Exploring the Evolution of Depression

CONVERSATIONS IN CRITICAL PSYCHIATRY

Jonathan Sadowsky, PhD, is the Theodore J. Castele Professor of the History of Medicine and Associate Director of the Program in Medicine, Society, and Culture at Case Western Reserve University, Cleveland, Ohio. He holds secondary appointments in the Departments of Bioethics and Psychiatry. He earned degrees in history from Wesleyan (BA), Stanford (MA), and Johns Hopkins University (PhD); he also studied psychiatric epidemiology at Columbia University. He is the author of Imperial Bedlam: Institutions of Madness and Colonialism in Southwest Nigeria (University of California Press; 1999); Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy (Routledge; 2016); and The Empire of Depression: A New History (Polity Books; 2020). His articles have appeared in journals including the Journal of the History of Medicine and Allied Sciences, Harvard Review of Psychiatry, Bulletin of the History of Medicine, and History of Psychiatry.

Awais Aftab, MD

Dr Sadowsky is a leading historian of psychiatry, and one I am proud to call him my teacher. As a psychiatry resident, I attended his lectures on history of psychiatry as part of our residency didactics and benefitted greatly from them. Sadowsky was previously interviewed for Psychiatric Times^TM in 2017 by Greg Eghigian, PhD, about his book, Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy, an interview that is well worth revisiting. The present interview is about his new book The Empire of Depression: A New History. I admire Sadowsky for his ability to tackle complex and controversial issues with scholarly rigor and fair-minded appraisal, and I am delighted to have him participate in this series.

AFTAB: I suppose some folks, on hearing the title of your new book, may reflexively think, “What…another book about depression? Don’t we have enough of those already?” In your opinion, why was a new history of depression needed?

Jonathan Sadowsky, PhD

SADOWSKY: Interestingly, not many of the books about depression are histories. Take The Noonday Demon: An Atlas of Depression by Andrew Solomon, PhD.¹ I think it is great, but it has only a single chapter on history, and it is a brief account. In addition, with a few exceptions, most of the history books are focused on antidepressants, but many other treatments have important histories—psychodynamic psychotherapy, cognitive behavioral therapy (CBT), electroconvulsive therapy (ECT), and the many approaches that were taken prior to the 20th century, for example.

A couple of long, detailed histories of depression barely mention ECT. This is weird. I know opinions about ECT are divided—my book about ECT is also about that controversy. However, whatever you think about ECT, many psychiatrists consider it among the best treatments psychiatry has for serious affective disorder. Imagine for a moment a medical historian in another specialty writing a long history of a particular ailment, and then only briefly noting a treatment many doctors say is among the most effective! Previous histories of depression have also been a bit weak on psychoanalysis, which is a strong interest of mine.

Little existing historiography of depression focused on patient experiences and self-representations. This is not an easy area to research, because a lot of depression treatment takes place in private office practice, a confidential setting, and documentation is not really publicly available. I would have liked to do more, but I hope I pushed the field a little in that direction. I want to add immediately that some historical and other critical studies of psychiatry see patient voices as only a way to criticize psychiatry. It is important to document patient complaints, but some critics of psychiatry go to tortuous lengths to deny any therapeutic benefits. Honoring patient voices also means seeing that many feel helped by treatment.

I also wanted to draw attention to the politics of inequality. Like so many other illnesses, depression hits different populations to different extents. Solomon drew attention to this, but most of the historical work on depression restricts inquiry to the gender ratio, which is an important axis, but not the only one. Class, race, and LGBTQ+ status, for example, also matter for depression, and I hope future historians will develop this further.

Finally, I wanted to make the story more global, less focused entirely on the West, and especially the United States, although I do give the United States a lot of attention. Anthropologists and global mental health workers have looked at the wider world, but historians really have not done so for depression. I would like to have gone further here, too, and I hope others will.

AFTAB: What I love about your book is that it does not settle for easy answers. It embraces the uncertainty, ambiguity, contradictions, and flux inherent in the very subject matter. One of the difficulties with studying depression is it’s a fluid entity, with variations across both time and space. Is depression the same today as it was in the 17th century when Robert Burton wrote The Anatomy of Melancholy? Is depression the same thing in the United States and, say, Nigeria? These are obviously thorny issues. Can you elaborate on the approach you take to address this? How can we tell a coherent history of something if we are having a hard time pinning down what that something is?

SADOWSKY: The various illness categories—or, as it may be in some contexts, conceptions that are not illness categories—are already included in a long-running discussion of the comparability of diagnostic categories and sickness experience across time and space. The discussion is a story itself.

Most of the illness states I compare have a core feature, which is excessive sadness or blue mood, in whatever that particular context considers excessive. But some definitions of depressive illness consider this a common, but not necessary, feature for diagnosis. As you know, DSM-5 does not require depressed mood as a necessary criterion for major depressive disorder (MDD), provided there is loss of interest and 4 other symptoms. I draw (lightly) on the concept of family resemblances Ludwig Wittgenstein, PhD: Things do not need precise overlaps to have similarities that justify comparison.² For all the imperfections of the DSM, I think if you look at the menu of symptoms for MDD, they do form a constellation of related signs of suffering that have been clumped together in disparate contexts.

Overemphasizing cultural differences has its own risks. I show in chapter 1 the idea that African societies had little or no depression had roots in some frankly racist ideas. Universalizing labels can be a form of cultural imperialism, but overinsistence on difference forecloses possibilities for meaningful comparisons. And some who think depression is a purely modern or Western illness might be surprised at how many cultures, across time and space, have had some conception of excessive sadness as a malady.

Chiara Thuminger, PhD, is a great historian of madness with whom I am collaborating on a new project.

She has set forth 4 principles for comparisons across time and space³:

1. The human mind is biological, a part of a shared evolutionary heritage, so you can expect some measure of universality.

2. The mind and mental life are not confined to the brain, but involve other parts of the body.

3. Mind and brain are situated in and shaped by culture, so universality will always be limited.

4. Every individual has an irreducible quality, uniqueness.

I think these are great principles to keep in mind.

AFTAB: You are clearly dissatisfied with a lot of popular critiques of depression. You write, “One thing this book is not is a long lament on the overdiagnosis of depression, and the turning of life’s normal suffering into a medical problem.” Tell us more about your dissatisfaction with this line of criticism.

SADOWSKY: Many people look at the high numbers of individuals with a depression diagnosis compared with previous times and take it as self-evident that we are overdiagnosing. It is not. Rising diagnosis rates is a valid reason for concern about overdiagnosis, but it is not proof. In 1950, much of psychiatry was concerned that we were underdiagnosing depression, so from that perspective, we may be finding a lot that we had been missing. We should at least consider the upside: More diagnosis means that more individuals who could use professional help are getting it.

As for medicating the normal pain of living, we should keep in mind that getting treatment for depression, whether in psychotherapy or with antidepressants, does not protect anyone from suffering, although one hopes it is reduced. Life remains hard. And many patients with depression welcome sadness as a relief from feelings of deadness or numbness inside.

In the book, I offer some defense of antidepressants against their most severe critics. But I also think we are probably overreliant on antidepressants. I think the benefits of psychotherapy, particularly long-term insight-oriented therapy, have become underrated in the antidepressant era.

Still, why some advocates of psychotherapy are so adamantly and categorically opposed to any medication use, or to any suggestion of a biological component to depression, is a mystery to me. I have read many hardline critiques of biological and pharmaceutical psychiatry that are focused on whether the evidence for efficacy is robust, or questioning the philosophical underpinnings of the enterprise, or worried about adverse effects, or indicting the pharmaceutical industry. The thoughtful challenges have reinforced my view that we are overreliant on drugs, at least for some populations. Other critiques have struck me as dogma masquerading as critique. But even the smartest of them have not convinced me that antidepressants are worthless, a claim several important voices have made.

The biology of depression is incompletely known, and much of it may remain permanently elusive. However, the idea that depression is purely psychological is, I think, implausible. Yet, so is the view that depression is purely biological. The dichotomy itself is the problem. Mark Solms, PhD, said that mind and brain are 2 ways of looking at the same thing. I find this more helpful. I do not understand how something could affect either the mind or the brain independently of the other. That is not a coherent idea.

I am getting away from your question a little, but it is an important point. Proponents of a life history emphasis in etiology sometimes take it as self-evident that if trauma or neglect is the cause, the better solution must be psychotherapeutic, as opposed to somatic. Psychotherapy might be the better treatment, but it is not self-evident just from the etiology. And the reverse: Individuals who lean toward more organic theories of etiology—genes, brain chemistry—sometimes take it as self-evident that the better solution must be something more physical, like a drug or ECT. Again, this could be true, but it is far from self-evident. In any event, I think monocausal approaches to etiology are misguided.

AFTAB: You write at one point, “The growing interest in depression led more people, both professional and lay, to learn to label problems as depression, which was a growing idiom of distress before the advent of antidepressants . . . The medications, though, provided new incentives for multiple actors—pharmaceutical companies, doctors, patients, and patient’s families—to identify cases of depression.”⁴ I suspect you would have been writing a very different history of depression if antidepressant medications had not been developed, or if their use had continued to be severely restricted due to tolerability.

A curious thing, however, is that anxiety disorders are more common in the general community than depressive disorders, and antidepressants such as selective serotonin reuptake inhibitors (SSRIs) are not just antidepressants but also antianxiety medications. We could perhaps imagine an alternative history in which anxiety was the idiom of distress, SSRIs had been marketed as antianxiety rather than antidepressant, and you would perhaps be writing a book about the empire of anxiety, and the continuous historical links between melancholia and anxiety! Is it merely an accident of history that we ended up in the age of depression rather than the age of anxiety?

SADOWSKY: Cross-cultural study has shown that the separation of anxiety and depression is a convention of Western psychiatry (which is rapidly becoming a global or cosmopolitan psychiatry, with both good and bad effects). Many healing systems around the world assume anxiety and depression are aspects of a single thing. And even in the West, the separation is somewhat new, a Kraepelinian innovation.

You present an interesting counterhistory. However, I am not sure the trajectory has been solely drug-driven. When the monoamine oxidase inhibitors and tricyclics were developed, psychiatrists were looking for depression treatments, and they had been doing so for decades. That is partly why these drugs came to be called antidepressants.

One curious thing is that important anxiety medications and antidepressants were introduced around the same time, and yet from a broad cultural point of view, we had first an age of anxiety—the immediate postwar period—followed by an age of depression, which started sometime in the 1970s and became more visible in the 1980s. In what I consider the most speculative portion of my book, I try to understand those periods as possibly representing wider cultural moods, perhaps rooted in different forms of capitalism. As speculative as that section is, I included it because I thought it was worth thinking about.

AFTAB: You don’t spend much time discussing the creation of MDD as a diagnosis in DSM-III. I wonder how different the future course of events would have been in the absence of such a diagnostic category. If you look at DSM-II, depression was fragmented across many different sections under many different diagnoses. In DSM-II, we had diagnoses such as involutional melancholia, manic-depressive illness, depressed type, psychotic depressive reaction, depressive neurosis, and neurasthenic neurosis. I suspect that this DSM-II organization of depression would not have been particularly conducive to the process of empire-building!

SADOWSKY: That is a great question, and I could have given this change more attention in my discussion of the DSM. However, I wonder if the creation of the category (if not the precise name) of major depressive disorder was already in process before DSM-III, reflecting the growing research interest in depressive illness in the years preceding the revision of the manual.

AFTAB: When I look back at the evolution of depression, a pair of developments in recent decades appear to me to be notable, although their historical significance is probably yet to be seen. The first is the notion of treatment-resistant depression (TRD). This has led to more aggressive pharmacotherapy, such as augmenting with atypical antipsychotics, and the relatively recently approved medication esketamine.

The second is that bipolar disorder has been steadily encroaching on the territory of depression, such that even in the absence of mania or hypomania, many psychiatrists classify the presentation as being on the bipolar spectrum. Just as the development of antidepressants led to an increase in the diagnoses of depression, development of medications for bipolar depression have led to an increase in the diagnoses of bipolar disorder. Any preliminary thoughts of these developments as a historian?

SADOWSKY: It is, of course, awful that some depressions are so hard to treat. I am not a clinician, but I wonder if many of those that seem resistant to aggressive medication treatment might respond to intensive psychotherapy, which can be expensive, or to ECT, which has risks of adverse effects (risks which are, in my opinion, generally greater than the risks of antidepressants, although I think in some cases, the risks may be worth it).

As a historian, however, I would ask if the whole category of TRD does not actually represent some progress, since it implies the other kind. A 19th-century alienist could not do much about any severe depressions at all. Many of my colleagues in history of medicine, and especially history of psychiatry, get nervous at any hint of a progress narrative, but I do not mind saying I think we have a better repertoire of treatments for depressive illness now than we did in 1850. All the treatments have downsides, but that is true of medical treatments in general.

I am aware of the rise of bipolar diagnosis, but I have not followed it closely. From a practical point of view, of course, what matters about a label is matching the individual in pain to the best treatment possible, and that is a clinical question. My historian’s take is: The safest prediction is that changes in diagnostic fashions are going to keep happening, and they will not necessarily be driven by genuine scientific advance. The whole enterprise is not worthless, but we should not assume the present trend represents the final or best word. On this point, I do worry about progress narratives.

AFTAB: In a very memorable passage of your most recent book, you compare history with psychoanalysis: “[P]atients are locked into repeatedly telling the same story about themselves— about their loneliness or their victimization, for example. The therapy helps patients see that they do not have to repeat the same story. They can tell new stories of their lives. History can have a similar role . . . We do not have to live the same story, time after time.”⁴ Later, in the epilogue, you again refer to history as a means of guarding against compulsive repetition. Can you summarize what history tells us we can do differently going forward when it comes to depression?

SADOWSKY: I will name 2 things. First, we do not need to keep having the same arguments about whether depression is fundamentally biological, or really the result of trauma in life, or the result of social forces. I fear that we will continue to do just that, because of the tenacity with which some individuals hold to the insistence that we must choose. It is my hope that by showing historically how insistence on a single approach leads to dead ends, we might be liberated from it. In the epilogue, I used the image of a quarreling couple, stuck in the same fights for decades on end. A good marriage counselor might be able to remind each partner that the other has things to offer.

I also hope we might be liberated from the cycle of hype and disappointment about new treatments. Most of the major treatments for depression over the last century (psychoanalysis, ECT, CBT, and antidepressants) have been overemphasized by some zealous proponents. Then disappointment (dare I say, depression?) comes when the harms or limitations of the treatments become clear. In turn, we rush to condemn the old treatment as worthless and latch on to something new, which is thought to lack the flaws of the earlier ones. But the old treatments still had something to offer, and the new ones prove to have flaws, although we may not see them right away.

New treatments are going to come, as they should. When they do, let us try not to overdo the hype, the radical rejection of the old ones, or the disappointment in the new that follows. In addition to helping patients overcome repetitions, psychotherapy can help patients to see individuals in and things in their complexity. Sometimes we, as professionals or as whole societies, can act like an individual searching for love, and finding partners we initially idealize, only to come to despise them when they inevitably disappoint us. We would do better to tolerate ambiguity. I hope Empire of Depression might help to foster that toleration.

AFTAB: Thank you!

Conversations in Critical Psychiatry is an interview series that explores critical and philosophical perspectives in psychiatry and engages with prominent commentators within and outside the profession who have made meaningful criticisms of the status quo.

The opinions expressed in the interviews are those of the participants and do not necessarily reflect the opinions of Psychiatric Times^TM.

Dr Aftab is a psychiatrist in Cleveland, Ohio, and clinical assistant professor of psychiatry at Case Western Reserve University. He is a member of the executive council of Association for the Advancement of Philosophy and Psychiatry and has been actively involved in initiatives to educate psychiatrists and trainees on the intersection of philosophy and psychiatry. He is also a member of the Psychiatric Times^TM Advisory Board. He can be reached at awaisaftab@gmail.com or on twitter @awaisaftab. Dr Sadowsky is the Theodore J. Castele Professor of the History of Medicine and Associate Director of the Program in Medicine, Society, and Culture at Case Western Reserve University, Cleveland, Ohio. He holds secondary appointments in the Departments of Bioethics and Psychiatry. He earned a PhD in history from Johns Hopkins University and also studied psychiatric epidemiology at Columbia University. He has authored numerous articles and books, most recently The Empire of Depression: A New History (Polity Books; 2020).

Dr Aftab and Dr Sadowsky have no relevant financial disclosures or conflicts of interest.

References

1. Solomon A. The Noonday Demon: An Atlas of Depression. Simon & Schuster; 2001.

2. Wittgenstein L. Philosophical Investigations. Basil Blackwell; 1953.

3. Thumiger C. A History of the Mind and Mental Health in Classical Greek Medical Thought. Cambridge University Press; 2017.

4. Sadowsky J. The Empire of Depression: A New History. Polity; 2020. ❒