Depression, antidepressants and an examination of epidemiological changes
Abstract—A 1968 review of previous epidemiological studies of depression found the prevalence of all kinds of depression to be less than one in one thousand. With a five to ten percent lifetime prevalence currently, the World Health Organization places depression as the second leading cause of Disability Adjusted Life Years (DALYS). This paper explores several possible explanations for the increased presentation of depression including changes in how the mental health professions understand depression, the effects of the marketing of depression and antidepressants and the role of depression in the capitalist market place. Using Michel Foucault’s concept of biopower this paper offers a theoretical interpretation of the various contributory factors as a possible explanation for the increased prevalence of depression in society today.
Key words—Depression, antidepressant, epidemiology, Foucault
Recently Olfson et al. (2002) reported that there has been a significant increase in the number of Americans treated for depression. In fact, depression, “the common cold” of mental illness and the “bread and butter” of psychiatry, is the second leading cause of Disability Adjusted Life Years (DALYS), a measure used by the World Health Organization (WHO, 2000) to evaluate the impact an illness has on a person’s life. Additionally, the WHO has reported that by the year 2020, Unipolar Major Depression will be the leading cause of DALYS for women and developing areas of the world (National Institute of Mental Health [NIMH]).
Depression, however, has not always been so common. Silverman (1968) reviewed seven previous epidemiological studies between 1938 and 1960, finding that “the prevalence rate for all types of depressed psychoses, manic depressive psychoses, involutional depression, psychotic depression and reactive depression” remained below 1 per 1,000 except in one study where the rate was 3 per 1,000 (p. 45).
These figures are startling in contrast to the generally accepted lifetime prevalence rate today of 5-10%, as reported by the Surgeon General (2000). This suggests a ten- to twenty-fold rise in the incidence of depressive illnesses since the publication of the 1968 report.
The central question that will be addressed here is, “How can we account for the rising rate of depression that we are clearly seeing?” This paper will argue that there are four to five distinct possibilities, any of which, if significant enough, could independently account for the change. This paper will examine the various possible contributions to the noted increased rates of depression while employing Foucault’s (Rabinow, 1984) conceptual schema of “biopower” to understand how the various different pieces may fit together.
The possible contributing factors are as follows: (1) changes in the definition of depression; (2) changes in the method of diagnosis; (3) changes in society or factors external to the individual, i.e. “exogenous” factors; (4) changes in people, i.e. “endogenous” factors; (5) changes in understanding the phenomenon of depression, which may or may not be distinct from the first category.
Though each of these has undoubtedly played some role in changing the rate of depression, it is far from clear that each of these has added to the overall incidence of reported cases of depression. For instance, changes in the definition of depression could increase or decrease the overall reported incidence of depression. A significant and confounding variable is the unlikely possibility that changes in the definition of depression would have led to a decreased incidence because earlier epidemiological studies lumped all forms of depression into one or only a few categories. Current practice involves several distinct depressed states, where Major Depressive Disorder is but one among several others. So while the criticism could be made that the previous epidemiological studies and the current reviews are comparing different groups, it would seem that all of what is currently called Major Depressive Disorder would have been included as a subset of the previous studies, suggesting an even greater increase.
One objection to this thesis may be, “Perhaps the current definition of depression extends the categorization of depression to populations of persons who previously would not have met criteria for depression.” This objection is distinct from the presentation problem, stated as, “Perhaps more people are simply presenting today for treatment.” This objection, however, begs the question, “Why are they presenting now and not before?” This will be addressed in the section examining exogenous factors. Though it is difficult to prove, it would be unlikely that a person who meets criteria for Major Depressive Disorder today would not have been recognized as having a depressive condition of one form or another in the past.
Another significant objection is that comparing antidepressant use and Major Depressive Disorder is a comparison of unlike groups, such that while persons with Major Depressive Disorder may receive antidepressants, not all persons who may receive antidepressants have Major Depressive Disorder. While this objection is noted, it doesn’t actually address the problem. There are two interrelated problems this paper seeks to address, they are an increased use of pharmacology to address a plethora of conditions ranging from Obsessive Compulsive Disorder and anxiety disorders to “Social Phobia”, Body Dysmorphic Disorder and the full range of depressive conditions, and an increased number of persons who are diagnosed and treated for depression.
The problems are, “why do so many people
need these medications at
all?” and “why are so many people depressed?”
The interpretive schema employed in this paper is Foucault’s idea of “biopower.” Foucault (Rabinow, 1984) notes that Western society’s political, economic and social structures have been influenced greatly by capitalism and thus increasingly function in specific ways.
Among these ways are the following: (1) all areas of life have become political targets, such that previously unregulated areas of life are examined, scrutinized and brought under juridical control; (2) scientific (reductive and quantifiable) categories are given priorities over conventional ones — for example, discussions of “brains” have largely displaced discussions of “minds” or intrapsychic events; (3) the human body becomes the central focus of disciplining and controlling practices; (4) knowledge and power become conjoined in inseparable ways; (5) docility is cultivated among members of society through training; (6) time, space, and action are standardized and controlled; (7) statistical measures used by the sciences to determine norms and deviations become axes for moral judgments; (8) deviants are punished or cured (Rabinow, 1984).
The thesis of this paper is that though antidepressants can serve an important social function, they do not do so in a politically or socially neutral way. The widespread use and marketing of newer antidepressants serves specific social interests, some of which may not be in line with the needs of the people they are said to serve. They have become part of the technologies employed to produce more efficient and productive workers. In doing so, they may contribute to external life conditions that are becoming increasingly damaging to individuals’ well being.
A Brief Review of Changes to the DSM
In each successive Diagnostic and Statistical Manual (DSM) we find an increased number of overall diagnostic categories and increased specification of persons meeting qualifications for previously established diagnoses. For instance, the second edition of the Diagnostic and Statistical Manual (1968) states that, “The DSM II indicates that the disorder of mood in the Major Affective Disorders does not seem to be related directly to a precipitating life experience and therefore is distinguishable from psychotic depressive reaction and depressive neurosis. Thus the term Major Affective Disorder in DSM II has a more restricted meaning than the corresponding term in DSM I” (p.130).
With the DSM III (1980), a greater attempt is made to move away from diagnoses embedded in theoretical constructs of etiology toward phenomenological descriptions of psychiatric conditions. Thus the condition of Major Depressive Disorder, with detailed criteria of inclusion and exclusion, is introduced. This diagnosis makes note of the presence of psychotic features or melancholic features but includes each as a quality of this new subtype of depressive illness. In the DSM III depressive neurosis is also renamed Dysthymic Disorder. In the DSM III-R (1987) and the DSM IV (1994), multiple subclasses of depressive disorder have been added, including “Atypical Depression” and “Depressive Disorder Not Otherwise Specified”. Recently Rapaport et al. (2002) have described “Minor Depression” as a condition for future editions of the DSM.
It appears clear that any later subcategory such as Major Depressive Disorder should have a smaller percent of the whole number of persons suffering from fewer previous categories. The depressions listed in the 1968 review (depressed psychoses, manic depressive psychoses, involutional depression, psychotic depression and reactive depression) should involve a segment of the population that is larger than those described by the incidence of Major Depressive Disorder alone. This would lead us to conclude that changes that have been made in the definition of depression should not reasonably contribute to increased numbers of persons diagnosed with Major Depressive Disorder.
The second possibility, that methods of diagnosis have changed, presents a mixed picture. On the whole, no significantly different techniques for diagnosis have been developed. There is no new technology employed to aid clinicians’ assessment or diagnosis. There are no widely employed laboratory tests or imaging tests available to aid in forming a diagnosis that could account for effective screening and diagnosis of previously missed populations of persons. There are some structured interview formats as well as some standardized batteries; however, there is little reason to see these as anything other than formalizations of longstanding interview techniques. While it is reasonable to suggest that an instrument like Beck, Steer and Brown’s (1996) Beck’s Depression Inventory may account for some piece of the increase of reported cases, it is unlikely to account for a significant portion.
There is one area that could fall under
“methods of diagnosis” that
could count for a significant rise in reported cases and that is the
effect of marketing. For reasons that should become obvious this
discussion will be left until exogenous factors are discussed. Another
change that has occurred since the 1968 epidemiological review is a
shift in psychiatry from a discipline focused on psychodynamic
processes to one whose focus is on neurobiology. This shift alone,
however, leaves little reason to think that the incidence of depression
Exogenous or reactive depression was a category of depression thought to develop in people due to changes in external circumstances. Death, birth, divorce, losses of significant others and work stress, to name a few, are areas that have been thought to contribute to or cause depressed states. “Reactive Depression” is rarely used as a category in contemporary practice, having been replaced largely by ”Major Depressive Disorder”.
Over the last hundred years, there have been many more societal changes that could affect depression prevalence than can possibly be discussed in this paper. Some of these changes may contribute to alleviating depressed states while others may exacerbate to them. For instance, technology may make life easier or may indirectly create job insecurity creating greater stress and increased incidence of depression. It is possible that being bombarded by information in the form of visual and auditory stimuli that were nonexistent one hundred years ago contributes to greater mental stress resulting in more depression. Though this area is worth further inquiry, systematic attempts to study this are lacking. Comments here will be focused on one factor that is relatively easily quantifiable, and at the same time which has near universal relevance: work life, specifically the demand to increase work hours and productivity.
Numerous writers have pointed to increasing work hours in the United States as a significant source of stress (Bluestone, 1997; Greenhouse, 2001; Lehmkuhl, 1999; Sheilds, 1999 ). Though there is much disagreement regarding exactly by how many hours the average workweek has increased, most observers are in agreement that the workweek has been increasing for quite some time. The National Center for Policy Analysis has reported that the average increase in the workweek has been 3.5 hours over the last 20 years: from 43.6 hours in 1977 to 47.1 hours in 1997. In 1998, ABC News reported, “Of the 5.4 percent growth during the first quarter of this year 1.4 percentage points came from increased productivity. The other 4 percentage points were increased hours.” Schor (1992) reported that Americans are working 163 more hours annually than they did in the 1960s.
These figures omit several other important social changes relevant to work stress. Greenhouse (2001) reported on an International Labor Organization (ILO) study that found that Americans added a full workweek in the 1990s. The total number of work hours Americans averaged a year, according to Greenhouse and the ILO, was 1,979.This was 137 hours, or three and a half weeks, more than Japanese workers; 260 hours more than British Workers; and 499 hours more than German workers. Business writers have followed these trends closely; Perlow (1998) reported in Administrative Science Quarterly, “In 1960, for example, 61 percent of married couples had a relationship in which the husband worked and the wife was a full-time homemaker; in contrast, by 1990 this number had dropped to 25 percent of married couples. During the same period, the number of couples in which both spouses worked increased from 28 percent to 54 percent”(p.2). Bluestone and Rose (1997) and Schor (1992) noted that studies examining increased working hours only count paid work. Thus they discount the impact on both spouses (working full time outside of the house) of negotiating childcare and housekeeping, which tasks further increase the work burden.
New technology, often marketed for time saving benefits, has shown a Janus face as well. In a four-year study of 3,129 full-time employees from Southern California, Weil and Rosen (2000) found that in 1999 the typical worker used technologies such as voice mail, fax, e-mail, cell phones, computers and the internet for work purposes 2-3 hours a day at home after work, as compared with 1-2 hours a day five years earlier. Additionally, Lehmkuhl (1999) reported that in a worldwide poll over half of business professionals stated that they perform at least 25 % of their work from home. Thus, though new technology can and often does increase productivity of workers, one way it does so is by increasing the overall number of hours in labor time workers put into their job.
Though the United States leads the industrialized world in numbers of hours worked a year and had the least vacation days, it is not alone in the trend to increase work hours (Brouwer, 1998). Both Canada and England have published concerns regarding increasing work hours(Greenhouse, 2001; Lehmkuhl, 1999; Sheilds, 1999). Specifically, these reports have focused on health risks that long work hours bring to the worker, including weight gain, smoking, increased alcohol consumption, high blood pressure, cardiovascular disease, asthma, migraines, gastrointestinal problems, substance abuse, and mental disorders such as depression and burn-out. Lehmkuhl (1999), reported that “Stress is the most common health problem attributed to long work hours…In the United States work place stress has doubled since 1985. Approximately one-third of all Americans consider job related stress as their greatest source of stress” (p. 3).
In short, some significant sources of stress arising from social trends have placed increased burdens on working people. Several such stressors are increasing work hours throughout the United States, Britain and Canada, increasing number of work hours performed at home or outside of the office; and the increased burden of childcare and housekeeping due to the loss of a person per household whose designated role was to care for these tasks. These sorts of changes in individual persons’ lives result in increased likelihood of depression.
Changes in Psychiatric Models
The change from psychodynamic models of psychiatry to neurobiologic models that dominate the discipline today has resulted in a change in how people are perceived by clinicians. This change mirrors Foucault’s claim that reducible scientific claims will replace conventional or juridical ones. As scientific claims to knowledge in neurobiology replace conventional ones, such as psychodynamic theories, the relative power of those who operate within these realms (e.g. doctors, pharmaceutical companies) increase as those who do not are marginalized.
To contextualize the problem adequately we must review in a cursory fashion the theorized mechanism of action of the newer antidepressants. Serotonin, among other neurotransmitters, has been discovered to be a key neurotransmitter related to our experience of the world. Not only do serotonin levels appear to correlate with happiness; serotonin levels have also been shown to correlate with motivation, concentration, energy, sociability, and libido, and to correlate negatively with anxiety (Kaplan, Sadock and Grebb, 1994). Too little serotonin in combination with other neural changes and we become isolated, lose motivation and ability to concentrate, and experience increased anxiety. If we have increased amounts of serotonin present in our neural synapses we become full of energy, gregarious, and our libido increases . If our serotonin levels are mildly elevated we reportedly feel as Kramer (1997) has written “better than ever.”
As psychiatry has become more biologically driven the distinction between exogenous and endogenous depressions has faded. Indeed, the first line of treatment for any of the many types of depression, anxiety, or obsessive disorders currently is an antidepressant — usually from a class of drugs called selective serotonin reuptake inhibitors (SSRI). Prozac was the first of this class brought to market in 1987 by Eli Lilly. The success and reported safety of these drugs has led many to conclude that depression is “caused” by reduced serotonin levels. The conceptual shift of psychiatry to this endogenous view of depression reduces the complexity of external life to a biological problem in the body. The human body, as argued by Foucault (1995) and Rabinow (1984), becomes the central focus of disciplinary and controlling practices.
The biologically reductive argument neglects to consider that, in a significant number of cases (and probably in most), life stressors have contributed to the depression. It is at least logically possible that a person’s biochemistry can go awry without an external cause. It is also possible that this may be treatable by antidepressants; thus all exogenous depressions have neurobiological underpinnings but not all endogenous depressions have contributory life correlates. However, if all or most cases of depression stemmed fundamentally from neurobiology, we should not see a change in the overall incidence of depression (unless the human body has fundamentally changed).
Depressions that have external correlates, then, have been effectively given a band-aid when treated with antidepressants alone. The suffering person may be better equipped to live with the problem of depression but they have not addressed life patterns that have made them depressed. While medical journals refrain from making a causal leap, discussion of external life factors as causal or contributory has been increasingly absent. In fact, medical journals have taken a new direction entirely, examining the impact that depression has had on productivity and absenteeism in the workplace; i.e. discussing the causal impact of depression on external factors (Crott, 1998; Gabbard, 1998; Greenberg; 1993; Hylan, 1998; Rost, 1998; Zhang, 1999).
Thus, under this perspective, the workplace suffers from those with under- or non-treated depression as opposed to people suffering from workplace conditions. The shift to biological models of psychiatric illness has carried with it the implicit consideration that depression is indicative of a broken person—not a broken or damaging circumstance.
This centrality of pharmacology is to be expected because double-blind placebo-controlled trials can be relatively easily performed with abundantly funded drug trials. However, the same standard cannot easily be performed to examine complex systemic interactions like the impact of workplace stress on depression. Of course, there are ways of studying such phenomenon but they do not rise to the same standard of scientific certainty and thus cannot pass the same scrutiny as the double-blind placebo-controlled drug trials that appear to have a high degree of certainty.
Psychiatry, however, is not responsible alone for these changes. Changes in the forms of payment to providers, such as third party reimbursement subject to auditors who demand that treatment forms meet specific parameters of cost efficiency, frequently result in insurers refusing to pay for care other than psychopharmacology. Relative cost-benefit and efficacy studies comparing drug treatment to therapy are abundant. However, pharmaceutical treatment is still the only option that provides quick and inexpensive care for problems with complex etiologies.
Productivity and Absenteeism
A basic understanding of market economics reveals a continued systemic need for growth of production. Competition in market economies demands that corporations either grow and continue to use newer more efficient means of production or go out of business. The only other option is to reduce pay and benefits of workers. Absenteeism and lost productivity at work due to morbidity threatens employers’ competitive ability leaving a substantial incentive for employers to minimize losses due to illness.
A central concern developed in the medical literature on depression over the last decade or so has been the impact that depression has on worker productivity and absenteeism. These issues are discussed both as a descriptive matter related to the natural course of depression and as a central issue in the overall economics of the social costs of depression.
Greenberg et al. (1993), in a study funded by a grant from Eli Lilly and Company, concluded, “employers as a group have a particular incentive to invest in the recognition and treatment of this widespread problem in order to reduce the substantial cost it imposes on them each year” (p. 419). What is curious, however, is that these writers do not consider the possibility that the context of work itself in contemporary society contributes to depression through the suffering of workers. Instead, corporations are presented as potential victims through the losses in productivity.
In another paper funded by Eli Lilly and Company, Crott and Gillis (1998) reported that newer antidepressants, of which Prozac is one, are more cost effective than traditional tricyclic antidepressants. Further, they write: “cost-of-illness studies have documented the high burden on society of this disorder and the associated losses of productivity and work” (p. 241). Again we find that contemporary medical economics literature emphasizes the economic burden depression allegedly places on society and corporations in the loss of productivity, with no mention of the impact of work conditions on the life of the suffering person — and consequently upon productivity.
In an often-cited article, Greenberg (1993) concludes that depression costs 43.7 billion dollars to society annually. Of this, 12.4 billion dollars are attributed to direct costs that include the treatment of persons with depression. Seven and a half billion dollars are attributed toward losses and costs due to mortality, and 23.8 billion dollars are figured to result from morbidity. Expanding on morbidity data the authors conclude that 11.7 billion dollars of this are attributable to absenteeism from work while 12.1 billion dollars are attributable to losses in productive capacity. A review article by Hylan et al. (1998), again funded by Eli Lilly and Company, finds that depression costs employers a great deal through indirect costs such as absenteeism and losses in productivity. Panzarno (1998), funded by Smithkline Beecham, makers of Wellbutrin, also citing Greenberg (1993), extends existing recommendations as to the efficacy of antidepressant use for reducing absenteeism and increasing productivity, to also note the efficacy of antidepressants for these purposes when prescribed by primary-care MDs as well as non MD therapists.
Additionally, none of these articles addressed quality-of-life issues for the persons with depression. Clearly, the focus of these papers was the effect that depression costs society. These studies point employers to the obvious solution that depressed workers can be treated cheaply and efficaciously with antidepressants thereby reducing absenteeism and increasing productivity.
Two other studies conducted by Katzelnick, Kobak, Greist, Jefferson and Henk (1997) and Rost et al. (1998) arrived at similar conclusions. These studies however, differ from the other studies mentioned in several significant ways. While both studies conclude with findings similar to the previously described reports regarding productivity and absenteeism, they also measured changes in the quality of life of the persons being studied. Unlike the pharmaceutical company funded studies, these studies demonstrated an interest in changes in the quality of life of the subjects as well as the impact of depression on absenteeism and productivity.
The Marketing of Depression
Foucault (1978) has described a phenomenon he calls “the perverse implantation,” where categories of behavior become named and subsequently are internalized by members of society where those named categories are used. Once internalized, these categories become formative elements of one’s self-identity. Foucault, among other writers, suggests that such complex phenomena as sexual orientation may serve as examples of this sort of social construction. A concerted effort has been made by government, corporate and public health groups to market the category of depression broadly. This raises the concern that depression may be the sort of category members of society have internalized, leading to specifically designated behavior changes and changes to one’s relationship with oneself.
Pharmaceutical corporations, government, and medical journals have increasingly teamed up to disseminate information about depression to the public and to medical professions. This has taken the form of outreach programs with the stated intent of raising public awareness of the prevalence of depression. This is presented as a service to the public and medical profession (Chain Drug Review, 1999; Houston, 2001; Rosenthal Berndt, Donahue, Frank, and Epstein, 2002; Project on the decade of the brain, 2000). The agenda of combating this most common of mental disorders is also supported through research and other writing intended for consumption by the medical establishment, such as, Guidelines for Treatment of Depression in the Primary Care Setting, issued by the Department of Health and Human Services in 1993.
President George Bush designated the 1990s the Decade of the Brain “to enhance public awareness of the benefits to be derived from brain research.” To foster this end the National Institute of Mental Health (NIMH) sponsored a variety of programs and publications aimed at introducing Members of Congress and the general public to cutting edge research on the brain. While largely ceremonial, this designation was the result of the previous decade’s successes and pointed to the increased perceived need to raise awareness of the public to a particular area of scientific development (Library of Congress). Since then, the NIMH has among many other things initiated an online screening process for depression, reported recently by Houston (2001). The Internet itself has been one source of incredible expansion of information of all sorts for persons who have access to it. A recent inquiry on a web search engine revealed over one hundred thousand web pages with the words “psychiatric depression” on them. Among them are a host of sites offering information about depression including questioners for inquirers to determine if they themselves may have depression; pharmaceutical web sites’ descriptions of depression; and numerous ways to obtain antidepressants.
Among other marketing and educational strategies, schools have become a primary area of marketing to young persons. Casey (2002) writes that among major corporations that market to high schools a cursory look finds Exxon providing curriculum about the cleanliness of the Alaskan ecosystem; Proctor and Gamble sponsoring lessons in oral hygiene where they provide students with sample of Crest toothpaste; and Eli Lilly, the makers of Prozac, teaching students about depression.
Concern regarding a trend of pharmaceutical companies’ promotion of prescription drugs directly to consumers was recently raised by Rosenthal et al. (2002) in the New England Journal of Medicine. They report that spending on pharmaceuticals has accelerated recently, now becoming the largest part of the health care budget. Additionally, they reported that a survey found that a startling 71% of interviewed family physicians believe that direct-to-consumer advertising has resulted in consumers pressuring those physicians to prescribe drugs that they would not have otherwise. The authors also report that spending on direct-to-consumer advertising for prescription drugs increased by 212% between the years 1996 and 2000, accounting for 9% of total spending in 1996 and approximately 16% in 2000. The remaining budget is spent on promotion of medications to healthcare professionals whose journals are filled with glossy full-page advertisements and who are provided luncheons, diners, free samples of medications, and all sorts of gifts (from the pragmatic and useful, like pens and copies of the Physician’s Desk Reference, to the gaudy and excessive, such as clocks and mouse pads). The luncheons are accompanied by brief promotional “educational” lectures and the gifts are, of course, emblazoned with company logos. Further, the article reports that spending on promotionals directly to consumers totaled 2.4 billion in 2000; dollars spent on promotionals to healthcare professionals that same year totaled 15.7 billion, with 7.9 billion going directly toward free samples of the medications. Spending on television advertising increased by a seven-fold factor between 1996 and 2000. In the year 2000, 92 million dollars on direct-to-consumer advertising was spent to promote Paxil alone. Paxil was approved in 1999 for use with social anxiety disorder, thereby expanding the current usages for this medication and the number of persons for whom the medication marketing may be addressed.
Of the possibilities reviewed it seems unlikely that changes in diagnostic categories or in methods of diagnosis have contributed to a significant increase in the prevalence of depression. Rather, it appears that at least two significant factors have coincided, leading to dramatic increases.
The first of these is the shift in psychiatry to a neurobiological model that has sought to isolate the underlying biological causes of depression and to find adequate methods of treating depression. In doing this, psychiatry and the pharmaceutical industry have developed relatively safe antidepressants. The success of this project has in turn changed how society and the medical profession conceive of depression. We have ceased considering that our external life contributes in significant ways to our state of contentment, instead relying on a belief that symptoms of depression are due to treatable changes in our biochemistry (or at least acting as though we believe this).
Second, depression has been marketed to society as a whole as a public-health matter, such that ads from pharmaceutical companies are received as public-service messages. This has contributed to a “better informed” population and a population that self diagnoses and seeks professional help in the form of name-brand medication when “symptoms” appear.
At the same time that these shifts have resulted in higher reported rates of depression, antidepressants have assumed a dual role. Antidepressants serve not simply as a band-aid, to mitigate symptoms, but also serve to directly contribute to increased productivity and decrease absenteeism at work. They become, from an employer’s perspective, the ideal worker’s drug: one that increases motivation, energy, attention, and concentration while decreasing the need for sleep and decreasing anxiety. As Listening to Prozac’s author Peter Kramer (1997) has written it makes people “better than ever.”
The effect of advertising through public-health campaigns geared toward raising awareness of psychiatric illness, complete with checklists and self-evaluations, has been to create people who now identify lived experiences as “depression” while previously they may not have done so. At one time, experiences of withdrawal may have been a biological response to overwhelming external stressors, and the ultimate result would be a decrease in those stressors. As society demands that individuals more rigidly adhere to artificial structures used to control individuals through control of time and space, individual persons’ tolerances are met, eventually leading some to withdraw and isolate themselves. Previously this withdrawal would have been explained as a reevaluation that may have led to eliminating or changing external stressors. Perhaps one would change one’s job, quit, or decrease overall work hours. Public-health changes that name signs and symptoms of depression encourage persons to seek help for these potentially healthy responses from medical professionals. This internalization of the category of “depression” brings with it a mandate to seek help from experts who provide antidepressants. Administration of antidepressants allows the person with the external stressors to better live with the stressors rather than being forced to change them. “I am depressed” becomes a category taken on with recommendations to seek professional help and urges the suffering person to take on a docile relationship to depression and a dependent relationship toward professions and experts who will cure the problem. Effectively, the ways people understand their own experiences and their relationships to themselves change.
With significant numbers of people taking antidepressants, overall productivity would be expected to increase. Indeed, this goal is a central focus of the cited medical journals. Most importantly, this increased productivity is a central need for a capitalist economy. If the technologies, assembly lines, computers, and so on are as efficient as they can be at any particular time — perhaps reaching the technological limits of a period, the only other way capitalism can continue to grow is to force workers to do more for less, i.e., to increase production or efficiency. Antidepressants open the possibility of using technology to change the worker directly by intervening chemically to decrease absenteeism and increase production and efficiency. Workers therefore become more productive but don’t change patterns of behavior. This innovation in worker productivity could not have occurred without psychiatry moving from psychodynamic models to quantifiable neurobiological ones. Nor could it have occurred without the advent of newer, apparently safe antidepressants. This, then, is an example of Foucault’s knowledge/power conjoining where quantifiable claims are stronger knowledge claims than the hermeneutic psychodynamic ones. Quantifiable claims are, in modernistic society, stronger because they provide clear causal relationships between an intervention and an outcome. They also distribute their findings over a normal distribution curve, where deviants become objects of discipline or cure.
Why is depression an increasing phenomenon? External stressors are increasing; a prime example is work hours. Technology has not succeeded in decreasing our work stress; on the contrary, it allows us to do our work from anywhere and it has taken the form of a medication that helps us do more work despite our tendency to become depressed and withdraw in the face of overwhelming stressors. Effective marketing has been directed at consumers, employers, experts and payers such that consumers self diagnose and demand name-brand treatment from experts. Employers are clearly told that effective treatment of depression will increase productivity and decrease absence, a universally desirable condition. Experts (clinicians), are exposed to a singular model for the proper care of their clients so that all problems are framed as biological in nature, requiring an evidence-based response. Payers (HMOs, insurance companies, etc.) insist on paying for “biologically” based problems with pharmacological means as the least costly and most efficacious method. The interests of modern industry lead to creation of a docile population that seeks socially sanctioned cures for their ills: in this way, the market economy has molded people’s understanding of their own experience.
If we are to develop a more humane society we must begin to address these problems in their complexity. We must refuse biological reductionism and its cozy fit with capitalist incentives, and recast the problem of suffering people as cultivated alienation intended to create a culture of docile consumer/workers who consume and produce into oblivion.
 Much more is going on than simply changes in serotonin levels. Neuronal plasticity can permit increases or decreases in the number and location of receptor sites, and a complex cascade of other neurotransmitters and transmitters acting in perhaps different ways in different areas of the brain.
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Affiliations—Robert G. Krause is Clinical Instructor Yale School of Nursing and Adjunct Assistant Professor of Philosophy Quinnipiac University.
G. Krause, MSN APRN-BC Yale
School of Nursing, 100 Church Street South, New Haven, CT 06536