Down, but Not Out
Why have diagnoses of depression reached near-epidemic proportions in our time?
Edward Shorter. How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown. New York: Oxford University Press, 2013. 272 pp. $29.95.
Are we crazier than we used to be? Thousands of pages have been dedicated to addressing this question during the past half century. Since psychiatry began crystallizing as a distinct medical specialty in the 19th century, the proportion of the population deemed of “unsound mind” has continued to increase at a fairly steady rate. Oft-quoted statistics note that one in four American adults suffers from mental illness in any given year and that an even larger proportion will deal with psychiatric problems at some point in their life. The consequences extend beyond an individual’s pain into the rest of society; mental illness has become the leading cause of disability in much of the Western world and beyond.
How did this come to be? Historians, sociologists, and professionals across the medical spectrum have put forth a variety of widely debated possibilities. Are we medicalizing previously “normal” behaviors, like shyness, by transforming them into conditions, such as social anxiety disorder? Has the world become a more stressful and lonely place, driving people into fits of despair and anxiety? Have dietary changes and a proliferation of air pollutants damaged our neurochemistry? Although no consensus has been reached on why the increase has occurred, few doubt that rates of depression, anxiety, obsessive-compulsive disorder, and a host of other illnesses are far greater than they were a century ago.
In How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown, historian Edward Shorter proposes a novel hypothesis that attempts in part to explain the boom in mental illness. Put simply, Shorter argues that the epidemiological explosion characterizing rates of depression, anxiety, and other diagnoses can be attributed to a “lost condition” he terms “nerves.” In the past many (and perhaps most) people currently diagnosed with “mild” psychiatric illnesses would have been seen as suffering from a “nervous condition.” Tracing the history of psychopathology over several hundred years, Shorter makes the case that medical science has lost track of “nerves”—a condition characterized by fatigue, mild depression, anxiety, a touch of compulsive thought and actions, and myriad physical ailments without clearly identifiable causes, such as insomnia and bowel complaints. In place of “nerves” we see epidemics of generalized anxiety disorder, obsessive-compulsive disorder, panic with agoraphobia, and an array of other modern psychiatric illnesses, most notably major depressive disorder.
This transformation did not occur by happenstance. Shorter identifies three primary culprits for the rise in depression diagnoses.
First, he singles out the psychoanalytical movement for criticism. In Shorter’s account Freud and his associates played a crucial role in shifting the focus of psychiatric inquiry from the body to the mind. By making the mood-centric “depressive neurosis” label the standard, psychoanalysts helped unseat “nerves” (which had a strong physiological component) and launched depression’s ascension to the most common psychiatric diagnosis.
Second, Shorter believes that the rise of depression as the most common psychiatric ailment could not have happened without the active participation of the American Psychiatric Association (APA), the organization responsible for drafting psychiatry’s so-called Bible—the Diagnostic and Statistical Manual of Mental Disorders (DSM). In 1980, with its third revision of the DSM, the APA fundamentally altered the way medical professionals and the public approached the concept of mental disorder. Shorter’s account of the horse-trading that characterized the revision process is magnificent. His blow-by-blow description reveals the tug-of-war to outline exactly what qualified as mental illness and how best to describe it. Ultimately, he suggests, the DSM-III served to further carve up the concept of the nervous condition, splitting it into a series of discrete (and less severe) diagnoses. In the process it became much easier to identify mental pathology in any given individual since the threshold for illness became much easier to satisfy.
Third, like a number of other critics, Shorter identifies the central role played by the pharmaceutical industry in loosening the criteria required for someone to qualify as suffering from mental illness. Shorter does not reject the use of psychopharmaceuticals: he is a keen defender of their usefulness for those suffering from debilitating melancholic depression. But he suggests that the epidemic of depression that has gripped us since the 1960s could not have happened without the concept of antidepressants. Shorter demonstrates that most scientists working on the biological foundations of mental illness have never accepted the so-called chemical imbalance theory, the notion that complex mental states can be reduced to the abundance or dearth of a single neurotransmitter, like serotonin or norepinephrine. That being said, the imbalance theory has proven to be a brilliant marketing tool easily digested by both prescribers and the public. Millions and millions of prescriptions later, the depression epidemic is still in full swing.
In brief this book does a masterful job highlighting the precarious nature of how we define mental disorder. Shorter demonstrates the elasticity of psychiatric illnesses and reveals the absence of, for now, any universally agreed-on test to prove their existence. By examining the ways in which the diagnosis of “nerves” has been balkanized into a number of discrete (and in his view illegitimate) categories of illness that are much more laxly diagnosed, Shorter offers yet another intriguing answer to the question of why rates of mental illness have skyrocketed in the past century.