Sunday, April 29, 2007
Down in the dumps in the penny press!
An article in the latest issue of Harper's couldn't help but attract our attention here at Stevereads. It's by Gary Greenberg, and it's called 'Manufacturing Depression.'
Greenberg is a practicing psychotherapist, and for the purposes of preparing his article, he gets himself qualified for Massachusetts General Hospital's Depression Clinical and Research Program. The qualification is based on his showing at least two out of the nine symptoms for Minor Depression listed in the latest DSM of the American Psychiatric Association.
Just so we're all completely clear on what we're talking about here, let's list the symptoms that qualify you for this disease:
2. Diminished Pleasure
3. Weight loss or gain
4. Trouble sleeping
7. Diminished concentration
8. Recurrent thoughts of death
A minimum of two of these symptoms will get you well on your way to being diagnosed with Minor Depression, a 'condition' which the DSM currently considers 'provisional' - meaning it lacks "the five-digit code that allows doctors to bill insurance companies for treatment." Greenberg's fairly obvious implication is that this approval is only a matter of time. In fact, the implication of Greenberg's entire article is that the gigantic amount of money involved in the medical and pharmacuetical world not only influences but dictates what constitutes medicable mental illness.
Here's Greenberg on the whole subject:
"In this nondescript office building beside the towers and pavilions of Massachusetts General Hospital in Boston, these dedicated people do research that determines whether drugs work - which is to say, whether drugs will come to market as government-sanctioned cures. In the process, they turn complaint into illness, and illness into diagnosis, the secret knowledge of what ails us, what we must do to cure it, and who we will be when we get better. This is the heart of the magic factory, the place where medicine is infused with the miracles of science, and I've come to see how it's done."
Once he's described his symptoms to the doctors involved in the study, they classify him not with Minor Depression but with minor Major Depression, which qualifies him for all kinds of drugs - or placebos, depending on which he's given (which is something even the doctors involved don't seem to inside info on).
And that's the crux of the whole article: placebos. Here's Greenberg again:
"In fact, in more than half the clinical trials used to approve the six leading antidepressants, the drugs failed to outperform the placebos, and when it came time to decide on Celexa, an FDA bureaucrat wondered on paper whether the results were too weak to be clinically significant, only to be reminded that all the other antidepressants had been approved on equally weak evidence."
Greenberg adds a footnote to this that deserves quotation too:
"The advantage of antidepressants over placebos in those trials was an average of two points on the HAM-D, a result that could have been achieved if the patient ate and slept better. The average improvement in antidepressant clinical trials is just over ten points, which means, according to Irving Kirsch, a University of Connecticut psychologist, that nearly 80 percent of the drug effect is actually a placebo effect."
That's pause-inducing stuff. Assuming Greenberg doesn't have any hidden agenda, assuming that unnamed FDA bureaucrat in his private communique doesn't have any hidden agenda, that's pause-inducing stuff.
We here at Stevereads have a long personal history with Clinical Depression ('major' or 'minor' it doesn't matter - if Greenberg's article says anything, it says that) - not personally, but through many, many friends. They span the spectrum of all humanity, these friends and friends of friends: from teenaged girls whose hormonal hurricanes ought to disqualify them from any drugs whatsoever, right up to the father of a former friend, whose basso profundo backporch wisdom was, his son averred, from time to time utterly halted by clouds of black depression.
We've seen co-workers simply stop showing up for work, thereby sacrificing their position. We've seen grown adults squander entire days, entire days, spooning themselves ice cream and watching old reruns on TV in the dark. We've seen fully functioning adults with good jobs and good families break down in uncontrollable tears with no visible provocation.
In all this time, that former friend's sagacious father has been our single and only cautionary tale, and even in that case, there's some cause for concern. And with everybody else we've ever known who claimed to be suffering from 'clinical depression,' the problem runs unsolvably deeper.
The problem is those placebo results. If placebos are out-performing drugs on a regular basis, there's one conclusion that becomes utterly inescapable: something's going on that ISN'T MEDICAL. If all those patients taking placebos were being treated for neck tumors, the placebos would have their normally-negligible effect on the final data. Again, if the placebos are regularly out-performing the medicine, the patients involved AREN'T SUFFERING FROM A MEDICAL CONDITION.
In 2007, saying something like that is equivalent to insisting that the sun revolves around the Earth, but nevertheless. Nevertheless, sugar pills don't reduce tumor growth.
The very hint of this suggestion causes hackles to rise ferociously everywhere, we've found. People are fierce in what they've seen in friends in loved ones - or what they've felt themselves. Time and time again, we've heard of the 'miraculous' effect antidepressants seem to have on those who need them: panic attacks finally controlled, chaotic thoughts finally subdued, wandering listlessness finally banished.
Normalcy, but not exactly. The crabgrass is eliminated from the lawn, yes, but so too are the grasses and flowers. The desperate lows are eliminated (or at least ameliorated) by drugs, but so too are the personal reservoirs of nerve and clutched-at optimism that allow the vast numbers of non-medicated to deal with life's setbacks and disappointments and unfairnesses.
There's a horrible-feeling moment that comes to everybody eventually. Most people slam into it directly after they graduate from college and realize they are now expected to deal with every single one of life's cold demands entirely on their own, outside the umbrella of their parents. But of course the moment can occur at any time in young adulthood; the point is, there comes a moment when every person in the West (needless to say, 'clinical depression' is, in terminology and manifestation, almost entirely absent from the East or Middle East) realizes on some level that they CAN'T GO BACK. They can never return to the time in their lives before they stood bare before bill-collectors, landlords, angry employers. Anybody who's ever stared at a bill they can't possibly pay has yearned to return to that carefree time (even, it should be pointed out, if they've never in fact experienced it before).
And it's more than that. Look at that list of so-called symptoms again: who HASN'T felt at least two of those conditions every day of their lives?
Or three? Even persistently? We've been told, by those personally involved, that 'clinical depression' feels different from this, feels different from simply feeling these things: that sufferers feel these feelings have utterly taken control of their lives - that such feelings aren't just temporary weather but seem permanent and unopposable. We have nothing but sympathy for the afflicted and their friends and loved ones, but we humbly suggest that the bathos of their plight has been buttressed over the past thirty years by the medical, psychiatric, and especially pharmacuetical concerns operative in this country and abroad - concerns that have learned, to the cynical health of their bottom lines, that offering people pricey medical RELIEF from the fact that life doesn't always leave its denizens feeling absolutely, resolutely and at all times happy and content is an extremely lucrative endeavor. But we reserve the right to at least CONSIDER the possibility that people so inclined will grasp at the so-called history, the so-called medical credibility of having a name and documentation and the appearance of clinical viability to make what they feel less ... debatable? blameful? shameful? ... to others and to themselves. We reserve the right at least to WONDER if those afflicted might, just might, feel slightly better saying 'I have clinical depression and don't feel like getting out of bed' than simply 'I don't feel like getting out of bed.'
It's a sad subject either way, but we can't help but wonder what doctors a century from now will make of so-called clinical depression. We can't help but wonder what you, our loyal readers, have to say on the subject. But we'll give the last word to Greenberg, since he opened this particular can of worms:
"I am already deflated when I arrive for my last interview. Of course, there's no place in the HAM-D to express this, to talk about the immeasurable loss that I think we all suffer as science turns to scientism, as bright and ambitious people devote their lives to erasing selfhood in order to cure it of its discontents."