The greatest challenge is stating the problem in a way that will allow a solution.

Monday, October 25, 2010

Is depression a disease?

LEAH MCLAREN From Saturday's Globe and MailPublished Friday, Jun. 18, 2010 2:19PM EDTLast updated Friday, Jun. 18, 2010 3:14PM EDT
It's all in your head” isn't something a chronically depressed person likes to hear. In the age of Prozac, when adjusting your serotonin level is as normal as checking the oil in your car, it seems unhelpful to suggest that someone might think their way into – or out of – a disease of the mind.

And yet depression is all in our heads. Where else would it be? The real question, still hotly debated in the scientific community, is whether its cause is chemical and ultimately curable (good news for Big Pharma) or something far more complex (good news for poets and pot-smoking students of existential philosophy).
There is no doubt that depression exists. Inexplicable sadness – or “melancholia,” as it was historically known – has been with us since Hippocrates conceived his famous oath. But a groundbreaking new study has found that not only is depression affected by the way we think about it, so too is its cure.
Last week Irving Kirsch, a professor at the University of Hull in the U.K., presented a study that found Prozac and its ilk are no more effective than placebos in treating depression. In his view, there is no substantial link between serotonin – the brain chemical that antidepressants are supposed to regulate – and chronic depression.
It's a controversial study – one that many members of the psychiatric community reject out of hand – but it also raises a nagging question about depression: How did it come to be recognized as a disease in the first place?
Like Hirsch, psychologist and writer Gary Greenberg is part of a growing number of psychiatric professionals who have begun to publicly question the underpinnings of popular thinking on depression.
His recent book, Manufacturing Depression, debunks the prevailing notion that depression isa disease and anti-depressants the long-awaited cure.
In his view, the game is rigged. As he told me in a phone interview, “the disease was invented to justify the cure.”
Greenberg sums up the history of modern depression like this: In the 1950s, doctors researching drugs for unrelated illnesses discovered that certain substances made people feel high. They didn't know why or how, just that they'd struck oil. These psychoactive drugs were marketed as mood enhancers and by the 1960s minor tranquilizers like Valium and Librium were routinely prescribed to people who these days would likely be classified as clinically depressed. Once the market was established, the race was on to develop the perfect mood-elevating pill. At the same time, pharmaceutical companies began to search for a way to increase the market share. An executive at the U.S. drug company Merck had a brilliant idea – why not broaden the diagnostic criteria for depression in order to sell more people the drugs? They recruited a doctor to write a book entitled Recognizing the Depressed Patient, which was then distributed to some 50,000 doctors around the country. The strategy was a resounding success and stands as an early triumph of viral marketing. And the script in that book is the same criteria doctors today use to determine whether a patient qualifies for anti-depressants and is, by extension, “chemically imbalanced.”
In his own book, Greenberg participates in a clinical trial himself, signing up first as a minor depressive (for which he believes himself qualified) and later getting upgraded to major depressive simply by answering the questions honestly.
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 oilspill.
“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.”
As a practising psychologist, Greenberg knows the dirty truth about anti-depressants – that the theory on which their effectiveness is based is just that: a theory. The notion of chemical imbalance has never been proven and remains highly controversial. It is, according to Greenberg, “a myth, which, like all great myths, gathers together the central beliefs and ethos of a society.” In this case, it's the belief in magic-bullet medicine combined with the prevalence of materialism (i.e. the belief that psychological truths can be located in the physical brain).
And of course, it's all very convenient for Big Pharma, which makes billions curing people of a disease that may not exist. Last year in Canada alone, almost 35-million prescriptions were filled for anti-depressants, at a total cost of over $1.5-billion.
This is not to say that Greenberg agrees with Kirsch. “His interpretation of the effects of consciousness-altering drugs doesn't really add up. Frankly I don't think he's taken many of them.”
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 mentalillness 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.”
“When we call a form of suffering an illness, we are saying it deserves recognition and resources. In this case, unfortunately, the kind of resources it commands are money for drugs. What if we could use those resources for other things – say, to figure out ways to make our society less isolating, less individualistic?”
There's no question where Greenberg lands on the scale between Big Pharma and the poets.
As for me, I'd rather get on with life. And by that I mean staring at the wall and contemplating whether it's actually worth living.