Madeleine Davies

Manufacturing depression

In Health on April 2, 2011 at 3:29 pm

At the age of 30 Gary Greenberg found himself on the floor, watching dust specks float through sunbeams for hours, “racked by some unspecific pain”. Newly divorced, it did not occur to him at the time – 1987 – that he was suffering from what was later diagnosed as depression.

Manufacturing Depression is his account of his search through history for the origins of both his diagnosis and the cures recommended by doctors. But this is not a self-help book or even, primarily, an autobiography. Greenberg believes that the medical industry has acquired too much power over our lives – “the power to name our pain and then sell us the cure one pill at a time.” He writes to expose, seeking to illuminate a climate of opinion – that depression is a chronic disease that can be treated through medicine – that has become “as invisible to us as the sea is to fish”. What he uncovers is difficult to ignore.

Over the centuries people diagnosed with depression have been subjected to all manner of inhumane experimentation, from overdoses of insulin to lobotomies. The story of depression as told by Greenberg is populated by profit-seeking pharmaceutical companies and a medical profession arrogantly convinced of its monopoly on wisdom.

At the heart of the book is a focus on the circular logic of the depression diagnosis: a doctor must assume a person is depressed in order for the person’s feelings to be considered symptoms, but the symptoms are the only evidence of depression. In the same vein, Greenberg points out the error in assuming that because antidepressants work you have worked out how depression works.

That is, if they work at all. According to his search of clinical trial records, 74 trials have been submitted to the Food and Drug Administration (the drug regulator in the United States) for the twelve leading antidepressants, of which 38 have shown an advantage of the drug over a placebo. Another analysis of clinical trials showed that 80% of the effect of the antidepressants is due to placebo effects.  

Applying the same scrutiny to the annals of medical history, Greenberg finds examples of doctors tacitly acknowledging the limitations of their science, such as the decision of a committee of psychiatrists to create a “bereavement exclusion”, whereby a recently bereaved patient displaying symptoms of depression is not deemed to be depressed. But only for a duration of two months. Why should other possible triggers of depression not be excluded he asks? Betrayal of a lover, several financial loss, political upheaval, or serious illness, or “simply existential despair kindled by an awareness of mortality.”

Greenberg is at his best when he casts his net wide and asks big philosophical questions. When he points out, for example, that doctors and drug companies, “don’t know any better than you and I what life is for or how we are supposed to feel about it.”

His argument is that the depression doctors’ approach is reductive, focused on biology rather than biography. Participating in a clinical trial for depression treatment he feels like the middleman that a doctor must go through in order to tackle the depression in his biochemistry, his inner life nothing but “the amino-acid-rich neuro-chemical soup that roils in dumb silence inside your head.”

Of course, Greenberg has his own stake in the outcome of his research, both as someone who has been diagnosed with depression and as a psychotherapist who charges by the hour. His is a profession, he says, “built on the idea that changing the story we tell about our suffering can relieve it.” His contention is that “an excess of truth is bound to make a person suffer” while psychoanalysis is a therapy which gives patients “the strength and courage to face the truth about himself.”

Interestingly, neither psychotherapy nor counselling – two therapies focused on biography – are prioritised as treatments for depression in England. Guidelines from the National Institute of Health and Clinical Excellence (NICE) state that they should be offered to patients who decline antidepressants or other forms of therapy, such as cognitive behavioural therapy, and that the “uncertainty of the effectiveness” of both treatments should be discussed with potential recipients. Waiting times for talking therapies remain lengthy while anti-depressants are the tenth most prescribed drug in GP surgeries.

The most challenging aspect of Manufacturing Depression is its prognosis for those affected by the feelings that Greenberg describes. He consistently points out that there are very good reasons why human beings living at this time in history may feel sad, angry, pessimistic or disillusioned. He make us question the medicalisation of these feelings, but that still leaves the feelings. What do we do with them? 

“To be told that depression is a disease is to be reassured that when we are discouraged, we are not really sick at heart. We are just pain sick. Which means we can get better,” he writes. “We don’t have to be stunned at the cruelty – or, for that matter, thrilled by the tragedy – of life on earth or worried that pursuing happiness by the way we do is also pursuing destruction. We can be healed. We can get our minds to work the way they are supposed to. And then we can get back to business.”

It’s a wake-up call but it is more than a cold shower. Greenberg’s call to let go of the medical model has frightening implications for those clinging to hope of long-lasting relief. If depression is not a medical condition to be cured then how do those diagnosed with it cope?  

Greenberg offers several ways of approaching this question. One of his concerns is that pessimism is being denied its power to motivate action; that if fewer people accepted their diagnosis and channelled their feelings into action, seeking to change what it is that is making them sad, angry or disillusioned, the world might be a better place. “By turning our discontents over to the medical industry we are surrendering the ability to look around us and say “this is outrageous. Something must be done,” he warns.

Secondly, Greenberg seems to be offering his fellow sufferers membership of a sort of club, initiation into a tribe cursed by sorrow but blessed by a perceptiveness unavailable to others. He cites for example, an experiment exploring people’s ability to identify the connection between their activity and a set of results (in this case the link between pushing a button and a light coming on or off). It was the people diagnosed as depressed who “excelled” at estimating the extent to which they were responsible for the results. The researchers concluded that “depressed people are ‘sadder but wiser’” while “non-depressed people succumb to cognitive illusions that enable them to see both themselves and their environment in a rosy glow”. 

You may stuck on the floor of your room, Greenberg suggests, but at least your perspective from there is accurate.

Greenberg concludes his account by advising his readers that, “when life drives you to your knees, which it is bound to do, which maybe it is meant to do”, they must not “settle for being sick in the brain.”

“Remembers that’s just a story,” he writes. “You can tell your own story about your discontents, and my guess is that it will be better than the one that the depression doctors have manufactured.”

His own story makes for demanding reading and I suspect will engender very different reactions in different readers, depending on their own susceptibility to the feelings he describes so beautifully. If the existence of depression as a chronic condition that can be medicated is a fiction, it is an appealing one. His alternative narrative requires an inquiring mind, the courage to challenge the orthodoxy of current thinking and the strength to strike out alone to create your own story. You wonder whether everyone currently pinned to the floor of their room by “some unspecific pain” will have the strength to follow his lead.

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