Manufacturing depression (12 page)

Gentlemen, the patient
you see before you today is a merchant, forty-three years old, who has been in our hospital uninterruptedly for about five years. He is strongly built,
badly nourished, and has a pale complexion. He comes in with short, wearied steps, sits down slowly, and remains sitting in a rather bent position, staring in front of him almost without moving…[S]peaking gives him a great deal of trouble, his lips moving for a little while before the sound comes out…That the answers come so slowly…shows that in this patient we have not to deal with a fear of expressing himself, but with some general obstacle to utterance in speech. Indeed, not only speech, but
all action of the will is extremely difficult to him
. For three years he has been incapable of getting up from bed, dressing, and occupying himself, and since that time has lain in bed almost without moving…

Here is a case
of a woman twenty-three years old…who bore her second child six weeks ago. Seventeen days later she got a great fright from a fire in her room, and she then became apprehensive and restless, saw flames, black birds and dogs, heard whistling and singing, began to pray, screamed out of the window, lamented her sins, promised to be good, and could not sleep. She sits almost motionless, with her eyes cast down, staring in front of her, and moving her lips slightly now and then…She nods when I ask her if she is unhappy and mutters to herself: “There are always so many carriages coming; a great number drive about outside.” Now and then she uses isolated, broken expressions, in a tone of lamentation, often repeating them one after the other: “I want to go home, to get out. Alas! Alas! only let me go away. I will not let myself be done to death. I cannot stay here. Good heavens! There is poison in the food!”

There were milder forms of insanity, of course—
“numberless…cases of maniacal-depressive insanity
which never come into an asylum and, indeed, are never recognized as morbid states at all.” These patients, whose insanity might manifest as indecisiveness
rather than a total loss of will “often passed off without any treatment” or were treated at “different asylums and watering-places, or ordered to travel”—prescriptions that patients, unaware of “how deeply maniacal-depressive insanity is rooted in [their] intrinsic disposition,” wrongly think have cured them when their disease remits. For most of the people so disposed, the mildness is only temporary: it’s just a matter of time before they find themselves completely unable to exercise their will. The rest are lucky to have a variation of the disease less severe than the others.

Kraepelin’s notion of mildness, however, was different from yours and mine—and from current psychiatric practice:

The mildest form
of the depressive states is…
simple retardation
…[M]ental processes become retarded, thought is difficult, and patients find difficulty in coming to a decision, in forming sentences, and in finding words with which to express themselves. It is hard for them to follow the thought in reading or ordinary conversation…Customary actions, such as walking, dressing, and eating, are performed very slowly, as if under constraint. When started for a walk, they halt at the doorway or at the first turning point, undecided which way to go…Sometimes they become bedridden.

If a person showed up at my office with this “mildest form” of depression, I would be very likely to consider hospitalization. When my doctor at Mass General determined that I was mildly (although still majorly) depressed, I showed (and reported) none of these symptoms. Indeed, today’s “major depression, mild” is one of the diagnoses that cause people to wonder if the diagnosis isn’t too freely handed out.

Still, even in Kraepelin’s time psychiatrists worried about whether or not the new diagnostic regime encouraged doctors to diagnose too many people as mentally ill. In 1907, just a few years after the sixth edition of the
Lehrbuch
appeared,
Georges Dreyfus
,
a former pupil of Kraepelin, published the results of a study he’d undertaken at Heidelberg Clinic. He had observed Kraepelin’s patients—the same patients whose cases had led Kraepelin to conclude that he’d been mistaken about melancholia—and determined that, judging by outcomes, the master had
not
been mistaken. He had simply stopped observing his patients too early. As a result, he’d misdiagnosed the very cases that had led to the realignment.

On the basis of this faulty assessment, Kraepelin had claimed that these patients suffered from the one form of melancholia that should not be folded into the manic-depressive diagnosis. He called it “involution melancholia”—involution being the stage of life that, according to the medicine of his time, sets in soon after forty, when the body starts its long wind-down to death, or, as Kraepelin called it, “the early senile period.”

It includes all the morbidly anxious states
not represented in other forms of insanity, and is characterized by
uniform despondency with fear, various delusions of self-accusation, of persecution, and of a hypochondriacal nature…leading in the greater number of cases, after a prolonged course, to moderate mental deterioration
[emphasis in original].

A diagnosis of involution melancholia, with its prognosis of a course straight downhill to death, was in some ways worse than manic-depressive insanity. At least manic-depressives had the benefit of remissions, times in which their cycles crossed through relatively benign emotional territory. And that’s exactly what Dreyfus found: many of Kraepelin’s melancholics actually got better, or at least cycled between states of sanity and insanity. The outcome of their cases, he said, proved that they hadn’t had involution melancholia in the first place. Indeed, he doubted that the disease existed in its own right, that it was anything other than yet another subspecies of manic-depressive insanity.

Dreyfus had hoisted Kraepelin on his own petard, and in 1913,
when he published the eighth edition of the
Lehrbuch,
Kraepelin wrote involution melancholia out of the official nomenclature. Outside Germany, this news caused some consternation. August Hoch, director of the New York State Hospital Psychiatric Institute, objected to the banishment of “
one of the most frequent forms
of mental disease, and…one of the oldest in psychiatry” from the kingdom of insanity. He and a colleague, John MacCurdy, reviewed Dreyfus’s review of Kraepelin’s cases and reported that Dreyfus’s “
zeal outran his judgment
. In a number of cases he ferreted out a history of depressions so mild as to seem to be…merely more or less normal mood swings.” And here was a problem. Bad enough that patients had been misdiagnosed and a psychiatric illness declared nonexistent as a result. Even worse, all this confusion meant that Kraepelin’s brainchild—the idea that insanity could be medicalized by means of an accurate and reliable diagnostic scheme—was in danger.

Variations of the emotional status
are of great theoretic, psychologic importance, but they should not be called “psychoses” as long as their manifestations remain within certain limits. Otherwise, nearly the whole world is, or has been, insane.

Prescient as they were in this worry, Hoch and MacCurdy’s concerns were purely parochial: that “
individual taste
”—rather than scientific knowledge—“is likely to determine the classification adopted by psychiatrists for many years.” They didn’t seem to grasp that the problem they had uncovered was not that Dreyfus had misused Kraepelinian nosology, but that Kraepelin had failed at what he had set out to do.
Manic-depressive insanity, involution melancholia, dementia praecox
—this was indeed a sophisticated language, and it certainly sounded medical. But mental diseases still consisted only of lists of symptoms, and the symptoms were only symptoms because they belonged to the disease. The logic was circular, the
language tethered only to itself, not to something as solid as a spirochete or a bacillus. That’s why the controversy could arise in the first place, why it could only be fought with language, and why it could not be settled. Without an ultimate referent for the sign, as a philosopher might put it, it was impossible to say with certainty whether Dreyfus or Kraepelin was correct, which meant that it was impossible to tell who was sane and who was not.

A diagnosis that renders the whole world insane is a scandal for a psychiatry that claims to have cut nature at its joints. But it’s an enormous market opportunity for an industry that would aim its magic bullets at insanity. It would take eighty years and much good fortune, not to mention some very clever advertising, but American ingenuity would eventually figure out how to put the authority of science behind the immensely profitable claim that the whole world is insane—or at least the large portion of it that meets the criteria for depression, a much greater population than Kraepelin at the height of his racialist paranoia ever imagined.

I was in the 7-Eleven one day, waiting in line to pay for my coffee. The clerk was talking to a friend, who had just asked her how she was doing.

CLERK
(early twenties, long permed ringlet curls): I don’t know. I’m still achy and weak. And I’ve just been
so
tired. I just want to sleep all the time. I feel, I don’t know, you know,
blah.

FRIEND
(same age, bigger hair, belly shirt revealing four-color wraparound tattoo): What does your doctor say?

CLERK:
He doesn’t know. I mean, it’s not like I have a fever anymore or anything.

FRIEND:
Have you been depressed?

CLERK
(surprised): Well, I was on antidepressants a while ago, but I stopped them.

FRIEND
(voice deepening a bit): It’s depression. You got a case.

CLERK
(looking a little sheepish): Oh, I don’t know…

FRIEND
(insistent now): No, really. Depression can make you sick. That’s how it can kill you, you know. You ought to go back to your doctor and tell him you have depression. Get him to put you back on the medicine.

It’s too bad the marketing folks from Lilly or Pfizer weren’t there with a camera crew. They would have gained incontrovertible evidence to show their bosses and shareholders just how deep into America their message about depression has penetrated—and they’d have a free ad in the can to boot.

But you have to wonder what Emil Kraepelin would say about the ease with which these women talked, about their familiarity with these medical terms, about the way that his language had escaped the asylum, taken on a life of its own, and turned up in what—despite the dozen coffee selections, three cup sizes with two lid choices, and phalanx of syrups and creamers and sweeteners—would have qualified as one of Auden’s miserable duchies. Frightening as their numbers were to Kraepelin, the ranks of the insane in turn-of-the-century Germany were still a very small portion of the population. And he certainly expected doctors, and not the patients, to render the diagnoses. He would likely have been shocked to discover that depression had become a subject fit for conversation among the
volk
at the 7-Eleven. I think he would have found this entire display vulgar and a mockery of his science.

Given what he wanted to do with the insane, Kraepelin was unlikely to see the value of expanding the boundaries of mental illness. Indeed, his system was a sort of reverse elitism, reserving the status of insanity for only a select few doomed souls. He may well have been appalled not only at the way my doctors at Mass General used his method to diagnose me with major depression, but also with the setting where they did it: not an asylum but an unlocked (except for the restrooms) modern office building shared with dermatologists and ophthalmologists and biotech startups, with a waiting room populated by a cross section of America—old and young, affluent and poor, white and black and brown, crazy and not so crazy—and presided over by a chipper receptionist who talked on the phone about depression as if it were the common cold, who made happy banter with the patients as she validated their parking
tickets. Perhaps Kraepelin would have seen this all as proof that the race had indeed degenerated.

On the other hand, the doctors at Mass General, like the 7-Eleven clerk’s friend, have a distinctly non-Kraepelinian idea about depression: that something can be done about it. It’s not a death sentence anymore. The possibility of cure has made this expansion possible, made mental illness safe for the masses, as common as a convenience store.

It is fitting then that the initial conversion of Kraepelin’s terrible and incurable disease into a mundane problem we can solve with a widely available product took place in the United States as the first wave of mass consumer culture washed over the country. The transformation in psychiatry was wrought largely by an ambitious immigrant, ready to take old European ideas and translate them into New World successes—the kind of man who was rapidly becoming a fixture in entrepreneurial capitalism. And by the time he was finished revolutionizing American psychiatry, that man, Adolf Meyer, had focused attention on biography as the source of our suffering.

When he left his native Switzerland in 1892, at the age of twenty-six, Adolf Meyer’s mother fell into a deep depression. His former professor in Zurich, Auguste Forel, wrote to him in Chicago to tell him that his mother was unable to shake the certainty, against all evidence, that her son was dead. “
She had been one of the sanest
persons in my experience,” Meyer later said. But now, at least according to Forel, a dyed-in-the-wool Kraepelinian, she was hopelessly and forever insane with melancholia.