Manufacturing depression (10 page)

Indeed, even as Ehrlich was working in Berlin, in another corner of the same hospital, another doctor was beginning to do just that. He wouldn’t have described his work that way, of course. As he mapped the landscape of psychic suffering, he thought he was discovering diseases, not inventing them, and he had no intention of curing his patients. Still, simply by insisting that there were mental illnesses in nature and that he knew how to find them, Emil Kraepelin set the machinery of depression in motion.

When my doctor at Mass General went to determine whether or not I was minorly depressed, he did what nearly any researcher in any clinical trial for a psychiatric condition does. He sat down across his desk from me and opened up a big loose-leaf binder. In it was the script for the Structured Clinical Interview for DSM-IV (SCID), a test derived from the DSM’s diagnostic criteria. The procedure is very simple. To find out if you satisfy the two-weeks-of-sadness requirement, the doctor asks you if you have been sad for two weeks. To find out if you have lost interest in the activities that usually bring you pleasure, he asks if you have lost interest in the activities that usually bring you pleasure. This goes on for forty-five minutes or so, the questions shunting you from one slot to another, like a coin in a sorter, until you drop into the drawer with all the other pennies.

What the doctor doesn’t do as he scores your SCID is pay much attention to how you are actually behaving, the words you use to express yourself, or the way you come across in person—in short, the qualities that we usually think make us who we are. In fact, my doctor didn’t even have my name right. He kept calling me Greg. I would have corrected him, but I didn’t want to embarrass him.

In the old days—which is to say back when psychiatrists paid attention to your own account of your interior life—the fact that I didn’t want to embarrass my doctor, had it somehow come up in the interview, would have mattered. A clinician might have seen it as a reflection of some aspect of my personality—a fear of conflict, perhaps, or disguised hostility, or even some compulsive need to take care of others. My suffering would have been seen as the outgrowth of that fear or need, the question of how I came to feel that way would have been central, and the diagnosis would have depended in part on the answer to that question. The symptoms alone, in other words, would not have been enough to render a diagnosis. The doctor would have needed to understand the context and meaning of my symptoms, and my illness would have been seen as at least partly a matter of biography.

It’s not hard to understand why diagnosis doesn’t work that way anymore. Reaching that kind of conclusion requires open-ended conversation and liberal interpretation, which would be very hard to map onto a troubleshooting chart. That’s an inefficient process, and it would yield an unscientific result. The difficulties raised by this approach to diagnosis reached a crisis point in the early 1970s. In addition to the Rosenhan study, psychiatrists were confronted with research that showed that they often disagreed about what mental illness a given person had.
Diagnostic trends varied
from country to country, from city to city, even from hospital to hospital, and diagnoses began to seem more like folk stories than medical categories. Even worse for the industry’s credibility, in 1973, after years of subjecting homosexuals to all manner of “treatment,” the American Psychiatric Association voted homosexuality out of the DSM. Developments like these seemed to indicate that psychiatrists didn’t know how to define mental illness to begin with. That kind of confusion could have been very bad for business.

So just a few years before Prozac came along, psychiatrists turned to what they called a descriptive nosology. In a development I’ll describe in detail later on, they came out with an entirely revamped
DSM, one that focused not on personalities or causes of mental illnesses but on lists of symptoms like the one that my doctor was using to diagnose me. These lists featured more or less objective criteria—duration of unhappiness, changes in weight, length of sleep. They were designed to meet statistical standards like interrater reliability, which made them much more friendly to the quantitative tests and measures that we equate with science. And they worked. It turns out that if you standardize the questions you ask, you will come up with standardized answers. Or, to put this another way, if you go into the interview looking for what you already know, then you are very likely to see it.

The trick with the descriptive approach to diagnosis is to keep your eye on the loose-leaf notebook and not on the patient. That’s why it didn’t really matter whether my doctor knew my name or noticed that I was cracking jokes, engaging him in relatively sophisticated conversation about neurochemistry, talking about sad things but not being sad—or, for that matter, that I had driven eighty miles, shown up almost on time (the subway was a little slow), was dressed and groomed, and so on. Details like these would have been inconvenient, to say the least. Clinical trials are hard to fill. Even more important, the mental health industry’s commitment to the DSM and the SCID is its best hope for maintaining its sometimes tenuous place among the disciplines of scientific medicine. If the SCID spits out a diagnosis that just doesn’t fit the patient, then what would that mean about the psychiatric enterprise?

The problem here is that all those descriptors, in all their detail and specificity, don’t necessarily add up to a disease. A good doctor would never conclude that a person with a sore throat and fever necessarily has a streptococcal infection, and a good scientist would not say that the disease of strep throat is constituted solely by a sore throat and fever. Both would insist that a bacteria must be present to complete the diagnosis. This is the great advance in diagnostics brought on by magic-bullet medicine: the symptoms of a disease are only the signs of the disease, not the disease itself.

Except in psychiatry, where the symptoms constitute the disease and the disease comprises the symptoms. William James had this tautology in mind when, remarking on another disease that doctors no longer believe to exist, he wrote, “
The name hysteria
, it must be remembered, is not an explanation of anything, but merely the title of a new set of problems.” To say that a person who suffers from sadness and lethargy and sleeplessness and the loss of appetite and interest in pleasure is depressed is merely to give his suffering a new title—at least so long as depression is no more or less than the condition in which a person suffers in this fashion.

Psychiatrists would no doubt love to be able to skip even the SCID’s superficial questions in order to diagnose depression. They would simply look into a microscope, at which point it wouldn’t matter what the patient said, or what the psychiatrist thought about what he said any more than it would matter what a cancer patient said. The industry is working hard to eliminate the human element from psychiatry, but for now the best it can do is to circle the answers in notebooks and train practitioners to ignore what’s in front of their eyes.

If this approach seems a little unsophisticated, a little primitive, and a little inhumane, there’s a reason for that. When the APA turned to a descriptive nomenclature, they weren’t exactly making an innovation. In fact, they were turning back nearly a century, to a nearly forgotten diagnostic system developed by Emil Kraepelin, a German doctor who was much more interested in weeding out the mentally ill than in curing them. Resurrecting Emil Kraepelin’s system, psychiatrists also dusted off his solution to the problem that William James had noted: act as if there is science behind your nosology, and eventually the name of the disease will seem to be an explanation of everything.

Emil Kraepelin embarked on his career as a psychiatrist with an interest in his patients’ inner lives.
His doctoral dissertation
, published
in 1879, was “The Place of Psychology in Psychiatry,” and early on he rebelled against his mentor, who believed that only the microscope could reveal anything important about mental illness. But within a few years, he was convinced that psychiatry, and perhaps the world in general, was much better off without psychology.

The problem, as Kraepelin saw it, was that the only source of psychological information about insanity was the patient, and the patient was, well, insane. So, he concluded, “
we cannot afford to pay
much attention to the patient’s account of his experiences.” Neither did he think that it was a good idea to indulge in “poetic interpretation of the patient’s mental process. This we call empathy,” he said, warning that a science-minded doctor employed it only at his own peril.

Trying to understand another human being’s emotional life is fraught with potential error. This is true in healthy people and much more so in sick ones. “Intuition” is indispensable in the fields of human relations and poetic creativity, but it can lead to gross self-deception in research.

Kraepelin felt that even his own interior was unworthy of exploration. When he published
an analysis of his dreams
, it was not to ferret out their meaning but to illustrate the way that the language of dreams resembled the language of insanity.

Kraepelin eventually landed a job in an asylum in Estonia, whose natives spoke a language that he didn’t understand. Now that it was impossible to listen to his patients’ stories, he was free to focus on the subject that he thought could put psychiatry on an equal footing with the rest of medicine: mental illnesses themselves, uncontaminated by unreliable psychology and fickle empathy. By the time he returned to Germany from the Baltic hinterlands, Kraepelin had given the modern world a conception of depression that fit the newly emerging medical model: it was, he said, a disease like any other. Indeed, he told his students, “
from the medical point of view
,
it is disturbances in the physical foundations of mental life which should occupy most of our attention.”

With this proposal, Kraepelin was entering treacherous territory. Although scientists had begun to identify brain structures that appeared to underlie specific faculties of mind—notably language—both this knowledge and the technology used to obtain it were rudimentary. Even more important, some doctors had already suggested that the mind could be reduced to a function of the brain, and they had landed in hot water as a result. The Parisian doctor
Julien Offray de La Mettrie
, for instance, had proposed in 1745 that the brain was a machine that produced consciousness, and that it was in this respect no different from the rest of the body: “
it possesses muscles
for thinking as the legs do for walking.” For suggesting that the mind was nothing more than the output of
a “machine that winds itself up
, a living picture of perpetual motion,” and the soul merely
a “vain term
,” and for prophesying that doctors would soon understand the clockworks so well that “
everything can be explained
, even the surprising effects of the disease of the imagination,” La Mettrie was exiled to Holland, from which he fled for Prussia, where he died in 1751.

Intolerance of materialism wasn’t limited to the French and the Dutch. Fifty or so years later, Franz Josef Gall had run afoul of the Viennese authorities by proposing that
the brain was divided
into twenty-seven organs, each of which produced a different aspect of the mind, and all of which Gall claimed to have mapped. What’s more, he said, a careful observation of the skull—measuring it, feeling its protuberances, taking a practiced look at its shape—would reveal the brain that lay beneath and with it the character and intellect of its owner. Gall’s
organology
resembled in some ways the
physiognomy
already being practiced across Europe, but he was the first to claim that cranial features were expressive not of the immaterial soul, but of the flesh-and-blood brain, which in turn was the seat of the soul. His reward was a letter from the Emperor Franz II. “
This doctrine concerning the head
, which is talked about with enthusiasm,
will perhaps cause a few to lose their heads,” he wrote. Because Gall’s materialism threatened “the first principles of morality and religion”—not to mention the delicate sensibilities of the women of Vienna—Franz II banned him from delivering further lectures.

The ban was good for Gall’s business. The ensuing sensation made his European tour, on which he dissected brains, read skulls, and displayed his collection of skulls of the rich and famous, a huge hit. “
There is always unending applause
at all the public demonstrations,” Gall wrote to a friend back home. But it was terrible for science, especially when Johann Spurzheim, one of his lab assistants, broke away. Gall’s cartography, Spurzheim announced, was inaccurate, especially insofar as it included too many territories of evil—there was a region, for instance, for murderousness—and no room for redrawing the boundaries or to rectify deficiencies.
Spurzheim claimed
that people were not so bad as Gall had said, and that to the extent that their brains were weak, he could show people how to cultivate and improve them. He gave his version of organology a new name—
phrenology
—and took his show on the road, playing to even fuller houses than Gall had, not as a scientist, however, but as an entertainer.

So by the time Kraepelin proposed that doctors look to the brain to understand the mind’s troubles, this idea was associated more with scandal and spectacle than with science. Kraepelin had done his part to make psychiatry more like the medicine that was emerging in the wake of the magic-bullet revolution. He had, for instance, determined that
nearly half the mental patients
at Berlin’s Charité hospital were suffering from syphilis. But such discoveries were hard to come by, especially for Kraepelin,
whose eyes were too weak
for microscope work, and he was doubtful that anyone else was going to parse the newly apparent complexities of neuroanatomy anytime soon. It was one thing to find a bacillus in a blood cell and quite another to figure out what was going on in that tangle of neurons and fibers.