Mikkel Borch-Jacobsen

  • La Fatigue d’être soi: Dépression et société by Alain Ehrenberg
    Odile Jacob, 414 pp, €8.35, August 2001, ISBN 2 7381 0859 8
  • Comment la Dépression est devenue une épidémie by Philippe Pignarre
    Découverte, 92 pp, €14.48, September 2001, ISBN 2 7071 3517 8

We all know how it happens. One day, without warning, you feel oddly removed from things and people, as if an invisible wall of glass were separating you from them. They go about their business but, for a reason that escapes you, none of it any longer concerns you. You could call out, but what would be the point? You aren’t worth it, and the friendly overtures of others come as a justified reproach. Day by day, the wall grows a little thicker. Soon, you are no longer able to leave the house, your bedroom, your bed. The only thing you are left with is the pain of existing. You no longer eat or bathe or sleep. You are agitated and exhausted all at once. You keep thinking of the barbiturates, of the razor that would allow you to cut short the terrible insomnia.

We’ve all read stories like this in autobiographies, or in the innumerable newspaper articles devoted to this strange illness. The depressed person is a relative, a neighbour, a colleague. Perhaps tomorrow her story will be ours: depression, it’s said, strikes one woman in five, and one man in ten. Its prevalence among the world’s population at any given moment is of the order of 3 per cent. One in six depressed people commits suicide.

Fortunately, however, we’re told on all sides that depression is no longer a fate. Antidepressant drugs have been around since the mid-1950s, and the new generation – the selective serotonin re-uptake inhibitors (or SSRIs) – work wonders. Under the influence of Prozac, Zoloft or Paxil, people for whom existence had been an unbearable burden suddenly find renewed pleasure in life, without having to suffer the unpleasant side-effects of the older generation of antidepressants, the tricyclics and the MAOIs (monoamine oxidase inhibitors). Admittedly, SSRIs sometimes lead to diminished libido and even, among men, to impotence, but that is surely a small price to pay for a restored capacity for happiness. Twenty million people worldwide are now thought to be taking Prozac, and we are hearing reports of a new era of ‘cosmetic psychopharmacology’, in which drugs will be used to treat not only clinical depression, but daily mood swings and existential angst. So farewell Kierkegaard and Heidegger.

There is a problem, however, with this therapeutic optimism. If it is indeed true that antidepressants cure depression, how is it that the illness is spreading ever more widely? These books by Alain Ehrenberg and Philippe Pignarre, along with a third, published a few years ago by David Healy,[*] forcefully underscore the incongruous fact that depression was never so prevalent as it has been since the introduction of antidepressants. It has always been with us, though it went by other names and sometimes assumed different shapes, depending on the era. From Hippocrates to modern psychiatry, ‘melancholia’ – that is, depressive psychosis, or ‘endogenous’ depression – has been described in remarkably consistent terms. Yet until very recently this type of depression was considered extraordinarily rare. Healy notes that in the North Wales Hospital between 1900 and 1945, only fifty out of a million patients were admitted for ‘melancholia’. Today, by comparison, 948 out of every million admissions to psychiatric hospitals are for ‘depression’, of which 268 are considered severely melancholic or psychotic.

Even more striking, in the mid-1950s, when the Swiss psychiatrist Roland Kuhn discovered the antidepressant effects of imipramine on a number of patients suffering from ‘endogenous’ depression, the pharmaceutical company Geigy at first declined to finance the drug’s development, judging the market to be too small. Less than forty years later, in 1994, Prozac was the second bestselling medication worldwide, just behind the ulcer drug Zantac. In the meantime, depression’s rise had been irresistible. In 1970, the psychiatrist Heinz Lehmann estimated that there were 100 million cases worldwide. In the US alone, the number of consultations leading to prescriptions for antidepressants jumped from 2.5 million to 4.7 million between 1980 and 1989. In France, the number rose sevenfold between 1970 and 1996, and no fewer than 14 million prescriptions were recorded in 1994. The World Health Organisation predicts that depression will soon become the second largest public health problem – the largest is heart disease. ‘What we are witnessing,’ Pignarre writes, ‘is a veritable epidemic.’ Yet as far as anyone knows, there is no such thing as a virus causing depression. How, then, did the handful of melancholic patients in the 1950s become the millions of the 1990s?

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[*] The Antidepressant Era (Harvard, 336 pp., £12.95, 1999, 0 674 03958 0). Healy’s most recent publication is The Creation of Psychopharmacology (Harvard, 480 pp., £27.50, 25 March, 0 674 00619 4).