How Everyone Became Depressed (20 page)

As early as World War I, depression became a significant diagnosis. In 1912 the New York Times, in one of its earliest uses of the term depression in connection with suicide, noted the death of Professor Robert Syms in the Manhattan State Hospital of “depressive insanity.” Professor Syms had been ill on several occasions and initially was taken to Bellevue Hospital in Manhattan “suffering from melancholia and mental depression.”
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Thus did depression begin its strut. In 1926 Farquhar Buzzard spoke at a meeting of the Section of Neurology and Psychology of the British Medical Association. “Dr Buzzard believed that this psychosis [manic-depressive ‘psychosis’] was very common, if not the commonest, mental disorder; it was rarely recognized, except by experts; but its recognition was a matter of great practical importance in relation to prognosis and treatment. It was as common as migraine … ”
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Today we think migraine afflicts around one in 10 people. That would have made the depression of Emil Kraepelin’s manic-depressive illness common indeed among Buzzard’s upper-middle-class practice.

At the Maudsley Hospital the percent of inpatients with a diagnosis of “depression” in selected years from 1924 to 1938 totaled 38% and of outpatients 25%.
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Again, these are sizable figures.

At the Basel university psychiatric clinic between 1945 and 1957, the number of patients “with depressive manifestations” increased more than five-fold, as Paul Kielholz told a Montreal meeting in 1959. “It is particularly marked in respect of female patients with reactive depressions, melancholias and involutional depressions.”
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Psychoanalysis was all the rage in Switzerland in these years, yet these are not Freudian diagnoses, and the Basel department of psychiatry was not a hotbed of depth psychiatry. So clearly, something had changed in the Swiss medical gaze to make all these patients, who previously would have received other diagnoses, now appear depressed, or to give these female patients in particular, who previously might have just been considered unhappy, medical labels.

At psychoanalytic centers as well, the frequency of depression diagnoses increased enormously in these years. At the C. F. Menninger Memorial Hospital, a psychoanalytic redoubt in Topeka, Kansas, 8% of patients had depression as their syndrome diagnosis in 1945 and 30% in 1965. (The patients received a character diagnosis as well as a syndrome diagnosis.)
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At the Massachusetts Mental Health Center, which increasingly became a bastion of psychoanalysis after World War II, there was a huge shift from “manic-depressive illness,” a Kraepelinian diagnosis of mainline psychiatry, to depressive reaction, a diagnosis that demanded psychotherapy. Cases defined as manic-depression declined from 71 in 1945 to 25 in 1965, and over those years the number of depressive reactions rose from 6 to 110. (Of these patients 82% were female and 51% were below the age of 30. The hospital abolished its ECT service. “The admission of young, bright, and verbal patients who are suitable for psychotherapy is encouraged.”)
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Depression, as a diagnosis easily given, increased in other settings as well. Willi Mayer-Gross was not a psychoanalyst, but in 1959 this refugee who imported German science to English clinical psychiatry saw which way the wind was blowing: away from neurosis and toward depression. “Illness seems to manifest itself nowadays … very much more by means of depression than by neurosis, so that depression is common enough in general practice if one care to look for it.”
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By World War II depression had become the standard term for any accumulation of symptoms involving fatigue, anxiety, and so forth. But this was a depression that was far from melancholia. In fact, many of the patients who got the diagnosis did not even seem depressed. As John Dewan, a psychiatrist trained in England but teaching at the University of Toronto, said in 1952, “An outstanding feature of mild depression is that the patient rarely complains of feeling depressed and often does not appear particularly despondent.” The patient was not slowed in thinking and acting. He might admit that his mood was “down” if questioned about it, “but attributes this to discouragement with the persistence of his other symptoms. Early and continuous complaints are fatigue, difficulty in concentrating and lack of interest.” Insomnia, lack of appetite, and loss of weight accompanied the description of “feeling ‘neutral,’ as if a ‘pall’ had settled over him.” There would be various pains and gastrointestinal upsets. “The patient is inclined to explain his illness on the physical disturbances.” There were seldom any physical or laboratory findings. “It is sometimes difficult to differentiate between anxiety states and mild depressions when features of both may be present,” said Dewan.
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That Dewan would implicitly assume the underlying diagnosis was depression shows what vast strides the diagnosis had made in these years.

In the 1950s depression began to expand from a doctors’ diagnosis to become a folkloric diagnosis, in the sense that this is what most people believe they have and they have the symptoms to prove it. In England and Wales in 1956, only 2.9 patients per 1000 population received the diagnosis of depression from their family doctor
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; very few, in other words. A systematic review of the literature in 2004 on the occurrence of depressive illness found the 1-year prevalence of “major depressive disorder,” “dysthymic disorder,” and “bipolar disorder I” combined to 6.8% per 100 population, in other words, more than 20 times higher than the earlier English doctors’ diagnosis rate.
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Clearly in the 1950s and 1960s, many patients did not realize they were depressed; they were unfamiliar with the term. A. M. W. Porter, a general practitioner in a small town in the county of Surrey, England, told his colleagues in 1972, sure, patients learn sooner or later to say that “It’s my depression again, doctor.” Porter continued, “But there has to be a first time when the patient has not been conditioned to say ‘I am depressed, doctor.’ This is a ‘doctor phrase’ rather than a ‘patient phrase’ and results from the constant reiterated question, ‘do you feel depressed’? The new patient will present with one or more of a great variety of physical and mental symptoms.”
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The inference is that it was only the physician who stamped upon this odd-lot the label “depression.”

Y ears later, patients had made the d-word part of their vocabular y. Psychiatrist John Marks said in 1987 that “in his experience in Liverpool, ‘depression’ was a term commonly used because patients had learned that it was an acceptable label: if they complained about their real problem—marital or financial for instance—no-one paid attention.”
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Depression had finally become part of the patients’ medical folklore, and they had all become depressed.

In the belief that they were doing God’s work, psychiatrists did quite a bit of public information work to assist patients, as well as their colleagues, to this understanding. Psychiatric efforts were unabating to convince people that depression was really a very widespread illness and was vastly underdiagnosed. In 1977, under the chairship of Gerald Klerman, 51 years old—Klerman was among the master figures in postwar American psychiatry and then at Harvard—the National Institute of Mental Health (NIMH) initiated a huge five-city study of depressive illness called the Collaborative Program on the Psychobiology of Depression. Klerman at this point had barely completed the migration from psychoanalysis, where he had begun, to psychopharmacology, where he was to end, dying prematurely of diabetes in 1992 in the middle of a large study of Xanax for panic disorder. In 1977 he and Myrna Weissman had described “the chronic depressive in the community: unrecognized and poorly treated”
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and now it was time to do something about that. “The depressions, like all severe mental disorders,” the investigators of the NIMH psychobiology project correctly noted, “are conditions of the whole organism.”
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Unfortunately, influenced perhaps by a residuum of the investigators’ interest in psychoanalysis, the findings of the project focused much more upon down-mood than they did upon the nervous condition of the whole body.

Articles from this large project peppered the literature for the next decade, alerting everyone to the omnipresence of depression. In 1982, for example, Martin Keller, at the Massachusetts General Hospital and Harvard, said there was not one but two depressions—not, alas, melancholia and nonmelancholia—but major depression, an acute illness, and an underlying chronic depression, a separate illness.
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These depressions would require being separately diagnosed, and, as it subsequently unfolded, separately treated, needing two prescriptions instead of one. The eyes of marketing agents in the pharmaceutical industry grew wide with expectation (and Keller, himself a considerable scientific figure, consulted widely and became a wealthy man
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). Much later, Myrna Weissman, who in the meantime had married Klerman, placed the NIMH study in perspective. She said it had “brought depression to the forefront.”
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How did everyone become depressed? A depression needed to be created that could be applied to everyone. The drafters of the third edition of the American Psychiatric Association’s (APA) DSM series did this in 1980 by creating major depression.

At the same time, the drafters completed the demolition of the nerve syndrome, which had been slowly unraveling. The analysts had removed neurotic depression from the nervous syndrome; psychiatry removed anxiety from the larger nervous picture with the diagnosis mixed anxiety-depression. And DSM-III completed the job by separating completely anxiety and depression, and fragmenting anxiety into a volley of meaningless microsyndromes. Fatigue was left completely out of the picture and ceased to be a psychiatric ailment. And obsessive thoughts had long vanished from the nervous picture into the vast anxiety basin, where they would tumble about with social anxiety, posttraumatic stress, and the like.

Like moving pieces of furniture from the room, all the furniture was removed from the nervous room except depression. Of the unitary diagnosis of nerves, a disease of the entire body, nothing was left except major depression, an expandable diagnosis that could be applied to almost the entire population—and a series of minianxiety diagnoses pseudospecific for different settings in which anxiety might arise: parties (social anxiety disorder), trauma (posttraumatic stress disorder), public places (agoraphobia), and so forth. The shattering of the nervous syndrome was complete.

In February 1973 the Board of the American Psychiatric Association decided that in the forthcoming edition of the World Health Organization’s International Classification of Diseases, scheduled for 1979, some minor terminological clarifications were necessary in the input of American psychiatry, including issues such as “problem-oriented records” and how, exactly, to classify levels of disabilities. These were not big problems, but they would necessitate another edition of the APA’s Diagnostic and Statistical Manual, the second edition of which has appeared in 1968 ; the Board asked the APA’s Reference Committee to get cracking, and in April the Reference Committee asked the Council on Research and Development to appoint a Task Force to revise DSM-II.
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The research council, composed of psychoanalysts, viewed the entire classification question as secondary. “They didn’t think diagnosis important,” said Washington University psychiatrist Samuel Guze later. “No one wanted to give it the time.” So in January 1974 they chose a junior figure, Robert Spitzer, to head the Task Force. There was no indication at this point that a major upheaval lay ahead.

Spitzer was an interesting choice. Born in White Plains, New York, in 1932, he earned his MD degree from the New York University School of Medicine in 1957, then interned at Montefiore Hospital, where he caught the eye of Sidney Malitz, a senior figure at the New York State Psychiatric Institute, which is the department of psychiatry of Columbia University; Malitz persuaded him to train at “PI,” as it is called. As was customary at the time, Spitzer also trained in psychoanalysis and, because he was plagued by chronic depression, he entered analysis with Abraham Kardiner and then Arnold Cooper. (Spitzer was ultimately cured of his depression by the drug Wellbutrin.) Something misfired in his encounter with psychoanalysis and Spitzer turned upon it snarling; in 1961 he became a research fellow in what is probably at the far end of the spectrum from psychoanalysis: the biometrics department at PI, headed by psychologist Joseph Zubin. Spitzer later said of Zubin, “He created a department where the atmosphere was, anything that’s valid, you have to be able to measure it, that was the Zeitgeist. Within that Zeitgeist, I flourished.”
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While in the Biometrics Department, Spitzer developed an interest in the classification of psychiatric disorders and began collaborating with Sam Guze, Eli Robins, and others in the department of psychiatry of the medical school of Washington University in St. Louis, which was then the prime locus of biological thinking in U.S. psychiatry. Spitzer had attracted the attention of the APA leadership as a result of his campaign to rid the DSM of the diagnosis of homosexuality, culminating in a historic vote in 1973 to depathologize gayness, and so he was a natural choice in 1974 to head the Task Force that was to draw up the U.S. contribution to the international classification of diseases (ICD), due 5 years later.

On the plus side, Spitzer was an engaging, lively—indeed, almost charismatic—individual with a strong will to put through his own ideas. He infuriated fellow Task Force members with what seemed authoritarian, unilateral decisions on vital issues, such as the diagnosis of major depression. It was this very force of character that produced DSM-III as the vision of the future of world psychiatry, a dramatic departure from DSM-II with its vague psychoanalytic constructs and lack of guidance for making diagnoses. On the minus side, Spitzer had had relatively little exposure to clinical psychiatry and did not have that deep intuitive understanding of psychological illness that many senior clinicians acquire. One noted U.S. specialist in psychopathology confided to the author, “Spitzer knew nothing about psychopathology. I wrote some papers on first rank symptoms [of schizophrenia] in the early 1970s and he invited me to his house in Westchester to discuss them. He asked me to describe them, as he might incorporate them into the proposed DSM-III. He typed my answers rapidly into the first desk-top computer I’d ever seen. As he did so, he muttered ‘too hard . . . too subtle . . . too complicated.’ He had no understanding of clinical psychiatry.”
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Also on the minus side was that Spitzer’s very determination to impose his own ideas made him a difficult figure to work with—and ultimately ensured that after DSM-III-R, the revised version in 1987 of DSM-III, the helm would be given to someone else. As Carolyn Robinowitz, a senior administrator at APA, wrote to the organization’s medical director Melvin Sabshin in June 1979 of efforts to educate psychiatrists in the use of the new manual, “ . . . Dr Spitzer has had an immense degree of effort and dedication to the process of developing a new nomenclature. The problem in that, however, has been that Dr Spitzer has not necessarily thought through how one goes about educating psychiatrists or other mental health professionals and is so exceedingly sensitive to any negative input (to which he responds as if there were an attack on his knowledge, integrity, etc.) that it is difficult to deal with him. He tends to respond with more personalized . . . attacks and accumulates data as if he were doing battle over a legal or political issue.”
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Doing battle is a good metaphor. Spitzer saw himself engaged in a political not a scientific exercise in drawing up DSM-III. The point was to win, not to establish scientific exactness, and, above all, to triumph over the hated psychoanalysts. In a later interview he dismissed DSM-II as “based on psychoanalytic concepts.” We wanted “a fresh start,” he said.
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Spitzer was determined to drive the diagnosis neurotic depression, the bread and butter of the analysts, from the scene, and in 1978 and 1979, when the horse trading at the bargaining table was most intense, he negotiated a number of political concessions that made little scientific sense. In April 1978 Donald Klein, one of the main players on the Task Force and a senior colleague of Spitzer’s at PI, wrote to him, apropos Klein’s suggestion that the depression diagnosis hysteroid dysphoria be included: “You and I have agreed that there are a number of categories included in DSM III in which we have little confidence concerning their reality but feel that at least this will afford the field an opportunity to decide whether they are there or not. I think the same logic applies to Hysteroid Dysphoria,” a diagnosis that Spitzer dismissed with the back of his hand.
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This is not how we usually do science.

The first fateful decision was taken soon after Spitzer became director. It was the decision in September 1974 to separate the committee that dealt with depression from that which dealt with anxiety. It is difficult to put it this way but I cannot think of any other way to say it: The fact that they separated depression and anxiety into two entirely different disease basins shows that they did not know what they were doing. A note from that month stated, “The grouping of the following conditions was made by the secretary [Spitzer] and does not represent product of Committee discussion.” Group V was dedicated to “affective disorders,” group VII, which at that point did not have a title, to “hypochondriasis, sexual disturbances, conversion reaction, and anxiety state.”
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This insured, for bureaucratic reasons, that there would never be a mixed anxiety-depression diagnosis.

A veteran clinician would probably have protested the separation. Spitzer seems to have made the separation almost as an afterthought. In 1975 he signaled that he disapproved of the concept of “mixed, anxious-depressed neurotics . . . because within that group will be included some people who have the full endogenous depressive syndrome, some who just have a dysphoric personality . . . and some who have just an episode of depression.”
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The separation must have seemed natural to him: He had been brought up in the world of psychoanalysis, and even though he tried to put it behind him it was probably a leftover psychoanalytic reflex to see depression, a matter of uninterest to Freud, and anxiety, the core symptom of psychoanalytic theory, as separate. In fairness to Spitzer, however, it must also be said that from the early 1950s on, the pharmaceutical industry had been flogging anxiety as an independent disease entity, not necessarily independent from depression but certainly independent from nerves and from the whole concept of sedation (see Chapter 10). Yet whatever the motivations for Spitzer’s thinking, the consequences were enormous: In the decades ahead, depression and anxiety would in academic disease classification be seen as separate diseases requiring separate treatments.

In New York in September 1974, at the first meeting of the Task Force, Spitzer gonged that he was going to lead the group far beyond the timid mission that APA had originally conceived for it: They were going to abolish the terms neurosis and psychosis (though they left intact the firewall between schizophrenia and manic-depressive illness that Kraepelin had constructed). “ . . . ‘Psychosis’ and ‘neurosis’ are useful possibly as adjectives,” the minutes of the first meeting said, “but not as classificatory principles. The term psychosis has become vague in usage.” And neurosis, said the Task Force, has come to characterize “a more or less steady state,” whereas Spitzer and colleagues wanted terms that would be adequate for episodes. As well, Spitzer intended to move “what has been known as depressive neurosis” from the neuroses to “the affective disorders.” Thus, a page was turned on a century of previous psychiatric history.

How about cause? Until then, American psychiatry had known only one main cause of psychiatric illness: Freudian doctrines about unconscious conflict. With a stroke, this entire tradition now ended. The Task Force professed to be agnostic about cause: “Etiology should be a classificatory principle only when it is clearly known.”
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But the only etiology that counted had been Freudian, and the Task Force ultimately came up with a system of “disorders,” rather than neuroses, that perfectly accommodated biological thinking: What could the cause of all these various disorders be if not brain biology? Spitzer’s Task Force was about to break the stranglehold of psychoanalysis upon American psychiatry.

Thus the DSM revision began with firmly fixed scientific principles. But what began as science ended as politics. Donald Klein looked back somewhat ruefully: “When we started out with DSM, it was quite hard-nosed. If you didn’t have data for a diagnosis, then screw it. Then Spitzer said if there’s a group in favor, we’ll take it.”
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Somehow, neither the public nor the profession ever quite understood that this is what happened.

It was Spitzer who devised all the committees, each specific for a different set of disorders, and appointed all the members. He also made himself a member of each committee, thus ensuring that he would be the spider at the center of the web.

If not neurotic depression, then what? The committee on “Schizophrenic, Paranoid, and Affective Disorders” was nominally chaired by Nancy Andreasen, a Washington University graduate now at the University of Iowa (which was becoming a psychiatric powerhouse); it included Paula Clayton, also at Washington University—replacing Robert Woodruff of the St. Louis school who had just committed suicide. Also on the committee was Jean Endicott, a psychologist at PI, and Janet Williams, a PI social worker who was initially Spitzer’s girlfriend, then his wife. Thus the depression committee very much embodied the whole Washington University–PI axis that was the backbone of the Task Force.

But the key decisions were made at the level of the executive committee, not the individual disease committees. The main players on the executive committee were Clayton, Andreasen, Endicott, and Rachel Gittelman and Donald Klein, who were married to each other, he of PI, she a child psychologist at Long Island Jewish Hillside Medical Center; both kept trying, more or less in vain, to pull the Task Force in the direction of science and away from Spitzer’s authoritarian control.

In the 1970s, as stated, Spitzer, together with the Washington University nosologists, had laid out a whole classification of disorders that culminated in the Research Diagnostic Criteria (RDC) of 1978, a subtle document including both major depressive disorder (with numerous subtypes) and “minor depressive disorder with significant anxiety”—another way of saying mixed anxiety-depression.
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(Major was already a familiar adjective in psychiatry and Michael Shepherd of the Maudsley Hospital had referred to “the major depressive illnesses” at a conference in Montreal in 1959.
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) It might have been expected that the momentum would continue and that the RDC would become the intellectual framework of DSM. Yet this is not exactly what happened.