Psy­chi­a­try gets un­der the skin

The Weekend Australian - Review - - Books -

LIFE is ar­du­ous, no doubt. And for some all the ef­fort steers only a course to the dol­drums. But do we suf­fer more now than in pre­vi­ous times? Are we more de­pressed or just more di­ag­nosed? Many crit­i­cal thinkers, within the med­i­cal in­dus­try and with­out, are in­cred­u­lous of the no­tion that, in fact, we do suf­fer more. For cen­turies peo­ple have be­lieved them­selves to be liv­ing in stress­ful times — in­deed, heav­ing away on Ham­let’s ‘‘ sea of trou­bles’’.

But what surely is cred­i­ble is the in­flu­ence of cul­ture, that change­able lens through which we view our suf­fer­ing. In 1950s Eng­land, few peo­ple re­ceived the di­ag­no­sis of de­pres­sion — about three in ev­ery 1000. Now, in Aus­tralia, some es­ti­mates of the preva­lence of de­pres­sion run to 10 per cent — about 103 in ev­ery 1000. So who crafted to­day’s lens?

In 1980, the Amer­i­can Psy­chi­atric As­so­ci­a­tion rad­i­cally re­vised its Di­ag­nos­tic and Sta­tis­ti­cal Man­ual of Men­tal Dis­or­ders (DSMIII), which finds wide­spread use in the US, Aus­tralia and across the world by physi­cians, re­searchers, courts and schools. In do­ing so, the APA ren­dered di­ag­nos­tic cri­te­ria for de­pres­sion so vague as to po­ten­tially en­com­pass us all.

At about the same time, phar­ma­ceu­ti­cal in­dus­try ex­ec­u­tives, wide-eyed at hav­ing sensed an op­por­tu­nity, be­gan pro­pound­ing the no­tion that, much like the com­mon cold, ‘‘ men­tal ill­ness’’ was epi­demic and cur­able.

That com­mer­cial op­por­tunism — the drug com­pa­nies’ re­lent­less mar­ket­ing to physi­cians and lay peo­ple — along with slack­ened di­ag­nos­tic cri­te­ria is cen­tral to Ed­ward Shorter’s ar­gu­ment in How Ev­ery­one Be­came De­pressed.

But let’s lighten the mood a lit­tle. Let’s talk about Sig­mund Freud and his lit­er­ary ca­reer.

In about 1900, Freud de­clared neu­roses, in­clud­ing ‘‘ neu­rotic de­pres­sion’’, were caused by sex­ual episodes in child­hood, too much mas­tur­ba­tion or both. And so, with doc­trine firmly in hand, he be­gan dis­man­tling psy­chi­a­try. Psy­chi­a­try’s epicentre at the time was Ger­man-speak­ing Europe. Through­out the pre­ced­ing cen­tury, Euro­pean psy­chi­a­trists had de­vel­oped a clear dis­tinc­tion be­tween ‘‘ me­lan­cho­lia’’ — the se­ri­ous, rel­a­tively rare psy­chotic ill­ness — and the more com­mon ‘‘ ner­vous ill­ness’’ (to use Shorter’s term) com­pris­ing fa­tigue, anx­i­ety, mildly de­pressed mood, so­matic com­plaints and ob­ses­sion about it all. In­deed, worry about worry.

Shorter laments the loss of that clear dis­tinc­tion. He ex­plains how Ger­man psy­chi­a­trists were also trained as neu­rol­o­gists and thus were fa­mil­iar with in­ter­nal medicine, ac­quir­ing, dur­ing their train­ing, ‘‘ a feel­ing for brain ill­ness as in­volv­ing the en­tire body’’.

But Freud and his ad­her­ents, self-styled ‘‘ sci­en­tists of the un­con­scious psy­che’’, were largely un­in­ter­ested in me­lan­cho­lia — for its suf­fer­ers were not read­ily amenable to psy­chother­apy — and, in the early and mid­dle parts of the 20th cen­tury, in Europe and else­where, they parleyed ner­vous ill­ness out of the body and into the mind. Cer­tain psy­cho­an­a­lytic cen­tres, es­pe­cially those in and around New York, be­gan en­cour­ag­ing the ad­mis­sion of ‘‘ bright, young and ver­bal pa­tients’’ suit­able for psy­chother­apy. A phrase be­gan to fig­ure promi­nently in pa­tient self-re­ports: ‘‘ Doc­tor, I am de­pressed.’’

But, in a strange plot twist, it was Freud who ef­fec­tively held the phar­ma­ceu­ti­cal in­dus­try at bay; at bay, that is, un­til the de­cline of psy­cho­anal­y­sis and the rise of ‘‘ neu­ro­trans­mit­ter chat­ter’’. By 1960, the main tech­nique in the US psy­chi­a­trist’s ar­ma­men­tar­ium was Freudian psy­cho­anal­y­sis. Though of­ten re­quired to pre­scribe drugs to the se­verely ill, psy­chi­a­trists did so ‘‘ re­luc­tantly and with an ab­sence of con­vic­tion’’, Shorter says. But late in the 1960s the de­pres­sion epi­demic be­gan to surge. Shorter ar­gues the key was the phar­ma­ceu­ti­cal in­dus­try’s ‘‘ mar­ket­ing to the pub­lic of drugs for de­pres­sion on the grounds that they rested on an un­shake­able foun­da­tion of neu­ro­science’’.

That foun­da­tion? The hy­poth­e­sis that a lack of the neu­ro­trans­mit­ter sero­tonin, al­low­ing the com­mu­ni­ca­tion of signals be­tween cer­tain brain sites, is the bi­o­log­i­cal ba­sis of de­pres­sion. Neu­ro­sci­en­tists quickly ac­cu­mu­lated doubt over the sero­tonin hy­poth­e­sis; to­day it is widely dis­be­lieved. But Shorter ex­plains it lives on in phar­ma­ceu­ti­cal ad­ver­tis­ing and in the ex­pla­na­tions doc­tors give to their pa­tients.

And all that has been po­ten­ti­ated by the DSM-III, which, says Shorter, ‘‘ com­pleted the job by sep­a­rat­ing com­pletely anx­i­ety and de­pres­sion, and frag­ment­ing anx­i­ety into a vol­ley of mean­ing­less mi­cro-syn­dromes’’ — in­deed, cre­at­ing a men­tal ill­ness that could be ap­plied to ev­ery­one.

The APA re­cently pub­lished the fifth re­vi­sion of the DSM, up­ping the num­ber of di­ag­noses from the 265 con­tained in the third re­vi­sion to more than 300.

Sig­mund Freud de­cou­pled ner­vous ill­ness from the body

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