With Wilson, the luminous gloom is mostly swamp gas. He admits he doesn't "do" happiness; melancholy is his true nature. So it's not really his moral or aesthetic choice, is it? Despite his protestations to the contrary, Wilson sounds like a goth kid sneering at the popular students: My moodiness makes me profound. I appreciate Herman Melville and you don't.
It's precisely this mystique of depression, its long association with soulful introspection and creative genius, that Peter Kramer took apart in "Against Depression." Kramer wanted to scrape away the "heroic melancholy" of depression to look at it face-on as a real disease. Depression acts like a multisystem illness; it damages the brain, it ages people.
Yet by the time he wrote "Against Depression" in 2005, Kramer's impassioned call for treating mood disorders as diseases -- treating them with antidepressants and therapy -- had more than swept the field. Or at least the antidepressant part had. Zoloft's American sales that year, $3.1 billion, exceeded those of Tide detergent.
Americans, it seems, no longer need convincing that depression is biochemically caused or treatable. We like quick fixes. We like drugs.
So we were more than receptive when depression was redefined during the '80s and '90s. Mercifully, as one of Tony Soprano's henchmen explained, depression has lost some of its "stigmata" -- it's just a chemical imbalance now. But this also made depression more accessible. The pivotal point came in 1980 with the third edition of the Diagnostic and Statistical Manual of Mental Disorders, the DSM-III. Dr. Robert Spitzer of Columbia University led the expanded revision of the reference work, and in order to sidestep the escalating turf war between psychiatrists and physicians for control of mental healthcare, he chose a "theory-neutral" term. What had previously been labeled "diseases" or "reactions" were now called "disorders."
A neurosis by any other name should feel as bad. But, Barber says, consider "social anxiety disorder" (i.e., shyness -- one of the many common conditions for which SSRIs are now prescribed): If it were called social anxiety disease -- with the herpeslike implication of infection -- how many of us would chat about it at parties?
One unintended consequence of defining depression downward has been an inability to distinguish -- with any accuracy -- severe depression from garden-variety glumness. Drug companies and doctors started a cascade, a blurring of categories between depression and anxiety, anger, laziness or low self-esteem. Treating them represented a huge market expansion into "lifestyle issues." As a result, millions of people have been prescribed pills -- that is, treated as if they were ill -- when they were just feeling, well, sad.
In "Artificial Happiness," Ronald Dworkin (not to be confused with the legal scholar) takes a wide-ranging, thoughtful view of this history. An anesthesiologist, a political philosopher and a traditionalist, Dworkin sees these changes as "ideological," representing a turning away from organized religion as a spiritual comfort. The pharmaceutical companies are just an easy target, he contends; they didn't prompt our pursuit of convenient happiness.
Maybe so, but in "Comfortably Numb" and "Let Them Eat Prozac," Big Pharma still has a lot to answer for. For starters, the drugs aren't even that effective: In treating mild depression, they're no better than placebos. Their list of possible side effects now begins with sexual dysfunction and extends to anxiety, agitation, nightmares and suicidal feelings -- the very problems they're supposed to resolve.
Yet almost every major company is being investigated criminally or civilly for allegedly trying to promote their drugs beyond their approved uses. Drugmakers like GlaxoSmithKline (makers of Paxil) cynically turned 9/11 into a sweet marketing opportunity -- their ads blossomed after the attacks. Even with all their profits, the companies are not bothering to research new wonder drugs; they're just milking the cash cows they have. Consequently, the market has turned especially competitive and nasty: The companies have helped turn the FDA into a toothless tiger, and they pay doctors to belittle rival products in medical journals.
So much for federal oversight or scientific rigor. Not surprisingly, Big Pharma has joined Big Oil as one of the most reviled industries on the planet. But as several of these books also make clear, there's plenty of blame to dole out. In my experience, the Serotonin Empire continues to expand for a simple reason: Try getting your company's health insurance to cover the expense of counseling. Odds are, it won't. But it'll pay for pills.
In "Comfortably Numb," Barber brings a street-smart perspective to all this: He worked for years with homeless psychotics in New York -- like the schizophrenic Irishwoman who thinks there is a tracking device implanted in her vagina. Accordingly, "Comfortably Numb" has a degree of sardonic anger powering its torrent of data and case studies: The psychotics he used to handle aren't benefiting much from the wonder drugs. It's the neurotics, Barber notes, who pay cash.
In the second half of "Comfortably Numb," Barber offers something several of the other books don't: practical, therapeutic alternatives to antidepressants, notably cognitive behavioral therapy. CBT has repeatedly been shown to be as effective as drugs in managing mild to moderate depression. It seems there is something to be said after all for psychotherapy's strengths, for narrative and context and conscious reform.
The drawback of CBT is that it requires time and work from a patient. And for the healthcare industry, there is little to sell beyond the current volumes that explain CBT techniques. Where's the profit?
None of the therapy authors mentioned here is opposed to antidepressants per se. They recognize that SSRIs can work. And at this date, turning back the wave of antidepressants may not be possible. In "The Loss of Sadness," Allan Horwitz and Jerome Wakefield hope that the DSM-V, set for release in 2012, will start a tidal shift by redefining depression more rigorously. It's a slender hope.
But better informing patients about what they're getting into certainly is possible, as well as combining antidepressants with counseling, one of the most effective options. Barber recognizes that changing our drug therapy culture will require more than just another behavioral repair kit like CBT. At the least, it will involve refiguring healthcare coverage and government policies.
In the '30s, bandleader Ted Lewis used to sing out, "Is everybody happy?" Actually, we never were. We probably never will be. But with care and effort and counseling -- and when needed, with properly managed drug therapy -- many of us can learn to live with that.
About the writer
Jerome Weeks is a long-time book critic in Dallas and a blogger for Artsjournal.com.
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