MANUFACTURING DEPRESSION: THE SECRET HISTORY OF A MODERN DISEASE
by Gary Greenberg
Simon & Schuster, 2010
Grammarians tell us that even our verbs have a “mood,” and these moods clue us into people’s disposition toward their topic. The three moods in English are the indicative, the imperative, and the subjunctive. It is interesting to look at the mood (in the grammatical sense) of “mood disorders” (in the psychiatric sense), because when people talk about psychiatric mood disorders—like depression—the first two grammatical moods are very common. But the last is quite rare. The indicative is the matter-of-fact mood of description and explanation. Examples include “depression is a malfunctioning limbic diencephalic system” or “depression is the result of anger turned inward.” The imperative mood is the stern request or command: “Take your medicine!” or “You should see a shrink!” The subjunctive mood, by contrast, infrequently shows up. This mood indicates a much more whimsical disposition. It is used to express wishes, possibilities, and fantasies. The subjunctive is the mood of “what if?” Some examples are “depression might be many things” and “I wonder what would happen if we were to think about depression this way or that way.”
The loss of the subjunctive with regard to depression is unfortunate because the cultural and phenomenal world of depression, whatever else we may want to say about it, is a world of uncertainty and a world of multiple points of view. When we use the indicative and imperative moods to discuss depression, we cover over this uncertainty and multiplicity. We make it seem as if depression were clearer than it really is. And, more important, we close down our options and limit our flexibility. We lose the capacity to imagine, to fantasize, and to creatively consider the advantages and disadvantages of the many possible ways of making sense of depression.
Gary Greenberg’s book is a delight to read because it is a sustained meditation on depression that stays largely in the subjunctive mood. Greenberg uniquely comes at the project from several different points of view: he is a science writer (and a good one at that), a psychotherapist, a historian, an investigative journalist, a patient of depression, a volunteer for clinical research trials, and—perhaps most important—by the time you finish the book, something of a friend.{{{subscriber|2.00}}} [trackrt] At least, I felt like I was in the presence of a friend, because Greenberg does a nice job keeping the reader company with his own often humorous and thought-provoking reflections about his project. Using his multiple hats, Greenberg explores the rise of psychiatric diagnosis, the insights of Freud and psychoanalysis, the controversies over talk therapy versus medications, the remarkable power of pharmaceutical marketers to get inside our heads, the experience of taking medications, the role of insurance companies and America’s can-do attitude in the promotion of cognitive-behavioral therapy, how yesterday’s phrenology compares with today’s neuroscience and neuroimaging, and even how a magical afternoon taking ecstasy and fooling around with a room full of naked strangers can relieve depression.
Since this is a review, I cannot go into the details but must move straight to the big questions. What does Greenberg find out about depression after such a wide exploration? In the last chapter, he sums it up this way: If you explore depression seriously,
you won’t necessarily get coherent advice.… More likely you’ll hear cacophony and contradiction, one voice beckoning you this way and another that way. But you shouldn’t be afraid of complexity. We’re pretty complicated creatures, no more so than when in the throes of an emotional state that colors all of our experience. And among all those voices, chances are good that sooner or later you will hear something that hits home, reaches down to you and lifts you out of your darkness.
Greenberg follows this conclusion with a little advice of his own: As we explore depression (what it means for us and what it has meant for others), we must be careful about swallowing too quickly the antidepressant medications that are so often the first thing we find in our exploration. Greenberg backs this up throughout the book by showing the way that hype and limited perspective surround these medications. The medications are oversold by a pharmaceutical industry bent on making profits through marginally effective lifestyle drugs, and the drugs are discovered and researched through an empirical reductionism that too easily becomes an ideology of brain over mind (and most everything else).
That does not mean that the medications may not be helpful for some people in some situations. It just means that we should be circumspect about what that “helpfulness” means before we buy into the idea of having a mental disease. And we should be imaginatively open to alternative possibilities. This imaginative process is invaluable because it not only shows us different ways to understand our sorrows and misfortunes, it also shows us different ways to make sense of who we are and different possibilities going forward.
For example, if I understand my depression as the result of a broken brain, or an unresolved childhood grief, or the result of white, capitalist, heteronormative patriarchy run amok, it makes a difference. It affects not only how I understand my history and my present, but also what I do in the future, whom I hang out with, and what practices and rituals I get involved with.
If I go with the broken brain narrative, I’ll see myself as having a psychiatric disability: I may apply for benefits; hang out with doctors, pharmacists, and other patients; and spend a great deal of time talking and thinking about my diagnosis and my neurotransmitters. If I go with the unresolved grief narrative, I’ll find a therapist or a support group and talk over the slings and arrows of my past, discussing how I can leave the past behind and stop repeating the most damaging patterns that have emerged with my significant others. And if I choose the political narrative, I may join an activist group, move to a cooperative housing community, or get involved in politics. And these three options only scratch the surface of the multiple possibilities for understanding and responding to depression. There are also perspectives centered on the family, interpersonal relations, yoga and meditation, spirituality, religious practices, and creative practices, just to name a few.
Greenberg gives us the background needed to understand this flexibility. One place where I would like to supplement his meditation on the interpretations of depression, however, is on the question of “the truth.” At times Greenberg seems to be overly concerned about this question. At these points in the book, he seems to fall into a commonsense view of science as capable of providing an objective truth that is independent of human perspective and values. With this view, once we know the “truth,” we can let go of other knowledge formations, labeling them as “myth” or “superstition” or “ideology.” That would be nice with regard to depression, because if we had the truth (say, that depression is a disease like diabetes), we could let go of the other options. But recent scholarship in science studies has moved past a sharp dichotomy between truth and myth. Science studies scholars now believe that the real world and human perspectives—which is another way of saying objective and subjective, nature and culture, material and semiotic, facts and values—contribute to meaning-making by intertwining and interacting. The worldviews that humans hold and act on are determined partly by the metaphors, linguistic distinctions, and cultural preferences through which we approach the world, and partly by the world itself—in its active capacity to accommodate or resist different framings. This science studies insight means that there is not “one truth,” nor do we live in an “anything goes” world of free play. It means that there are multiple ways of understanding the world, which will result in multiple ways of being in the world. Each way says something true (and something mythical) about the world, and each has advantages and disadvantages for organizing a way of life.
If we apply this science studies work to depression, we see that the question about the many perspectives on depression is not so much which one is true, but rather, what will be the lived experience of inhabiting the many different truths possible. What kind of narrative identity will I create for myself if I adopt truth option A, B, C, etc., or a hybrid combination of several truth options? From this science studies perspective, theologians, neuroscientists, psychoanalysts, cognitive therapists, political activists, and creative artists all have value; they all touch the reality of depression.
One of the fascinating findings of depression research is that outcome studies tend to support this science studies perspective. Outcome studies show over and over again that the many different therapeutic ways of approaching depression are similarly effective. And, though medications are not usually included in these studies, it seems to be equally relevant for medications as well. For all of these treatments, the human qualities of the healer and the expectations of the healed are more important than the specific interventions. In other words, science shows that multiple approaches to depression can be effective. This means that people have multiple options. They do not have to figure out which narrative about depression is true. Instead they can spend more time figuring out which is the best fit for them. Each intervention is better at some things than others, so it is unlikely that a single intervention will be more effective for everything. And even if it were, if a magical substance, soma, appeared that took everyone to a higher plain in all areas of life, that does not mean everyone would have to (or want to) take it. Taking soma would still be a personal and cultural choice rather than a medical necessity, and there might be good reasons to say no to such a drug.
I doubt that Greenberg would disagree with these last couple of paragraphs. Indeed, he reviews the outcome studies I just cited in detail. My guess is that the science studies perspective of multiple truths (and therefore multiple options) is more or less a default position for him as well. But it does seem that with a little help from science studies, we can hold on to this multiplicity a little more clearly. The advantage of doing so is that in the face of a cacophony of ways to understand depression, we can spend less time asking, “Which is true?” and more time in the subjunctive mood of possibilities, asking, “Which way or combination of ways might be right for me in my particular situation?”
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(To return to the Spring 2012 Table of Contents, click here.)