‘How Everyone Became Depressed’ — Is It Really Just Nerves?

"Melancholy," an 1801 painting by Constance Marie Charpentier (Wikimedia Commons)

“Melancholy,” an 1801 painting by Constance Marie Charpentier (Wikimedia Commons)

The venue: A tiny kitchen at a party for friends of the family, a few months ago.

The cast: Four other middle-aged women and I.

The topic of conversation: Celexa. Wellbutrin. Viibryd. Zoloft. The effects and side effects thereof.

I was the odd woman out, I realized. I was the only one of the five of us not taking an antidepressant (if you don’t count exercise.) Something seemed wrong with this picture, and my best guess was along the lines of “When you have a hammer, everything looks like a nail.” The hammer, it seemed, was likely the availability of antidepressants.

Right? I put my theory today to Dr. Edward Shorter, author of the provocative and brilliantly titled new book “How Everyone Became Depressed.” He is a professor of the history of medicine and also of psychiatry at the University of Toronto, and he blogs regularly for Psychology Today here. Our conversation, lightly edited:

Dr. Shorter: The hammer is the availability of antidepressants. And because it is so widely advertised, people are inclined to construe their disorders as depression, whatever they have. But I think it’s important to point out that there is real illness, and these women may well have had a real illness, but it may not necessarily be depression.

Dr. Edward Shorter (Courtesy)

Dr. Edward Shorter (© Margaret Mulligan)

And then there is non-real illness — that is, unhappiness, and maybe these four women were just unhappy without having an illness at all. That’s a determination that I really can’t make from this room. But if they were ill with a nervous disease, let’s say this combination of dysphoria and anxiety, maybe antidepressants wouldn’t have been the best medication for them. Maybe they should have been on something else.

So is this a fair statement of the thesis of your book? That we’re over-focused on ‘depression’ and in fact, what is so heavily diagnosed as depression could perhaps be better explained by a sort of a return to the old-style thinking about ‘nervous disease’ or ‘nervous exhaustion?’ And that this common constellation of symptoms — fatigue, anxiety, somatic complaints or aches and pains, insomnia — is in fact being mistaken for depression when it could better be considered something like nervous disease?

That’s the argument exactly. But this becomes relevant for your audience when we talk about treatments, and the treatments for real depression are in fact quite different from the treatments for nervous disease. ‘Nervous disease’ sounds so antique that we can call real depression ‘melancholic depression’ and call nervous disease ‘non-melancholic depression.’ People would probably feel easier with that terminology — but the point is, the treatments are different.

In the book you mention some antique treatments for the antique nerve disease — spas, exercise, rest…

Yes, but that’s not what I mean at all. There are also sections in the book about modern treatments for these things. If you have real, melancholic depression, it’s important you be treated with effective medications, and the effective treatments in this case would be the old tricyclic antidepressants that were introduced in 1959 and electro-convulsive therapy. Those are anti-suicidal treatments without question because suicide is a real risk in melancholic illness.

Now if the subject turns to non-melancholic depression, to what used to be called nervous disease, the treatments are very different: the treatments would be the benzodiazepine-style drugs introduced in the 1960s, such as Librium and Valium, or even the SSRIs, the Prozac-style drugs, are useful in nervous disease, but the Prozac-style drugs should not be prescribed in people who have melancholia. That message is very definitely in the book.

True! Apologies. The melancholic or major depression aspect is clear to me. But what’s so grabby to a layperson about your book is that we do tend to know a zillion people who have this thing you describe, the more minor, nervous disease-type thing. It seems provocative to think about prescribing benzodiazepines to those people.

And there’s also this huge community movement against benzodiazepines — which Scientology in particular has latched onto — and lots of physicians are very reluctant today to prescribe benzodiazepines because they fear inducing a terrible addiction in their patients, which is quite an unrealistic fear. So benzodiazepines, for the treatment of depression at least, have really receded; though they’re still widely used for the treatment of insomnia.

A physiological question: You use the term nervous disease quite a bit. Are we talking literally about some sort of nerve fatigue?

That’s a good question. What caused people in the past to think they had an organic affliction of the nerves was the fact that they were very tired. And so this just implicitly seemed to them that it must be a problem with the nerves. And also they were anxious. And they had the physical symptoms of anxiety: When they woke up in the morning they might have diarrhea, or vomited, or they sweated, their pulses were up.

These are all somatic symptoms of anxiety and the word ‘nerves’ just springs to the lips here. The word ‘psychiatry’ does not spring to the lips! If you’re chronically tired and aren’t restored by a night of sleep, is your first thought, ‘Oh I have a psychiatric illness!’? No. But you might well be convinced that your nerves were physically tired.

So is there anything actually to that, physiologically?

No, there’s not.

So it’s just a metaphor?

But it’s a metaphor that is meaningful to many people. It was a sort of a fig leaf to protect them from the P word. In those days, psychiatric illness was thought to be inheritable, and if you had a daughter, for example, who had a serious psychiatric illness, it wouldn’t be possible to marry her off. But if you could say ‘Helen’s problem is that she’s nervous,’ that’s different. Then Helen’s problem becomes that her nerves were tired and you could still get married if all you had was a ‘nervous disease.’

Mightn’t it be possible that in fact we are all just a whole lot more depressed than we used to be?

No. People have always thought they were more depressed than anybody ever in history, because people have always thought they were so much more stressed out than any previous generation. When people speak at cocktail parties, everyone talks about how stressed they are, and it just seems the most natural thing in the world to assume depression would be the consequence of all this stress. And that’s not necessarily true at all.

Over the years, ever since the 18th century, you have all these comments about fast-paced society. They didn’t use the word ‘stress’ in the 18th century but they talked about ‘the fast pace of modern life,’ the same kind of rhetoric you get today. But serious depression has a heavy genetic component, and anything with a genetic component is not going to change that much over the years because your genes don’t change.

I noticed you only used the word ‘stress’ two or three times in the whole book. I kept thinking, ‘Aren’t these symptoms he’s describing classic response to stress?’

Stress is a kind of construct, it’s not really a medical concept. This is something that gave rise to modern neurophysiology, trying to figure out what stress was and exactly what hormones it corresponded to, and people have never gotten very far with that. Because stress is kind of a metaphor, it’s not fundamentally a scientific concept, and that’s why I don’t use it a lot.

The illnesses that I’m talking about are real illnesses, and very often they spring from deep wellsprings in the biology of the brain. And to say, ‘Well, all of this is a result of having had to drive too fast to the airport this morning,’ is a very superficial analysis that doesn’t get to the heart of things at all.

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  • RubyB

    I think it is, at best, disingenous to not inform your audience that “Dr. Shorter” is not a medical doctor, but a PhD. That means that he has never physically treated patients and has not studied the biological side of treating patients. Psychology PhDs have a very rigorous program, but it is not based on physical medicine.

    I agree that too many people are on antidepressants, but in most cases it
    is not because they do not have a physiologic illness of depression or
    that benzodizepines are not used more often.

    I think the biggest reasons we have more depression are the same things that are causing an increase in inflammatory illnesses–changes in the food
    supply, decline in the middle class and subsequent damage to the
    supportive structure of our society, the stress of income insecurity as
    well as the stress that comes from living in a society that is at war.
    Did you know that rape, wife abuse and child abuse increases in a
    country at war, even among people who are safely away from the fighting
    and do not have a part in the fighting? There is, as well,
    environmental pollution that is increasing inflammation, especially
    mercury, which is terribly inflammatory and pesticides which disrupt the
    endocrine system.

    I treated patients for 35 years as a child and adult psychiatrist, who also trained in internal medicine and pediatrics. Before I went to medical school, I studied Clinical Psychology in graduate school. I’m not sure I can agree that
    benzodiazepines should be used more. Benzodiazepines cause cognitive
    problems and had more of the effects of a band aid than of a true cure.
    People with mild depression or mild anxiety disorders did best when
    they could access competent psychotherapy for a sufficient period of
    time. People with severe depression or severe anxiety disorders did
    best when they could obtain both appropriate medication and
    psychotherapy. I started my practice over 30 years ago. It has become
    harder and harder to get psychotherapy for patients as the
    pharmaceutical companies have taken over more and more of the research
    funding.

    In the mid 1970′s about 3/4 of medical research was
    funded by the federal government–that meant researchers could study
    things that did not lead to a patent. Cognitive therapy, interpersonal
    therapy and all the other effective therapies were actively researched
    during the 1960′s and 1970′s. The Reagan took office and started
    defunding medical research, along with nutritional and education support
    programs for the poor, programs to help old people, education, etc,
    etc, etc. By 1995, 3/4 of all medical research was funded by private,
    for-profit entities. This has greatly impacted the research performed,
    and thus the practice of medicine.

    As for using benzodiazepines for depression, why not improve the causes of depression and use cognitive-behavioral therapy first? If the patient is not suicidal, one has time for psychotherapy to work. Cognitive-Behavioral therapy works for major depression, dysthymia, almost all anxiety disorders, and
    addictions.

    I am quite surprised that I, an MD, have to point out to a PhD that many psychotherapies are as effective as pharmacological treatments for a wide variety of psychiatric problems. But this is not the first time. Since the late 1990s, PhD psychologists I worked with were increasingly less aware of the psychotherapy
    research that had developed effective, nonpharmacological treatments for
    a wide range of psychiatric disorders.

    (I also do not understand why this website reformatted my paragraphs in such a strange way making them less readable. I appreciate the “edit” function so that I could go back through and correct the improper formatting.

  • Marcia

    The doctor’s comments leave out nutritional deficiencies that can cause depression, like candida (more common in women). These types of problems with nutrition are not very well understood by regular doctors. Naturopathic doctors have a better understanding of connections between nutrition and mood disorders (as well as the other symptoms that go along with them, like foggy thinking and itchiness and digestive problems with candida, for example.)

  • ronpies

    As a psychiatrist specializing in mood disorders, I would like to comment on a few aspects of Dr. Shorter’s claims, with the caveat that I have not read his book; however, I am familiar with his work, in collaboration with Dr. Max Fink, on the reality and seriousness of melancholic depression–on which point we are all in agreement.(In brief, “melancholic” depression is a severe, incapacitating form of depression, often characterized by profound changes in weight, appetite, and energy; inability to experience pleasure, and impaired clarity of thinking. For more
    on this, see http://www.nejm.org/doi/pdf/10.1056/NEJMbkrev57417 )

    With respect to the incidence and prevalence of (unipolar) depression among adults, the best epidemiological studies do not support the general claim that rates of depression are greatly increasing, when studied using the same basic diagnostic criteria, over long periods of time. (Prevalence refers to total number of
    cases; incidence refers to number of new cases). Nor do most data support the “epidemic of depression” narrative that often gets headlines in the popular media. I think Dr. Shorter and I are actually in agreement on this point, at least as regards the more serious forms of depression.

    For example, a study of the Baltimore, Maryland catchment area between 1981 and 2004 was recently carried out. Participants were selected from the household population in 1981, and interviewed in 1981, 1993, and 2004. Diagnoses were made via the Diagnostic Interview Schedule according to successive editions of the DSM-III and IV. There was indeed a rise in the prevalence (total number of cases) of depression in the prior quarter century among one subgroup: middle-aged females. However, overall depression incidence rates (new cases) in the period 1993-2004 were actually lower than the period 1981-1993, suggesting that the rise in prevalence is due to increasing chronicity. In other words, previously depressed patients were continuing to be depressed, and these older cases were “accumulating”—there was no evidence of an “epidemic” or “surge” of new cases of depression.

    That said, researchers Ramin Mojtabai and Mark Olfson found that the rate of antidepressant drug treatment in the US increased more than 4 times between early 1990s and early 2000s.(Mojtabai R, Olfson M. National trends in psychotherapy by office-based psychiatrists. Arch Gen Psychiatry. 2008;65:962-970) Of special concern, the rate of antidepressant treatment increased more in the group of less severely ill individuals than in those with more severe psychopathology. These findings are certainly cause for concern, and are arguably consistent with Dr. Shorter’s thesis.

    This trend (increased medication of milder depression) may reflect a number of factors; for example, more awareness of depression among both patients and clinicians; the declining use and availability of psychotherapy among psychiatrists, and limited access to psychiatric physicians. However, rates of antidepressant prescription —largely prescribed by general physicians—cannot be used to compute or infer incidence or prevalence rates of depression. Indeed, many prescriptions for antidepressants written by non-psychiatrists are for the treatment of pain, insomnia, or other non-psychiatric conditions. Moreover, there are many studies showing that major depression is often unrecognized, especially in some primary care settings, and is sometimes under-treated–either by failing to recommend psychotherapy, or by using inadequate doses of antidepressant medication. The sad reality is that most persons in the U.S. with clinically-significant depression rarely wind up getting the best, “evidence-based” treatment–either psychotherapy or appropriate medication.

    Finally, I think Dr. Shorter’s comments on benzodiazpines–and he is
    commenting as a historian, not as a physician–need to be very carefully qualified.
    I agree that this group of medications (Valium, Librium, Klonopin and related agents) may be useful and appropriate for the short-term (2-6 weeks) treatment of anxiety; and, in carefully selected cases, when severe anxiety complicates and worsens major depression. However, I am not aware of any randomized, controlled evidence showing that benzodiazepines are effective in the long-term treatment of non-melancholic (mild-to-moderate) depression as such. Indeed, these medications (benzodiazepines) may sometimes worsen depression, in addition to posing some risk of dependence, tolerance and withdrawal. Like Dr. Shorter, I do not take the view that “benzos” are highly addictive for most carefully-screened patients (i.e., those without a history of drug or alcohol abuse or dependence). But their role in treating mild-to-moderate depression is very limited and they are certainly not recommended as first-line agents for mild-to-moderate depression. Indeed, cognitive-behavioral psychotherapy would be my first-line treatment in such cases, as it would be for most mild-to-moderate cases of anxiety and distress.

    Ronald Pies MD
    Professor of Psychiatry
    SUNY Upstate Medical University, Syracuse;
    and Clinical Professor of Psychiatry, Tufts USM, Boston

  • Kristina S.

    This is fascinating and I’m adding the book How Everyone Became Depressed to my reading list. It’s funny because I’m currently reading the book Learned Optomism by Martin E.P. Seligman. He describes a trend of increased depression throughout the 20th century. I don’t know yet if he offeres any explanation for the increase, but I wonder about two possible causes.
    1. The more we have, the more we want. Or maybe it relates to the ease of obtaining something. People today (I’m in my 30′s) have so much more than our parents did, with much less effort. This seems to bring less joy to people.
    2. We see such luxurious, and seamingly easy, lifestyles in the media, that we think of that situation as normal. As if it’s normal to make tons of money and have an easy job, or no job at all… Kardashians? This may not be the reality of the lives for these celebrities, but it’s what is presented for public viewing, and skews the publics perception of normal. People today expect that they can have an easy life, so any set-back or challenge seems extremely unfair to us.

  • theronbothunter
  • pennyroyal

    5 middle-aged women, which he extrapolates as “people.” What’s missing is a gender analysis: one male doctor addressing a broad topic that affects mostly women–or at least women are more likely to seek treatment.
    Maybe depression has a social clause: the silencing and shunning of women’s voices (constantly on TV, Congressional panels, all male leaders speak for and past women and women’s reality). That’s depressing right there.

    How do you make meaning, how are you effective in the workplace, how do you create and innovate when your input is trivialized and your ideas attributed to men?
    And that doesn’t address non-white women who are doubly oppressed…even today.
    It’s so unconscious.

    Read: Dana Crowley Jack’s Silencing the Self: Women and Depression
    and Allan G. Johnson’s The Gender Know
    and then let’s talk about root causes of depression.