn’t a pill for it. We may empathically bear witness to the suffering of others, but that only goes so far. It is not surprising either that these individuals are incorrectly diagnosed as depressed, and that this misdiagnosis increases in those over 65 and live in a world that has no use and sees no value in those who no longer work. It’s much easier for everyone to transform this endemic misery into depressive illness, because if it’s depressive illness then it may benefit from medical or psychological remedy. Those in primary care feel an enormous pressure to ‘do something’ and prescribing a pill is easy enough. It temporarily satisfies both patient and clinician that something has been done. The reality is by seeing the individual as a problem, we conveniently ignore the wider social, economic, and political forces that oppress, and yes, depress. These are problems that need resolution through public policy, and not through pills or psychotherapy.
Blame the DSM-5
The Diagnostic and Statistical Manual of Mental Disorders is certainly beleaguered with problems, but the emphasis on the description of major depression as being responsible for overdiagnosis is just not true. The DSM is irrelevant to clinical practice, especially in primary care, because nobody uses it. People who felt depressed following bereavement were diagnosed and treated for depression long before the DSM-5 and will continue to do so. Sadly, the DSM-5 does not include a term that would aptly describe much of what we see, without labeling it a mental illness. That term is demoralization. Many of the patients I see are demoralized by their situation – in the face of a relationship they cannot escape from, a diagnosis of terminal illness, dashed career hopes. This is not an illness, but it deserves recognition.
As discussed above, most people diagnosed with depression don’t meet the criteria for DSM major depressive disorder. This isn’t because doctors can’t tell the difference between normal sadness and depressive despair. It’s because, when you have 10 minutes to see someone, and they tell you they’re depressed, and they want your help, and you feel pressure to ‘do something’ you are going to tell them they’re depressed and you’re going to give them what they want. And in the UK at least, there was a whole campaign that told you that’s exactly what you were supposed to do.
The medicalization of endemic misery and its medical treatment is our own doing. It takes time and resources away from the management of those with more serious physical and mental maladies, and is profitable for neither clinicians nor patients. The one actor that has profited, and handsomely at that, is the pharmaceutical company. The real money always lay not in convincing sick people they were ill, but well people they were sick. And so we continue to mask social suffering in the guise of depression.