IRA FLATOW, host:
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Depressed? Feeling guilty? Do you have thoughts of suicide, insomnia? How about your weight? Does your weight change? Maybe you're losing interest, or you're losing your appetite.
These are all factors measured on the Hamilton Rating Scale for Depression. It's sort of a standardized checklist to measure how severe a patient's depression is, and estimates say around 14 million Americans suffer depression each year. At least 32 million Americans will do that, suffer depression, over a lifetime.
Antidepressants use shot up from about 13 million Americans taking the pills in 1996, to 27 million in 2005 - making depression, anti-depression pills, the most commonly prescribed type of medication in America, according to a recent study. How did that happen? Are we getting more depressed? Maybe we're getting overdiagnosed or we're getting overtreated.
On top of all of that, one recent study - in the prestigious Journal of the American Medical Association - says some antidepressants don't do much more than a placebo for patients who aren't severely depressed. So what to think of all of this?
Well, hopefully, my next guests can help us sort through all of this and explain and talk about depression. So let me introduce them.
Gary Greenberg is a practicing psychotherapist and author of "Manufacturing Depression: The Secret History of a Modern Disease." You may have also seen his pieces in Harper's, The New Yorker, Mother Jones, among others. He's in our studios here in New York. Welcome to SCIENCE FRIDAY, Dr.�Greenberg.
Dr.�GARY GREENBERG (Author and Psychotherapist): Hello, Ira.
FLATOW: Hello there. Dr.�Peter Kramer is the author of "Listening to Prozac" and "Against Depression." He's also a clinical professor of psychiatry and human behavior at Brown University in Providence, Rhode Island, and he joins us over the phone. Welcome back to SCIENCE FRIDAY, Dr.�Kramer.
Dr.�PETER KRAMER (Author and Professor of Psychiatry and Human Behavior, Brown University): Thank you.
FLATOW: You're welcome. Let's talk to you, Gary, first, and talk about your book, "Manufacturing Depression." Why the name for that book?
Dr.�GREENBERG: Well, I named the book "Manufacturing Depression" because, like many people, I lived through the last couple of decades, during which those antidepressant figures skyrocketed. The number that you gave, the doubling as of 2005, is actually a quadrupling since the mid-1980s, and while I noticed there was a great deal of controversy about the use of the drugs and what they did and whether they should be prescribed, I also noticed that the idea about what depression was, was changing at the same time. And it occurred to me that the just as the pills had been invented, so, in some ways, the idea of depression had been invented.
FLATOW: What do you mean, changing? Give me an idea.
Dr.�GREENBERG: How the idea how depression had changed?
FLATOW: Yeah, the definition of it.
Dr.�GREENBERG: Largely, what had changed was the question of how common it was and how easily it could be seen. Those skyrocketing antidepressant numbers were also accompanied by skyrocketing epidemiological figures, which seemed to show that more and more people were afflicted with depression. And there were a number of ways to account for that, all of which may be true: better reporting, better testing, better surveillance. But it also was clear, particularly given the recent changes in the way psychiatric diagnoses are made, that in a way, the diagnosis had been tailor-made to the drugs.
And moreover, the diagnosis had been made in such a way that if you showed certain symptoms, then regardless of where those symptoms came from, how you might come by them, what they might mean, then de facto, you were depressed. So the disease consisted of the symptoms, and the symptoms consisted of the disease.
FLATOW: So, is ordinary human sadness being erased by a depression diagnosis, then? You're feeling sad? You're not sad, you're depressed.
Dr.�GREENBERG: I think there's a tendency that way, yeah. I think what happens is that there's, among people who might be sad, who might be demoralized, I think more and more, given the way that this message has gotten out, I think people you sort of have to consider it.
If you're feeling bad and you're feeling demoralized and you're feeling apathetic and you're feeling sad for a long period of time, chances are very good that you're at least going to consider that there's something wrong with you that should take you to your doctor. And if you go to your doctor and complain about those things, chances are very good that he's going to tell you yes, indeed, you have this biochemical imbalance, and there are drugs which we can use to treat it.
FLATOW: There's a pill for that. Like there's an app for that, now we have -there's a pill for that.
Dr.�GREENBERG: Yes, and the pills came before the apps.
(Soundbite of laughter)
FLATOW: Peter Kramer, what's your take on that?
Dr.�KRAMER: Well, clearly, depression is diagnosed more. I don't know that mental illness is diagnosed more. If you want to look at the peak of our diagnosis of mental illness, excuse me, it's around 1959, 1960. There were some surveys in which 85 percent of people had something wrong with them that a psychoanalyst would be happy to treat, and that came under the heading of disorder.
So I think, you know, part of the question is how we apportion what psychiatrists see as problematic, and I think the illness rates are much lower, actually, now, than at the middle of the last century.
I think part of what has happened is due to medication, that when you have something that is reasonably effective and doesn't have terrible side effects, and it treats conditions that are common, you know, you see those conditions more.
Now, we can have the discussion about how effective the antidepressants are, but I think in general, if you're depressed, and it's really harming your life, this is a better time to be alive than any time in history.
FLATOW: But starting that discussion, there was there's a famous article, I'm sure you are aware of, in the Journal of the American Medical Association that says that for people with these mild depressions or moderate depressions, that the antidepressants are no more effective than just taking a placebo. You take either the pill - it could be a placebo - or the medicine, and they just have about the same effect.
Mr.�KRAMER: Yeah, and I don't buy that study. There are detailed, statistical reasons why that study is problematic, but let me say what I think the field sees.
It looks as if antidepressants are good for specific, very tough types of depressions, so the kind of depression you have after a stroke, the kind of depression you take with anti-cancer you get when you take certain anti-cancer medication, postpartum depressions, the severe depressions that show up as being reasonably well-treated in that JAMA article.
It's also good for chronic, mild depressions. If you look at the JAMA article, they start out by saying they're going to get rid of all studies of chronic, recurrent, minor depression, which is probably what most of what psychiatrists see because it's well-established that antidepressants work for that.
It look as if depression antidepressant drugs have effects on people's personality styles, making them more assertive, and that seems to be true both for people who have depression over a broad range of depressive illness, and for -probably - normal people with nothing wrong with them.
Also, these medicines are useful in a range of disorders, anxiety disorders, very serious mental illnesses that have anxiety or depression as components.
So there's this one little hole that's complained about in the JAMA article, which in the end, you know, they screened 2,000 studies of depression and ended up focusing on six studies of two medications. So in this small study, they said the less-severe depressions that aren't recurrent don't respond well to these medications. And that very narrow finding, you know, appears in the newspapers.
There's, you know, a cover of Newsweek saying that antidepressants don't work. And it seems to me both, you know, very unlikely. How could that be? It works in animal models and so on. How could that be? And also, you know, a little off to the side, most people getting antidepressants are not in that category, and most people with depression aren't getting antidepressants, which is probably more the problem.
FLATOW: Gary, would you say that they're overprescribed, though, with all those people getting all that medication?
Dr.�GREENBERG: I think I don't know if they're overprescribed. I think that the disease is overdiagnosed, and I think that's actually a much more fundamental problem. I think that the JAMA article is one of a series of articles that indicates that there's a distressing lack of robust effect for antidepressants in clinical studies.
That wasn't the first article to say that they don't do much better than placebo. More just about half of the clinical trials for the antidepressants that have been approved failed to distinguish the antidepressant from the placebo.
But it's possible that what's going on is something like what Peter just said, which is that these drugs are doing something for people. It's just that the Hamilton Depression Scale isn't measuring it, that in fact what's happening is that we've got a mismatch between diagnosis and drug, and that the diagnosis in some ways and I write about this in my book the diagnosis in some ways gives cover for people to take the drugs and physicians to prescribe them. But when you actually go to measure depression and the effect of antidepressants upon it, you don't get a good reading of what the antidepressants are doing. Trying to measure what the antidepressants are doing with the Hamilton is like looking for feathers with a magnet.
So what we have is a drug that we don't maybe we dont understand very well, what it's actually doing. We don't have a good phenomenology of the way it alters our consciousnesses.
FLATOW: 1-800-989-8255 is our number, and there's some dispute about even how the drugs work in your brain, what they're doing in your brain -antidepressants.
Dr.�GREENBERG: I think it's fair to say that nobody knows all of the implications of what we do understand about what antidepressants do in the brain. We know that they change metabolism of certain neurotransmitter systems, but we don't really it's a black box. You put the pill in, you get the behavior or the experience out, but nobody really understands exactly why that happens.
FLATOW: Peter, you agree?
Dr.�KRAMER: Well, I think that's right, although I think we know more and more and that - my fear is that the public thinks that the news about antidepressants has been really bad over the past 10 years, that these medicines look worse and worse.
You know, they foment suicide, their withdrawal effects and so on. And I think most of the bad news about antidepressants, and most of the news about how they compare to placebos, was really out, with some exceptions, really has been available for 10 years, and what the news of the last 10 years concerns is just how these medicines work. You know, in the first instance, they change the way the brain handles these neurotransmitters. But it looks as if downstream, they really make the brain more resilient in certain ways.
They encourage connections between nerve cells, new connections. They allow the brain, if in depression, a capacity has been muted, to make new cells in certain - limited parts of the brain.
So I think yes, there's bad news. There's also good news about these medicines and really, increasing knowledge about how they work.
FLATOW: All right, we have to take a break. We'll come back and talk more with Dr.�Peter Kramer and Gary Greenberg, author of "Manufacturing Depression: The Secret History of a Modern Disease." Our number, 1-800-989-8255. And you can tweet us @scifri, @-S-C-I-F-R-I - and hang over with folks over in Second Life. So we'll be right back after this short break.
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FLATOW: I'm Ira Flatow. This is SCIENCE FRIDAY from NPR.
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FLATOW: You're listening to SCIENCE FRIDAY. I'm Ira Flatow. We're talking about depression this hour with Gary Greenberg, practicing psychotherapist and author of "Manufacturing Depression: The Secret History of a Modern Disease"; Peter Kramer, the author of "Listening to Prozac" and "Against Depression," also clinical professor of psychiatry and human behavior at Brown University, in Providence.
Our number, 1-800-989-8255. Gary, let's get to a central theme of your book. And you do say - "The Secret History of a Modern Disease" - and one of the stories you tell is how something that we all have, unhappiness, how that has been turned into something called depression. How did we go from just, welll, we're all unhappy but oh, no, now you're depressed? I feel like it's a George Carlin routine, you know?
Dr.�GREENBERG: Well, that's a long and gradual process. I hope it's somewhere near as funny as George Carlin, and if I told you the whole story, then nobody would buy my book, so...
(Soundbite of laughter)
FLATOW: Well, give us a thumbnail.
Dr.�GREENBERG: I'll tell you a little piece of it. Well, you know, we all come to the table with an idea that a disease is a form of suffering that has a biochemistry a biochemical pathogen. That's our, sort of, working definition of disease.
It's probably not a good definition, but it's what you think if somebody tells you that you have a disease and that it functions independent of your character and your will.
And so there's a great impulse to take as much as we can of our suffering and put it into that category. That's what's happened with addiction, and that's what's happened with many psychiatric disorders, you know, and I think this helps people a great deal.
When it comes to depression, there was just a historical movement toward that. And in the early 1960s, a drug came along, called Elavil, which is an antidepressant that was invented toward the end of the 1950s. And Merck, which owned it, wanted to sell it.
And they were faced with a problem, which was the drug was really competing with other psychiatric drugs that were very popular: Miltar(ph), Librium, to some extent, Valium. And the question was: How do we sell this drug? And they turned to marketing people, and the marketing people said well, that's easy. What you do is, you associate it with a disease. You teach people that there is a disease out there that the drug works for.
And there was a doctor named Frank Ayd who was sort of the Johnny Appleseed of depression. He wrote a book called "Recognizing the Depressed Patient." He wrote that book for Merck, and Merck distributed 50,000 copies of it to doctors across the country. And in the book, doctors were encouraged to start to think about patients who came in with an assortment of ailments that they wouldn't normally think of as an illness, as a single illness, and that that ailment was depression.
It even provided a script for the doctors that told them how to approach the patient. Look, this is what you've got. It's a real, physical illness. You're not going crazy. There's nothing wrong with you morally. It's a disease.
FLATOW: And we have a pill for that.
Dr.�GREENBERG: And we have you know, and Ayd was tremendously restrained. He wrote 125 pages before he wrote about the pills. But yes, of course, you're selling it to doctors.
And what's really interesting about that is that they weren't selling the drug. They were selling the idea behind the drug, and that is the embedded message in every antidepressant ad that you see. It's not just advertising the virtues of the drug, it's advertising the disease. It's advertising to you the idea that if you're feeling this way, then you must be sick, and you should see your doctor and consider taking the pill.
FLATOW: And that's and that was the beginning of the road to where we...
Dr.�GREENBERG: It's say that that doctors are still telling patients that. Now, as Peter said earlier - and as I also said earlier; I think we agree about this - we don't know that much about the actual biochemistry of depression, but you wouldn't know that if you go into your doctor, and he says you need an antidepressant because you have a biochemical imbalance, which happens all the time.
FLATOW: And Peter, how hard is it to diagnose depression in patients, and what level they have it?
Dr.�KRAMER: Well, I think one of the conveniences of this cookbook form of diagnosis is that it does make it easier for doctors in general to see depression.
I don't think that this is a manufacturing of mental illness. As I say, if you came in in Frank Ayd's time, in the 1960s, you know, likely your doctors saw that you had neurotic anxiety or neurotic depression and that as the medical research became more and more feasible, you could start looking at the brain, as there was a rise of neuroscience.
There was a need for comparable diagnoses across places, and that gave rise to these simpler forms of diagnosis, which have been very, very useful for research -and I agree probably have a mixed effect on clinical practice.
They tend to make people think in more biological terms, but they had this advantage of allowing doctors, really, to recognize it as a problem and to start a discussion with patients.
FLATOW: 1-800-989-8255 is our number. A recent study from the National Institute of Mental Health suggests that over half of the people diagnosed with major depression received treatment of some kind, and only a fifth receive adequate treatment.
FLATOW: How do we reconcile those numbers?
Dr.�KRAMER: Right. Well, you know, I think there's all this worry about loss of sadness, and the there's a book about the loss of sadness by Jerome Wakefield and Alan Horowitz - which I disagree with - which says that depression is more and more impinging on sadness.
And if you look at the categories that these, you know, psychologists and social workers, sociologists, raise as possible areas where sadness is kind of getting smaller and depression is getting larger, and you actually look at the data on patients, it turns out these patients aren't getting medication. Many of them aren't getting psychotherapy, either.
But the kind of person who comes in with a concrete problem, where, you know, they just lost a job, they're only within a couple of weeks of the loss, they're feeling awful, they don't mostly walk out of doctors' offices with medication.
So I think that, you know, the problem still remains more or less on the other side, that if you take kind of broad definitions of what's adequate treatment, a few weeks of a medication or four or five visits with a psychotherapist, very few people who meet this broad definition of depression are getting that treatment.
And if you look at specialized groups like African-Americans, Mexican-Americans and so on, almost nobody's getting even a little adequate treatment.
FLATOW: Is that because they are not showing up in the offices, or they're just not being treated well?
Dr.�KRAMER: It's a mixture. Partly, you know, the drop-off occurs at every stage. First of all, even using these broad definitions, most people who are diagnosable with depression at all have severe depression. I mean, that's really where people cluster whom you find when you go door to door. But you know, it used to be said that about half of people with depression aren't diagnosed; about half of those aren't treated; and then looking at the last quarter, about half of those are treated adequately. So about one in eight people, it used to be said, was being treated adequately. And now we're maybe up to about one in five.
FLATOW: 1-800-989-8255 is our number. Gary?
Dr.�GREENBERG: Well, I think that there's the numbers of people who are diagnosed and the way that people are treated, those numbers don't line up very well. I think that's undeniable.
I also think that you've got a problem here because the disease that we're looking for, the kind of disease that we're looking for - that is to say, the kind with a biochemical pathogen - is only one kind of disease.
Disease can also be seen as a way for as a form of suffering that we consider worthy of devoting social resources to relieving. And when you start to ask questions about people who are disadvantaged, people who are out of jobs and so on, their unhappiness there is a very important the fact that so many people can be diagnosed with depression may be an indication of a social problem, rather than some kind of epidemic of brain pathology.
FLATOW: And one of those just this week was talked about. There was a study out just this week in the Journal of Psychotherapy linking obsessive Internet use and depression.
Dr.�GREENBERG: Yes, and so do you you know, the standard question is: Is the Internet use causing the depression, or is the depression causing the Internet use, right? But they could both be indicative - the correlation could be indicative of something even further underlying, people who are feeling detached and alienated.
FLATOW: That was the Journal of Psychopathology; I misspoke. 1-800-989-8255. Let's go to Sheila(ph) in Cleveland. Hi, Sheila.
SHEILA (Caller): Hi, how are you?
FLATOW: Hi there.
SHEILA: We have, or I have a situation at home where I had my husband and two sons both go through short- and long-term periods of depression that did require treatment. And what was interesting is on my side of the family now mind you, you know, this is in my home, I'm living with these individuals, raising my boys - and on my side of the family, there's nothing, but on my husband's side of the family, there is some a severe chain of mental illness.
His mother is schizophrenic; there was suicide, his uncles, his grandfather. So there is a weakness there that I often feel the boys possibly inherited. So I'd like to address the question of, you know, can it be genetically passed down?
And in the instance of my husband, he's on long-term treatment and he absolutely - the drugs that - the medication that he's on have been - have been a savior. They saved his life. He was getting to the point where he could not function. You know, we're not just talking about sad on cloudy days, but we're talking about ceasing to do all the things in life that give a person joy and that he is capable of doing. And with my sons, they both incurred the problem as they went into their teenage years. And medication, shorter term, in the sense of, you know, like a six- to eight-month period for my one son and about a year for my other, managed to allow them to cope through the day as they fought through these situations and got on the other side of the issues, but it's very disruptive. So I'm curious about the genetic factor.
FLATOW: All right. Thanks, Sheila. Peter, you want to comment?
Dr. KRAMER: Yes. First of all, I'm so glad that Sheila called in, because we have been talking sort of up in the air, and these are serious disorders that affect people very gravely - are very disruptive to families or tough to deal with. And I think Sheila was talking about the level of depression that all the studies we're talking about count as major depression, that most cultures count of some kind of an illness and where the drugs, you know, have - medications have been shown to work.
The depression is reasonably heritable. I mean, this question of what identical twins have and non-identical twins have less in common is interesting in mental illness - some things you think of maybe is less heritable or more so, so things like attention deficit disorder and autism, and that range of disorders are highly heritable.
Depression is about at the level of things like common forms of diabetes. So it's fairly heritable. But you know, that being said, you can have an identical twin who's depressed and never be depressed. And partly that's because environment really does play a role, that we know that things like, you know, losing a job, terrible things like sexual or child abuse, trauma, that all kinds of losses and stressers have something to do with depression. And then when people are made vulnerable, ordinary stressers seem to have some effect.
FLATOW: Talking with Dr. Peter Kramer, author of "Listening to Prozac" and "Against Depression," a professor of psychiatry and human behavior at Brown University in Providence; and Gary Greenberg, practicing psychotherapist and author of "Manufacturing Depression: The Secret History of a Modern Disease," on SCIENCE FRIDAY from NPR. I'm Ira Flatow. Let's go to the phones and see if we can get a - a lot of people want to call. Mary in Denver. Hi, Mary.
MARY (Caller): Hi there.
FLATOW: Hi there.
MARY: Glad to be able to voice my question on the air here. I'm glad to hear Mr. Greenberg address, you know, the possibility that depression is - has social factors that are accounting for the rise in diagnosis, as well as the manufacturing kind of angle I enjoy hearing about that.
The other question I want to raise is the fact that, you know, we're treating depression primarily with an antidepressant rather than looking at depression as a multisystemic disease within the body, and really going after addressing factors like inflammation. You know, excess levels of arachidonic acid and low levels of vital omega-3s can lead to inflammation. And inflammation hurts and makes you feel crummy.
MARY: Or blood sugar instability, and having your blood sugar rise and fall through the course of the day, if you're pre-diabetic or you've got metabolic syndrome. You know, there are these other factors...
FLATOW: Yeah. Let me get a reaction. Gary?
Mr. GREENBERG: Well, I think that I think that that's a really important point. The molecular biology of the brain is vastly interesting and vastly complex. And it's also sort of a magnet for this kind of work. The question of looking at larger bodily systems is related to the question of looking at larger social systems that might be responsible for depression.
You know, the kind of depression that Sheila, the earlier caller, referred to is - I think every clinician has seen it, but it is fairly uncommon compared with the numbers of people who are getting diagnosed. The people that might be getting diagnosed with other kinds of depressions, if we had a way to distinguish them, might be people who are suffering from troubles like - can we imagine how much less depression would there be if we all didn't have to walk around worrying about paying for health care, paying for tuition, paying for retirement, if we didn't have to think about how we were going to run our households with two people working and still have time for our children.
And the kinds of things that people complain to me about in my office, who would certainly qualify for some diagnosis of depression, are social issues. And our society doesn't do a very good job of taking care of people. Instead, what we do is, we have people look at increasingly - at their molecular biology, which very few of us have the capacity to understand, and say OK, the way to deal with that is to change your molecular biology.
FLATOW: So is depression lower in, say, Sweden, where a lot of these things...
Mr. GREENBERG: I don't think that there's very much interest in answering this question.
Dr. KRAMER: I'll have go at it...
FLATOW: (Unintelligible) quickly, because I got about a minute left.
Dr. KRAMER: Depression goes with latitude, so it's very high in Sweden. But beyond that - this is an old sociology question of simpler and more complex societies. And I think almost every study shows that simple societies are very stressful, also. You know, I say to college kids, would you rather be in a small, rural town where everybody knows your business or would you rather be, you know, here where, you know, there are lots of intellectual resources and so on? I don't - I agree that social factors are very important in depression, but I think the notion of utopia - you know, being a simpler kind of living - is, you know, perhaps illusory.
FLATOW: But we have social issues, not just, you know, what am I going to do, go to the library today? We have other real problems - health insurance, things like that, that are not the simple - I'm just bored today in a small town.
Dr. KRAMER: Yeah. No, no. But I think human life has stress and there are you know, that other eras and other cultures have stressors as well. You know, it may be true that in some real communitarian societies - people have studied Bali and Fiji and so on - that there are different distributions of mental illnesses, but you still see almost all the mental illnesses. And you know, some of them maybe just do better in places where you can be out in the rice fields every day and where even mentally ill people get married.
FLATOW: All right. We have to take - say goodbye, take a break. Thank you, gentlemen, for joining us this hour.
Peter Kramer, author of "Listening to Prozac" and "Against Depression," a clinical professor of psychiatry and human behavior at Brown University. Gary Greenberg, a practicing psychotherapist and author of "Manufacturing Depression: The Secret History of a Modern Disease." Thank you both for being with us today.