Manufacturing depression (15 page)

Some of these people suffered from what Meyer called “
constitutional depression
,” “a pessimistic temperament that is inclined to see the dark side of everything and is led to gloominess and despondency upon slight provocation.” Others, the simple melancholics, experienced “an excessive or altogether unjustified depression…a susceptibility for the unpleasant and wearing aspect of things only.” Still others tended to complain of a strange malaise, which they sometimes attributed to stray electricity or nocturnal rape or other problems of “an absurd character.” There were also cases of postpartum depression, depressions that accompanied other diseases, presenile depressions—depressions indeed for every
stage and style of life. Meyer wasn’t entirely clear about whether these were all diseases in their own right or just symptoms of other diseases, but he also said that this didn’t really matter. The important diagnostic distinction was about the role of the patient’s mental life in his suffering.

There are conditions
in which disorders of function of special organs are the essential explanation of a mental disorder…and in these, the
mental
facts are the
incidental
facts…But there are cases in which…we must use terms of psychology—not of mysterious events, but
actions
and
reactions
…a truly dynamic psychology.

Meyer never clarified how to distinguish the two kinds of conditions, but his proposal that at least some depressions were psychogenetic opened up an entirely new possibility in psychiatry: that people who were not hopelessly insane could still be psychiatric patients. They fell into some middle ground, into a region that Kraepelin had overlooked when he mapped the landscape of mental illness. Indeed, they were only suffering an exaggerated version of a universal experience, different from “
normal depression
,” as one of Meyer’s disciples put it, only “in its greater fixity, depth, and…disproportion to its causative factors.” Where the insane were delusional, the pathologically depressed were merely irrational. They were more like Job in the view of his comforters—unhappy beyond what the conditions of their lives warranted—than like Kraepelin’s psychotic patients. But unlike Eliphaz, commonsense psychiatrists could offer real comfort: the news that something indeed had gone wrong with the depressed patient, but because it was in his mind rather than in his constitution or his brain, he could be cured through self-knowledge.

In this respect, the psychogenetically depressed were the lucky ones. They were spared the life sentence, their families dodged the stigma of degeneracy, and they could be cured—but only if the
psychiatrist did exactly what Kraepelin warned against: listen with empathy, interpret, pay attention to the patient’s experience. Psychiatrists, in other words, should offer patients exactly what Freud and Charcot and some other European neurologists had recently begun to offer: psychotherapy. By placing the patient’s own story at the center of treatment, psychiatrists could help “
the
person himself
transform the faulty and blundering attempt of nature” that had brought him to unhappiness in the first place. All the doctors had to do was to replace their fixation on disease entities and their presumed biochemical causes with a recognition that diagnosis is a storytelling device more than a medical category. If they renounced their “mystic halo,” if they made themselves less strictly scientific, or at least less dependent on what Meyer called “
brain mythology
,” psychiatrists could actually help patients—at least those with psychogenetic depressions—figure themselves out and get better. Psychiatrists could do what neurologists had been doing—minister to everyday suffering—without resorting to “neurologizing tautologies,” and, more importantly, without eliding the life of the mind.

You’ve probably never heard of Adolf Meyer before. But as of 1941, according to the
History of Medical Psychology,
written by two psychiatrists and published that year, he had been “
the dominant figure
in American psychiatry” for fifty years. His fall into obscurity isn’t all that mysterious. Meyer’s own taxonomy of mental illnesses, the one he proposed to replace Kraepelin’s, was anything but commonsensical—a self-contained mythical world populated by reaction types with quasi-Greek names like
thymergasia
and
kakergasia.
His ideas about therapy, on the other hand, were the kind of bromides that give common sense a bad name.

The physician can offer
a patient with a depression a sense of security by communicating understanding based on his personal knowledge of him and of the situation. He must be
able to maintain the patient’s contact with a well measured regime…to avoid inducing any antagonistic attitude which would interfere…with the rapport that may keep him reasonably in touch with the condition of the patient.

Shorter sums up history’s verdict: Meyer, he says, was “
a second-rate thinker
and a verbose writer” whose conclusion—“that everything is very complex”—turned out to be “poisonous to the advance of scientific discipline.”

But if that’s so, then what are we to make of those first fifty years? Why would a second-rate thinker be judged a giant in his own time? The answer has little to do with nosology or therapeutics and everything to do with marketing.

Meyer’s attempt to free psychiatrists from their deadhouse and asylum ghettoes depended on his affirmation of what Hoch and MacCurdy had denounced: the possibility that the whole world could be insane, or at least maladjusted enough to need psychiatric services. Everyday people, he insisted, could be depressed without being crazy, and their difficulties could be understood and treated by expanding psychiatric reasoning beyond “strictly medical thought.” By focusing on “life problems,” psychiatry, as Shorter put it, was “
acquiring a Main Street beachhead
” and transforming itself into the mental health industry.

Meyer’s efforts intersected with another development in early twentieth century America. Men like John Watson—a prominent psychologist who took his talents to the J. Walter Thompson Company after he was forced out of Johns Hopkins in 1920 for his affair with a graduate student—and Sigmund Freud’s nephew Edward Bernays were teaching manufacturers how to use the mass media to sell their products. Their efforts were informed by psychological knowledge. Watson was famous for his extravagant tabula rasa claim:

Give me a dozen healthy infants
, well-formed, and my own specified world to bring them up in and I’ll guarantee to take
any one at random and train him to become any type of specialist I might select—doctor, lawyer, artist, merchant-chief and, yes, even beggar-man and thief, regardless of his talents, penchants, tendencies, abilities, vocations, and race of his ancestors.

And Bernays
, known as the “father of public relations” advised his clients to “make customers” by understanding the “structure, personality, the prejudices of a potentially universal public.”

The ad men also capitalized on what psychology, thanks to efforts like Meyer’s, was creating as it ministered more and more to everyday concerns: what the cultural historian Jackson Lears has called the “
therapeutic ethos
,” in which soap is sold not on its ability to get you clean, but on its advertised “promise of psychic security and fulfillment.” With the careful guidance of men like Bernays and Watson, manufacturers could turn people’s psychological suffering into a market for their products by convincing them that their troubles were a particular kind of problem—the kind for which the company just happened to have a solution. The ad men discovered, in other words, that if you could name people’s pain, you could sell them a cure.

Which is exactly what Meyer accomplished. Lowering the bar for entry into the psychiatrist’s office, he gave his profession unique and privileged access to the average citizen, the one whose life wasn’t as happy or productive or fulfilled as he thought it should be. Meyer claimed that cure could be found in the one resource that everyone, especially every American, had: a life story. This democratization of mental suffering was enhanced by other developments in American life, notably
the mental hygiene movement
, spearheaded by activist (and former asylum patient) Clifford Beers, that made “mental health” a subject of polite conversation. People could now talk about their “life problems” without fear that they would be carted away to the loony bin. They could be depressed without being insane and they could be cured.

In this sense, Meyer was the victim of his own success. For all the time that he was making mental illness safe for democracy, Sigmund Freud and his followers were busy in Europe crafting a different kind of antidote to suffering. Like Meyer’s, it steered a course between Job and Eliphaz, between the conviction that life is hopelessly rigged against us and the certainty that only a hopelessly flawed soul suffers, by claiming that our suffering was inflicted by history, which meant that redemption could come through narrative. The kind of life story the Freudians encouraged their patients to tell was anything but commonsensical, but it was largely thanks to Meyer that when psychoanalysis came across the Atlantic, America—psychiatrist and patient alike—was ready to think that their psychic suffering, and the hope for its relief, lay in their biographies.

I had two doctors during my clinical trial—George Papakostas and Christina Dording. They were both at least a decade younger than I and accomplished enough in their field to have been accepted into the clinical faculty at Harvard Medical School. Papakostas, who did the first four interviews, was soft-spoken and affable, with a boyish face framed by wire-rimmed glasses, and seemed to enjoy nothing more than a good conversation about serotonin transporters. He was unfailingly kind, greeted me at each visit with a smile and handshake. And he managed to inject genuine concern into the questions about sleep and appetite, headaches and constipation, and worry and guilt that he asked each week, in exactly the same order, using exactly the same words.

Dording was not quite so likable. But then again we met under less than ideal circumstances. She came out to fetch me on my fifth visit, announcing that she was my doctor as if it were the most normal thing in the world to hand patients from one psychiatrist to another without any notice. Which, she explained to me, it was. What was strange, in fact, was that we hadn’t met before. “By this point in the study, I’ve usually had you,” she explained. Somehow that sounded ominous to me.

Still, I had to wonder whether it was something I said, whether my repeated attempts to get Papakostas to talk about what we were actually doing here, about the enterprise of turning my inner life into algorithm-friendly numbers, about the complexities of neuroscience and its still tenuous relationship to the consciousness it was supposed to explain, had led him to want shut of me. I took Dording at her word when she explained that the switch was just the standard operating procedure. But when we passed by Papakostas’s door and he was at his desk, peering at his computer screen, I felt a little pang. After all, we depressives are
rejection-sensitive
.

You would think they’d factor that into your treatment, at least when it comes to abruptly changing your doctor. But this wasn’t really treatment, at least not in the usual sense. They surely wanted me to feel better, but the real focus wasn’t me. I was just the guy they had to go through to get at depression, the carrier pigeon whom they had to treat well while they carefully unwrapped the message from his leg—or at least well enough to return home for the next dispatch. It didn’t really matter which pigeon flew in the window or which soldier debriefed him—or, for that matter, what the bird’s name was.

This detachment makes sense, especially if you are a Kraepelinian. Disease is disease, after all. If your oncologist or your ophthalmologist is tied up, indisposed, or just plain tired of you, then why shouldn’t he send in an associate to see you? Your tumor or your glaucoma don’t care who treats it, so why should your depression? And if you complain to your psychiatrist about this, or betray your injured feelings—let alone if you want to talk about what you think makes you depressed—then your psychiatrist should remember what Emil Kraepelin told his colleagues: “Trying to understand another human being’s emotional life is fraught with potential error.”

The depression industry is dedicated to not making this mistake. The major instrument of its vigilance is the Hamilton Depression Rating Scale.
The HAM-D
, as it is known to the depression doctors,
was developed in the late 1950s by British psychiatrist Max Hamilton. At the beginning of the antidepressant era, he saw the need for a way to measure depression and its absence so that the benefits of the drugs could be assessed. This was back in the days when depression was an incapacitating illness that required hospitalization, so Hamilton was able to observe many patients closely and over a long time. No one seems to know whether he was familiar with Kraepelin’s method (it would still be a couple of decades before descriptive psychiatry was rehabilitated by the American Psychiatric Association), but Hamilton’s approach was similar: he proceeded empirically, teasing out the symptoms in order to break down the illness into its constituent parts.

Hamilton determined that depression had seventeen hallmark features. Some of them were psychological—feelings of sadness and guilt, for instance—but the majority were physical: quality and quantity of sleep, various physical complaints, weight gain or loss. He gave each of these symptoms its own item and assigned point values based on the severity of each item. The absence of guilt was a zero, hearing voices of denunciation earned the maximum of four; the physical symptoms of anxiety like stomach cramps or palpitations were worth four points if they were incapacitating and zero points if they were absent. Hamilton gave doctors one gimme—an item that awarded two points toward depression for a patient who “denies being ill at all”—and proposed that a patient’s improvement (although not his original diagnosis; the test was standardized on people whom Hamilton had already decided were depressed) could be measured by repeatedly assessing these symptoms, adding up the scores, and charting the trends. Which is exactly what Drs. Dording and Papakostas were doing on my visits to Mass General.