- 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?
The full text of this book review is only available to subscribers of the London Review of Books.
[*] 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).
Vol. 24 No. 15 · 8 August 2002
Mikkel Borch-Jacobsen’s review of my book, La Fatigue d’être soi (LRB, 11 July), has already been published in practically the same form in a French journal (Ethnopsy, 4 March 2002) and in his book Folies à plusieurs: De l’hystérie à la dépression (the relevant chapter is called ‘La Grande Dépression’). The publisher of both is Philippe Pignarre, author of Comment la dépression est devenue une épidémie, which Borch-Jacobsen reviewed in the LRB alongside my book. Pignarre pans La Fatigue d’être soi in his volume, which is fair enough, but is it proper for an author to review his own publisher’s book, especially when that review is an apologia?
Because my book is not available in English I think I should give an account of what it does say. It is the final volume of a trilogy on contemporary individualism, and addresses two questions: why and how has depression become such an important illness, and what does depression tell us about changing notions of the individual at the end of the 20th century? Two hypotheses are proposed: the first concerns the relationship between depression and the transformation of democratic society since World War Two and holds that there has been a reduced emphasis on guilt and discipline, in favour of a stress on responsibility and personal initiative. Borch-Jacobsen sees this as a proposition that depression is a ‘simple reflection of changes in society’, but I make clear that social norms do not penetrate people’s heads the way that rain is absorbed by the ground: mediation is necessary. The second hypothesis concerns the role played by depression in the transformation of individual pathologies during the same period: I argue that depression’s prevalence can be attributed to the reduced importance of the notion of ‘conflict’, which was the basis of ideas of neurosis in the late 19th century.
I also contest the idea that the invention of antidepressants created depression. Such a thesis is a by-product of technological determinism. I distinguish two eras of contemporary depression. The first begins with the invention of ECT – not antidepressants – and ends in the early 1970s. During this period, depression was an appendage of neurosis; psychotropic medications were used as ‘boosters’ for psychotherapy. This paradigm was then rejected, in large part through the development of the Diagnostic and Statistical Manual of Mental Disorders III in the US, but also because of the evolution of the place of depression in psychoanalysis (the increasing attention paid to narcissistic pathologies). Depression is now used to refer to a whole range of problems, from fatigue to psychotic melancholy.
It is inaccurate to claim that I lose ‘sight of the link between the epidemic and the marketing of antidepressants’. For that link, my book refers the reader to David Healy’s The Anti-Depressant Era, as well as to his volumes of interviews (The Psychopharmacologists). But I contest Borch-Jacobsen’s use of the word ‘epidemic’ here as metaphoric at best, absurd at worst; and in accounting for the ‘success’ of depression as a diagnostic category, I would want to emphasise sociological conditions (which seem not to exist for Borch-Jacobsen) as much as chemicals and their marketing.
Contrary to what Borch-Jacobsen writes, Roland Kuhn thought – as did other psychiatrists in the 1950s and the early 1970s – that antidepressants could also be used to treat neuroses, particularly obsessional ones. By diminishing the intensity of symptoms, they allowed the patient to engage in ‘talk’ therapy. Also, neurosis in the psychoanalytic meaning of the term is not a ‘reaction’, but rather the expression of an internal unconscious conflict. And so on.
Centre for Research on Psychotropics and Mental Health, Paris
Mikkel Borch-Jacobsen nods approvingly at Philippe Pignarre’s so-called syllogism. ‘1. I feel depressed; 2. I want to feel better. 3. I’m going to get a prescription for antidepressants.’ This elides the distinction between ‘depression’ as a clinical diagnostic category and as a description of how I’m feeling. Pignarre ignores the institutional and professional conditions under which a clinical diagnosis is established through dialogue. These conditions are under increasing pressure, to be sure: salesmen for Eli Lilly recently mailed out free samples of Prozac. But there’s still a difference between getting antidepressants and ordering a nice dinner. ‘The point is,’ Borch-Jacobsen writes, ‘that I wouldn’t feel “depressed” if I didn’t know that there were drugs for treating it.’ Slipping the scare-quotes around ‘depressed’ clears a nice space for condescension here, separating the tough-minded from the corporate dupes. I would, however, still be feeling something – melancholia or acedia, ennui, despair, nameless dread or another such psychic state historically lacking effective treatment. No doubt Borch-Jacobsen finds these conditions nobler than depression because accompanied by a sense of helplessness.
Vol. 24 No. 16 · 22 August 2002
Alain Ehrenberg (Letters, 8 August) complains that one signatory of this letter, Philippe Pignarre, is the publisher of work by the other signatory, Mikkel Borch-Jacobsen, in order to imply that Borch-Jacobsen’s favourable review of Pignarre – and his unfavourable review of Ehrenberg – is tainted by nepotism. In the interest of full disclosure, we readily admit that we are both, along with Tobie Nathan, Isabelle Stengers and Bruno Latour, on the editorial board of Ethnopsy, a French journal that advocates a constructionist approach to mental illness and psychotropic drugs. ‘Les Empêcheurs de penser en rond’, a series edited by Philippe Pignarre at Editions du Seuil, was set up as an outlet for this group’s publications, and has translated into French works by authors sharing similar views, such as Ian Hacking and David Healy. All this is well known to Ehrenberg, which makes his imputation of review-fixing all the more contrived. Why not admit that if we publish and review each other, it is, quite simply, because we appreciate each other’s work?
Mikkel Borch-Jacobsen & Philippe Pignarre
University of Washington, Seattle & Paris