We are witnessing the rise of the anti-antidepressants.
The '90s, of course, were the age of Prozac, a decade when a class of antidepressants called SSRIs (selective serotonin reuptake inhibitors) came to dominate psychological treatment and public discusssion about why life in America had become such a downer -- even before 9/11. After Prozac's FDA approval in 1987, some 80 million new prescriptions for antidepressants were written in the next 10 years. It was as if America had suddenly caught a bad case of the Superpower Blues: Office visits to doctors for treatment of depression tripled.
With the pills came books. Along with volumes about the new psychopharmacology like Peter Kramer's bestseller, "Listening to Prozac" (1993), there were Martin Seligman's "Learned Optimism" (1992) and "Authentic Happiness" (2002), which helped launch "positive psychology," a broader attempt to understand not illness but happiness.
But soon enough the good feelings gave way to a backlash: Where there was once "Listening to Prozac," now there is David Healy's "Let Them Eat Prozac." "Authentic Happiness" has been countered by the newly published "Artificial Happiness: The Dark Side of the New Happy Class" by Ronald W. Dworkin. In 2005, it was Kramer's "Against Depression"; now it's Eric G. Wilson's "Against Happiness."
Yet the recent volley of books represents more than an attack on our current overreliance on drug therapy to treat depression. They rip into the massive sales of the drug companies, dispute the medical thinking behind doping the populace and question whether the antidepressant advocates understand depression, happiness or the human mind.
What happened in the '90s wasn't an epidemic of the blues or just a new biomedical discovery taking hold. In Charles Barber's compelling new book, "Comfortably Numb: How Psychiatry Is Medicating a Nation," the author contends that we underwent a major shift in attitudes toward mental illness and medications. Depression was redefined and popularized; the use of psychotropic drugs was greatly expanded to include what might be termed "personality repair."
And psychiatry became Big Science. Because of the speed and effectiveness of the new drugs in treating conditions that traditional therapies struggled with for years, psychotherapists lost their leadership in mental healthcare. Amazing advances in brain imagery and neurosurgery only heightened therapists' poky obsolescence. The bioengineers took over.
They weren't the only ones. The advent of managed care gave primary caregivers the power to greenlight treatments. This means that therapists are often dependent on the family doctor for patient referrals -- at least when the family doc isn't the one dispensing the pills. Of those 80 million new antidepressant prescriptions in the '90s, non-psychiatrists wrote 60 million. And if studies of primary caregivers are any indication, most of those diagnoses of depression were made in less than three minutes.
Once we add the multibillion-dollar weight of the pharmaceutical corporations behind some of these changes, we have what Barber calls "the Serotonin Empire": "a formidable testament to the ease and rapidity with which massive sociological change can occasionally be realized."
A counterrevolution by therapists, sociologists and humanists was probably inevitable. This was so not just because of their losses in prestige, income or turf. The mechanistic model of the brain that biological psychiatry is founded on -- block a neurotransmitter here, snip a tumor there -- is seductive but reductive. Almost by definition, it is mindless; it bypasses human consciousness entirely. It offers the illusion of mastery over thought.
Yet no direct link between serotonin and depression has been established. As "Comfortably Numb" notes, all of the new brain pills affect only four neurotransmitters. We're not sure how even those work, and there are more than a hundred others we haven't a clue about. We might as well be trying to map out a chess match when we're not clear how even the pawns move.
Accordingly, many current therapy books -- including "Comfortably Numb" and Dworkin's "Artificial Happiness" -- preach a degree of humility before the resistant complexity of the human mind (and of depression itself). Among other suggestions, they call for a greater acceptance of ordinary unhappiness as a temporary but unavoidable fact of life.
To that end, Eric Wilson's "Against Happiness: In Praise of Melancholy" is a loopy, feeble blow against the empire. The new book is a heartfelt defense of being bummed out. The chairman of the Wake Forest University English department, Wilson is Hamlet-mad for sadness. He extols depression the way 19th century aesthetes swooned over tuberculosis because it made them fashionably pale and broody.
Life means pain and death, Wilson repeatedly reminds us, and we must embrace these to find our "sorrowful joy." But most people are too harried and hollow to grasp this, too distracted by happy pills and shopping malls. We've probably never taken the time to walk through "autumn's multihued lustrousness ... with hearts irreparably ripped." Nor have we "stared for an hour at the sparrow lying stiff on the soiled snow."
No, never have. But they're at the top of my to-do list: ripped heart, dead sparrow.
In attacking our American way of happiness, Wilson is not suggesting we wallow in misery. There are severely depressed people out there; they need medical help. It is the enforced cheerfulness of contemporary consumerism that bugs Wilson, the great mass of "paper-thin minds" that can't appreciate the "luminous gloom."
Wilson actually makes sense on the irritations of our jollied-up culture or the need for normal grief. Lesley Hazleton made the same arguments, pre-Prozac, in 1984's "The Right to Feel Bad." Barber and Dworkin, among others, also cite our self-absorption, isolation and materialism as contributing factors. Americans gulp down chemical boosters whenever things aren't perfect. If that sounds harsh, consider that we report suffering from mental disorders at three times the rate of other developed countries.
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.