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The rise of depre$$ion

Depression “is in many ways a thoroughly social creation”

I think there are strong societal pressures to view “depression” in a particular narrowly defined way, and a brief look at how this has evolved can help us understand that the modern concept of depression “is in many ways a thoroughly social creation”7.

Deeply felt sadness, even despair, are of course nothing new and have been experienced by people throughout the ages. We meet this, for example, in ancient writings, including the Judeo-Christian tradition. Consider the laments of Jeremiah: “Oh, my anguish, my anguish! I writhe in pain. Oh, the agony of my heart! … My eyes fail from weeping, I am in torment within, my heart is poured out on the ground…1” Consider also Shakespeare’s Hamlet as he wonders if it is better to live or to die “To be, or not to be...To die, to sleep”.

Although the experience of depression is not new, the idea that so many of us are considered to be depressed is a very recent phenomena. According to the World Health Organisation (WHO), "Globally, more than 350 million people of all ages suffer from depression." The WHO also claims that "Depression is the leading cause of disability worldwide" 2.

There was a time when depression was rarely spoken about and infrequently diagnosed by doctors. Back in the 1950s drugs (known then as “psychic energisers”3) were already being prescribed for what today would be called depression. People did not commonly speak of being depressed in the way that we do today and those diagnosed as such were more likely to be psychiatric hospital inpatients than people living in the community. So, what has changed? Why are so many of us diagnosed as depressed today and prescribed antidepressants?

Clearly there has been a change in the way we think about depression. The counter-culture of the 1960s, with many people experimenting with recreational drugs – with so-called uppers and downers, and also with hallucinogenics (such as "magic mushrooms") – seemed to open the way for a desire for mood changing medicines. Although various so-called antidepressant drugs were developed in the 50s and 60s - it was what were then known as the "minor tranquillisers" (later re-branded as "anti-anxiety" or "anxiolytic" drugs for marketing purposes) such as Valium and Librium that really took off. Some of us are old enough to remember the Rolling Stone’s track “Mother’s Little Helper”, an ode to Valium (1967):

The age of depression

She goes running for the shelter,
Of a mother’s little helper;
And it helps her on her way,
Gets her through her busy day.

Historians 4 sometimes describe those times as "The Age of Anxiety" as people tended to think more in terms of anxiety rather than depression. It was a time when psychiatrists believed that 80% of depression was self-limiting and as such did not require treatment.  Yet today, figures for depression in England alone indicate near 5 million people. (For details on recent year-on-year rises in the prescriptions of antidepressants and cost to the NHS for antidepressants, see Sec 4.3 here, from the National Information Centre for Health & Social Care). According to NHS data the number of people living with depression in England has increased by nearly half a million in just three years. How things have changed.

Rather than being the exception, to go to a GP for concerns over depression has become the norm. If we speak of feeling down, a friend or colleague is likely to say: "Have you seen a doctor?" This change in how we think about depression has in many ways been driven by medicalisation, disease-mongering, and marketing: all fuelled by commercial interests rather than public healthcare concerns.

The medicalisation of depression

By “medicalisation” I refer to the practice of taking an ordinary function and reconstructing it as a medical disorder. This happens in general medicine too: lower the threshold for a particular disorder (often on a quite arbitrary basis) and millions of new patients (customers) are created overnight. This happened in 1997 when a committee (not new scientific research or evidence) changed the threshold for Diabetes 2: “Suddenly those previously considered to have normal blood sugar levels (between 126 and 140) now had diabetes”. This “change turned over 1.6 million people [Americans] into patients”5 overnight.

 
   
 
 
   
           
   

In a sense, the Age of Depression has replaced the Age of
Anxiety. In reality, the personal concerns and heart-felt pains
experienced by people are much the same - but re-branded for
commercial purposes into the modern-day diagnostic entity
"depression".

   
 

Something akin to this has happened with depression. Think about it like this. People experience a range of emotions that are an essential aspect of being human. On the down side we become sad, anxious, fearful, and desperately low (and even despair). It could be work, stress, people, circumstances – a whole spectrum of situations, people and concerns weigh heavily upon us. We are not ill, we don’t have a medical condition - and that’s not to minimise the distress and suffering associated with feeling depressed.

But in the public and professional (psychiatric) perception a change has occurred: distress is now an illness and has become an aspect of a physician’s responsibility. As Dr Iona Heath points out, “disease mongering relies on the pathologising of normal biological or social variation. 6” This is what has happened with the construct of depression, and it is of course “in the interests of pharmaceutical companies to extend the range of the abnormal so that the market for treatments is proportionately enlarged.” 6

A key factor in the medicalisation of depression was a radical change in the way depression was defined and thus diagnosed. This came about with the publication of the DSM-III reference book in 1980 by the American Psychiatric Association. These classification changes “transformed a condition that was thought to be very serious and rare into one that was extremely common”4 - thus changing the way we think about depression. From now on people who are sad, weary with work, wrestle with interpersonal difficulties and the like have a diagnosable disease, a “depressive disorder” 4. Well, that’s what people were led to believe even though the diagnostic changes were bereft of scientific substance. Public perception about depression radically changed so that “while as recently as the late 1970s depression was a relatively uncommon disorder, just fifteen years later it had become a public health problem.” 7

Drug companies also recognised the potential for re-framing our everyday emotional and mental distress as a medical condition that supposedly needs drug treatments. Here in the UK there was a carefully orchestrated campaign to extend the boundaries of what constituted depression. This was the 5-year “Defeat Depression Campaign” (1992-1997) which helped raise prescriptions for antidepressants by well over 200% in Britain within just 10 years. “Coincidentally”, this was at a time when the drug companies were releasing newer antidepressants (following on from the release of Prozac after its licensing in 1987) onto the market. 

By the 1980s it was widely known that the benzodiazepines (the so-called anti-anxiety drugs) were seriously addictive and harmful. The drug companies tried to keep a lid on this news for as long as possible (not dissimilar to the tobacco companies fighting earlier assertions that smoking is linked to cancer). At that time many people who were reliant upon the so-called anti-anxiety drugs were then being prescribed antidepressants - which the Defeat Depression Campaign was keen to promote as non-addictive. (How history repeats, as today millions of people struggle to come off these antidepressants).  In fact, the Hamilton Rating Scale for Depression (HAM-D) originally devised in 1960, is in some ways testing for anxiety – thus, in psychiatric diagnosis the boundaries between depression and anxiety are often merged.

The misleadingly called “Defeat Depression Campaign” was largely funded by manufacturers of the SSRI antidepressants (like Prozac) and aimed to help GP's better recognise depression (that’s the new liberal version of depression) and to encourage the public to be more likely to seek treatment (synonymous with drugs in this context). “Only two years into the campaign, over 3 million leaflets about depression had been circulated to the public and many other initiatives had been sponsored as well 8.” Essentially, it was a marketing promotion campaign for depression and the need for antidepressants that co-opted the endorsement of the Royal College of Psychiatrists and the Royal College of General Practitioners.

And now to the present day. It only takes one small change to make an enormous difference in the numbers of people being diagnosed as depressed. The recently published diagnostic guidelines, DSM-5, make it possible for the sadness of grief to be diagnosed as depression if this lasts for more than two weeks. Previously (with DSM-IV) the time considered appropriate for normal grieving was two months. Both of these are sheer folly as any reasonable person knows that grieving takes not just months but years too. As we read in the Lancet medical journal: “Medicalising grief, so that treatment is legitimised routinely with antidepressants, for example, is not only dangerously simplistic, but also flawed…Grief is not an illness; it is more usefully thought of as part of being human and a normal response to death of a loved one. Putting a timeframe on grief is inappropriate.”9

In a sense, the Age of Depression has replaced the Age of Anxiety 4. In reality the personal concerns and heart-felt pains experienced by people are much the same - but re-branded for commercial purposes into the modern-day diagnostic entity "depression".

Whilst it is true that the idea that many of us are depressed is being promoted for commercial gain, it is equally true that there is much about modern life that can get us down [see my web here]. We look at what might help those who feel depressed here.

References - Bibliography - Further reading

1 The Bible. Jeremiah 4:19; Lamentations 2:11

2 WHO here

3 Moncrieff, J. (2008) The Myth of the Chemical Cure. UK: Palgrave MacMillan

4 Horwitz, A. (2011) Creating an Age of Depression: The Social Construction and Consequences of the Major Depression Diagnosis. Society and Mental Health. American Sociological Association 2011 1: 41

5 Welch, H.G. (2011) (With Schwartz, L.M., Woloshin, S) Over-diagnosed: Making people sick in the pursuit of health. Massachussets: Beacon Press.

6 Heath, I. 2006  Combating disease mongering: Daunting but nonetheless essential. PLoS Medicine April 2006 Vol 3 Issue 4. Available here.

7 Grob, G. & Horwitz, A. (2010) Diagnosis, therapy, and the evidence: Conundrums in modern American medicine. Rutgers University Press.

8 Medawar, C. 1997 The antidepressant web: Marketing depression and making medicines work. International Journal of risk and safety in medicine, 1997, 10, 2 75-126. Available here

9 The Lancet, Volume 379, Issue 9816, Page 589, 18 February 2012. Full article here

 
         
 
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