Manufacturing depression (6 page)

You don’t know, in other words, whether to read bleakness as symptom, which is exactly what Eliphaz does.

Does a wise man
answer with airy reasonings,

Or feed himself on an east wind?

Does he defend himself with empty talk

And ineffectual wordiness?

You do worse: you flout piety . . .

A guilty conscience prompts your words,

You adopt the language of the cunning

Your own mouth condemns you, and not I

Your own lips bear witness against you.

Or as a latter-day Eliphaz might put it, Job is in denial and cannot see that disorder in his inner world has led to his view of the outer world, that “
it is man who breeds
trouble for himself as surely as eagles fly to the height.”

Job’s inner life has been the subject of this story from the beginning, when God and Satan squared off about whether his piety was authentic or God-bought; Eliphaz is only taking this scrutiny one further step. Confronted with Job’s abjection, he does exactly what a depression doctor does: first, he invokes an idea about what a human being is supposed to be—someone who can take these blows and still maintain his faith and piety—and then he claims that Job’s problem is a failure to be that way. If Job were healthy, a modern Eliphaz would say, he wouldn’t be so distraught but instead would be able to see how he had bred trouble for himself (if not in the catastrophes themselves, then in his response to them). He would be able to roll with the punches and then move on to the rosier future, where, according to Eliphaz,

You shall be safe
from the lash of the tongue,

And see the approach of the brigand without fear.

You shall laugh at drought and frost,

And have no fear of the beasts of the earth . . .

In ripe age you shall go to the grave,

Like a wheatsheaf stacked in due season.

If only he were sufficiently pious, Job would have the ability to live through setbacks without losing heart.

With all of this anticipation of the modern world, it’s tempting to say that Job was suffering from an undiagnosed case of depression, and that, had his comforters had prescription pads and an acquaintance with the techniques of cognitive-behavioral therapy, they could have relieved his suffering. But this misses a much more important way in which Job anticipates our modern understanding of depression: at the dawn of history, when confronted by the bewilderments of loss and by the human capacity for deep despair, self-appointed physicians sought to diagnose pessimism as a pathology within the suffering person. By the time the story leaves the comforters behind, when Yahweh thunders his answer “from the heart of the tempest,” informing Job of his insignificance and impertinence, of the absolute irrelevance of his puny notion of justice to the raw majesty of creation, the fix is in: the fault lies not with creation, not with a god who would sell out his best customer or, for that matter, who would send a man with a sense of justice into a world in which the gods roll us like dice, but with the man himself. Job’s desolation is an affront to the convictions of his therapists, and they desolation back with a diagnosis.

“
In its commonest form
,” Peter Kramer wrote in
Against Depression,
“depression is a disorder of emotional assessment of experience.” People, struck by the inevitable misfortune of life, lose the ability to bounce back, which Kramer calls “resilience.” The result is what he describes as “
a fixed tragic view
of the human condition” that prevents people from moving “
toward assertiveness
and optimism.” This is Job’s problem from a psychiatrist’s point of view: he fails to see not only that he is mired in negativity, but also that his attitude itself is the problem. He mistakes his pathological view of things for an apprehension of the truth about his pain and the world in which he suffers.

This misunderstanding, Kramer says, is a hidden wellspring of Western civilization, a culture that he says valorizes depression
because it has been shaped by depressives. “
Our aesthetic and intellectual preferences
have been set by those who suffer…deeply,” he wrote. “If the unacknowledged legislators of mankind…are depressives, then we might want to examine the source of our value judgments when it comes to pessimistic views of the human condition.” Those judgments are flawed, Kramer believes; affronted by their victory, by the history they have written, he strikes back with a diagnosis.

Not all the depression doctors are as articulate and forthcoming as Kramer, but I think he has spoken for them here, or at least accounted for one of the reasons that so much of our psychic suffering has come under the rubric of their disease. Your sadness doesn’t become depression until it has settled in for a while—officially, according to the DSM, for two weeks. So what happens on that fifteenth day? The depression doctors will tell you that the threshold is derived from statistics, but like so much about depression, it’s based on circular logic: the number was derived from the experience of people the doctors already considered depressed. So it’s left to us to figure out that what’s at stake is persistence. After two weeks, it seems, your dejection is at risk of becoming a fixed and tragic view that is not only unpleasant but also nearly taboo in a society dedicated to the pursuit of happiness—and that was, for different reasons, taboo in the land of Uz. Your sadness becomes depression, in other words, when it turns into pessimism.

The arbitrary nature of fortune, the near certainty that unbidden catastrophe will visit each of our lives, the inevitability of mortality, a nature that is more generous with pain than with pleasure, in short, all the stacked-deck calculus of human existence—these are challenges to optimism if not outright invitations to pessimism, and that’s before we even consider what a hash we’ve made of both civilization and nature. But I don’t wish to mount a broadside against optimism or, Kramer forbid, more legislation for pessimism. Instead, I want to point out that the depression doctors have done exactly what Eliphaz and company did. Psychology may have
replaced theology, but pathology is still the point: for Kramer no less than for Eliphaz, pessimism is evidence of interior disturbance.

“
On this medication
, I am myself at last”
: this is what Kramer tells us his patients say when their depression lifts. This may indeed mean that they have become healthy, that to be able to “laugh at drought and frost” is to feel the way nature intends them to feel. But it may also be that the self they have become can, thanks to the drug, give up the fixed and tragic view and live comfortably in an unchanged world. The usual—and, as we will see later, justified—rap against medicalized depression is that it doesn’t really distinguish between ordinary sorrow and pathology. But it may be, indeed I think it is the case, that the diagnosis also can’t distinguish adequately between disease and demoralization any more than the cure can distinguish between making people well and making them feel better about their lives. The depression doctors, in other words, may not be able to avoid the errors of Eliphaz.

I don’t want to overstate this. I’m not worried that antidepressants will turn us into mind-numbed, smiley-faced zombies. The drugs aren’t that effective, at least not yet. But I do think we need to pay attention to our feelings of demoralization. Pessimism can be an ally at a time of crisis, and I think we’re living in one right now. Regardless of whether or not the drugs work, to call pessimism the symptom of an illness and then to turn our discontents over to the medical industry is to surrender perhaps the most important portion of our autonomy: the ability to look around and say, as Job might have said, “This is outrageous. Something must be done.”

For religious people—in Job’s time as well as in ours—the solution to the problem he represents is to relinquish the expectation that human sensibilities can grasp the sense of life and to replace it with a conviction that there is a divine, if inscrutable, plan behind our suffering. Job’s pessimism and outrage, in this view, dissolve when he gives up that expectation. His suffering over the unfairness of
his life is transformed into faith in a God whose justice surpasses understanding and whose mercy can soothe his grief. (Although the restoration of his wealth that Yahweh finally grants to Job, in an ending the rabbis tacked onto a book otherwise considered too bleak, seems to miss this point; for why would Job think that it will not be taken away again? And what about his children?)

For those of us who look to science for revelation, however, suffering has a very different fate and its cure rests on a different transformation. We place our faith in doctors and their science. Founded on the idea that knowledge moves us forward, that ignorance is all that stands between us and the best of all possible worlds, scientific medicine embodies the faith that we can figure our way out of our troubles. This belief rests on some optimistic assumptions: not only that the world will yield its secrets, but also that it has secrets to yield, that life is lawful in a way that will make sense to us. It’s no wonder then that depression has fallen into the hands of the doctors: science is the natural enemy of pessimism.

To say that a particular form of suffering is a disease is always to go beyond the observation that the suffering exists. It is also to say—as Kramer does when he looks forward to the elimination of depression—that the suffering doesn’t belong in our world, that we would live better lives without it, and that we ought to do so. When doctors turn suffering into symptom, symptom into disease, and disease into a condition to be cured, they are acting not only as scientists, but also as moral philosophers. To claim that an affliction ought to be eradicated is also to claim that it is inimical to the life we ought to be leading.

With some diseases, it barely matters that there is a philosophical dimension to a diagnosis. It is hard to imagine a world in which cancer and diabetes are not best understood as illnesses. But when the pathology is an attitude, a “fixed tragic view of the human condition,” and when the treatment is touted as the restoration of the true human selfhood, then we really should consider whether that attitude is best understood as an illness to be eliminated. We should
wonder whether doctors who urge us to come out against depression aren’t, wittingly or otherwise, also urging us to adjust ourselves to a world that our pessimism shows to be deeply flawed.

And above all, we should recognize that to talk about why we suffer and what we should do about it is also to talk about how things ought to be. To say that a young man is sick when he is lying on the floor of his office, reeling from personal disaster, is to make a moral statement, and then to cloak it in the language of science, which plays the same role in our world that religion did in Job’s. And just as Eliphaz and his colleagues overstepped with Job, so too the depression doctors, and their drug company sponsors, have overstepped with us. They don’t know any better than you and I what life is for or how we are supposed to feel about it.

I became an officially depressed person in 2006. I received my diagnosis from a highly respected Harvard psychiatrist working at the Mood Disorders Unit at Massachusetts General Hospital who said I had major depressive disorder, recurrent, mild, with melancholic features. I wasn’t entirely surprised that I turned out to be mentally ill. I had shown up at his office to enroll in a clinical trial of an antidepressant medication, and a diagnosis is a requirement for entry.

But I was expecting a different diagnosis—minor depressive disorder. This isn’t an official psychiatric disease, at least not yet. It is listed in the DSM-IV, but in an appendix of “Diagnoses in Need of Further Study.” Much depends on this further study, notably whether the diagnosis will get the official four-or-five-digit code that compels insurance companies to pay for its treatment, and whether the Food and Drug Administration will then be able to give a drug company an
indication
—that is, the right to claim that its drug treats the new disease.

Not all research diagnoses turn out to be winners. Take premenstrual dysphoric disorder (PMDD) for instance. The idea that PMDD is a psychiatric illness must have looked like a good idea to someone. My money is on Eli Lilly, which wanted to squeeze a few more dollars out of
Prozac, or Sarafem
, as the company had relabeled
it for treatment of PMDD. But despite (or perhaps because of) its corporate sponsorship,
the diagnosis ran into stiff opposition
from feminists who objected to the way that it pathologized what they considered to be a normal variant of human behavior. PMDD has turned out to be a bust. It’s still languishing in the back of the book and may even disappear completely when the DSM-V comes out in 2012.

Minor depressive disorder, on the other hand, seems like a shoo-in for advancement. To qualify, you only have to report three of
the nine depression criteria
, one of which has to be either a sad mood or loss of interest or pleasure in all, or almost all, activities. (Major depression requires five.) You could have trouble, for instance, eating and concentrating and, so long as you were also unhappy most of the time for most of the days in a two-week period in the last six months, you would qualify. By the time I got diagnosed, about twenty years after my bout on the floor of my study, I’d had enough disappointment and setback, not to mention nearly six years of the Bush administration, to ensure plenty of periods like that—none quite so bad as the first, but all of them unpleasant enough. I hadn’t exactly come to value this experience, but I’d learned to tolerate it the same way that you tolerate a difficult friend or watch a disturbing movie, and for the same reason: that you get something out of the bargain, some insight into the world, some glimpse of the way things are.