A decade or so ago, psychological depression was something of a cinderella among the troubles of our age. Coming off the back of the sixties, when the star turns of schizophrenia and anxiety had moved from being something more than mental illnesses and were increasingly seen as metaphors for the human condition, depression was lacking in character — a black hole in life, rather than something to which meaning could be attached. The widespread recognition that the occurrence of the condition was on the rise, and the publicity that surrounded the release of the new generation anti-depressant medication Prozac, were still insufficient to push the condition to centre stage.
All that has now changed magnificently. Today, depression has become recognised as a key social problem now and for the future. Across the OECD, public health campaigns strive to increase awareness of the condition as an illness, to urge people to know the symptoms, to not feel shame about presenting to a GP or psychiatrist with the condition. Narratives of depression — from Elizabeth Wurtzel’s Prozac Nation to Kay Redfield Jamieson’s An Unquiet Mind — were joined by depression subplots in mainstream TV shows such as Party of Five. In Australia, the focus on health initatives targetted five areas, one of which was depression, and this was followed up by the launch of Jeff Kennett’s mental health initiative on the area. Newspapers began to run series — such as the recent five-day extravaganza in the Age — which explored the phenomenon from all angles, and with impressive degrees of sophistication on issues such as psychotherapy versus drugs, depression and self-definition, and so on.
Suddenly it seemed everyone could quote the WHO observation — made in its Global Burden of Disease study — that depression was set to become a leading public health burden of developed countries by the year 2020. Everyone knew someone who was on Prozac, or one of the dozen or so other new generation anti-depressants. Everyone could talk about serotonin, the mysterious brain chemical that seemed to be running the show.
Indeed, as the nineties wore on, the new hyper-awareness of depression became alarming in itself. As the Prozac wave crested, it seemed as if every second person was on the drug, if only for a few months. Passages in people’s lives that would have hitherto been classed as being ‘down in the dumps’ were self-medicalised, and GPs reported many cases of people turning up and specifically requesting the drug. That the drug was helpful for many people whose depression could not be alleviated by psychotherapy alone — people whose neurochemistry had become ‘stuck’ — and for many hitherto intractable problems, such as high-repetitive obsessive-compulsive disorder (repeated hand-washing and the like), was not contested. What was in doubt was the many people who reported improvement for minor depressions that the drug was never intended to alleviate, and those who reported feeling ‘better than well’. The latter were from a depressive sub-group classed in the official manual as ‘dysphoric’ — those who had a persistent ‘endogenous’ unhappiness: one that was unrelated to external events. Many of these people — who had hitherto been regarded as substantially untreatable — responded ‘well’ to Prozac, and became substantially brighter. Many psychiatrists found this disturbing, since the definition of dysphoria as a medical condition was already controversial. Was it indeed a pathology, or simply one feature of the ecology of personalities that made up a complex society? What was being medicalised in a modernised US was a sort of personality type that would have been seen as appropriately ‘serious’ or possessed of ‘gravitas’ in another culture — such as a Scandinavian or Calvinist one. The capacity of Prozac to transform personality confounded the easy divisions that had hitherto been made between normal and pathological mood states. New anti-depressants came to market and it was realised that they treated different aspects of the overall state known as ‘depression’. Some were then marketed as a cure for ‘social phobia’ — the overwhelming hypersensitivity to negative aspects of social encounters. Many believed that such a targetting had less to do with a concerted attack on disease x or y than it did with the need to pseudo-differentiate products in a crowded market.
Yet as the prospect of a new and challenging relationship between psychiatric drugs and humanity was opening up — one in which it would be possible to shape one’s mood and personality by the use of different drugs in different combinations — the backlash began. Prozac was accused of being a contributing factor in a number of murders and suicides — charges which manufacturer Eli Lilly successfully defeated in court, or settled out of it. That the drug could tip a small number of users into sudden moods of suicidality had been acknowledged in original studies and was a documented side effect. Nevertheless the hype about the drug as a wonder substance with no drawbacks had drowned out persistent and increasing reports of frequent and widespread side effects — anxiety attacks, jitters, excess energy, sexual dysfunction and many others. By 1997 studies were beginning to show that the drug induced tolerance — meaning that discontinuation would create withdrawal effects and that increase of dosage might become necessary. In retrospect of course this is a bit of a no-brainer, so to speak — it should be obvious that any externalisation of a self-regulating system like neurotransmitters will make those drugs part of the whole system. Anyone regularly using anti-depressants is to some degree a chemical cyborg.
Yet such was the cultural desire for a ‘magic bullet’ that would blow away the blues that these obvious features of any medication were forgotten. Despite the bitter lesson of tranquilisers — the last magic bullet, and far more harmful than anti-depressants — the belief in an existential free lunch had become widespread.
In vain did psychotherapists point out that cognitive-behavioural psychotherapy (CBT) — in which the client is encouraged to gradually reflect on and change negative mental frameworks and assumptions — was found to be as effective as chemicals in the treatment of depression, and that the use of CBT with medication greatly diminished many of the emotive side-effects, such as increased anger. Not only was the cultural bias tilted towards chemicals, but the economic structure of the health industry made it difficult for people to get CBT — or any sort of psychotherapy — even if they wanted it. The vast majority of people presenting with depression would be treated by a GP and no other specialist, and the bulk-billed GP’s average consultation time is adjudicated at around 10 minutes. The increasing numbers of people presenting for depression began to wear many GPs down emotionally — the last thing many were willing or able to do was to ask people to open up further.
The state of play by the end of the 1990s was better in some respects — people were increasingly capable of identifying themselves as depressed and in need of assistance — but worse in others. The public health approach to the issue had constructed depression as a sort of emotional RSI, an inevitable by-product of contemporary living. The implicit assumption was that fundamental conditions of everyday life should remain unreflected upon, and the condition isolated and treated as an individual occurrence. While this was now more sophisticated than purely physical medicalisation — the literature now speaks of depression as a ‘biopsychosocial’ problem, and identifies issues such as social isolation, stress, and so on — it foreclosed inquiry into the meaning of an increase in depression as a social phenomenon.
Furthermore, a shift in the process of self-understanding had begun to occur, with people’s reading of themselves as ‘systematic’ beings — rather than as selves or souls — starting to become a dominant mode by which behaviour is interpreted. This was not a new phenomenon of course — everyone learns to recognise the effects upon themselves of, say, drunkenness, and to distinguish between their ‘intrinsic’ and chemically induced emotions — and this sort of self-understanding is vital within a limited scope. But to give oneself over to this sort of thinking about one’s whole personality is to make it impossible to interpret any given emotion as a meaningful event? Angry? That’s a rush of adrenalin. Stressed, nervous, hunched, tired — your cortisol is out of whack. Feeling low? No, you’re serotonin deficient.
It is the last of these conditions that has become so visible, and a shorthand for the spirit of the age. People such as Tom Peters, the management guru who authored In Search of Excellence, talk of themselves as serotonin-deficient, thus turning their existential state into a physical condition — a piece of bad luck, over which he has triumphed. That the fluid, unstable, chaotic structures that he advocates for corporations and society might have something to do with his ‘deficiency’ is not explored. More critically, the UK social psychologist Oliver James talks of a ‘serotonin-deficient’ society, pointing out that people would appear to be somewhat less happy overall than they were in 1950. James’s aim is to document the way in which many features of social life which maintained people’s baseline level of contentment — social closeness, more manual labour as a component of work — have been diminished, leading to higher levels of base dissatisfaction. Much of his criticism is directed towards the enthusiastic and unquestioning adoption of hi-tech solutions by the ‘third way’ Blair government. Nevertheless the formulation of ‘serotonin deficient’ is inherently technocratic, since the frequent response may be to ‘fix’ the serotonin levels as an act independent of any contextual life change.
Art critic Robert Hughes told everyone who interviewed him at the time of the release of American Visions, his mammoth book on American art, of the depressive collapse he had suffered prior to the composition of the book, and the manner in which he used anti-depressants (and CBT) to jack himself out of it. True, in earlier times he might have used something more dangerous and damaging, such as amphetamines, or the vast amounts of coffee that Balzac drank in order to churn out work for publishers, but such substances have more of an immediate and noticeable impact — the side effects are more noticeable and a separation between self and substance more easily established. In Hughes’s case the irony of using a chemical to make meaningful a project that should have been inherently meaningful — the deep contemplation of art — seems to have been bypassed. Any question that the depression may have been bound up with the project, and indicative of a need for deeper reflection, was lost. What, one might ask, is so visionary about art if chemical alteration is required to contemplate it? What meaning does it, or anything have?
The point being ignored here — and in the public health approach to depression — is that shifting the definition of one’s mood from being ‘miserable’ to being ‘depressed’ has become a category shift, in which two competing versions of human being are ranged against each other. In some cases this may be unquestionably and absolutely valid — a hypoglycemia sufferer may fall into a sudden and major depression due entirely to a drop in blood-sugar levels, and with no external existential causes. Interpreting one’s world in the light of one’s mood in such a case would clearly be disastrous and in error.
Yet such cases are comparatively rare in the vast swathe of people complaining of depression — and often used to avoid contemplation of existential causes. Most people who have fallen into a persistent state of bleakness and inability to feel pleasure may well have fallen into a state of depression that has a specific chemical correlative — that is to say their serotonin/adrenalin levels may no longer be responsive to good events in their life. (The analogy would be that of a motor falling below a certain rpm and stalling). On the other hand, they may be in a persistent circle of what cognitive-behavioural therapists called ‘crooked’ or ‘rigid’ thinking that leads them to think of their situation as hopeless and moves them towards the state of ‘learned helplessness’ that the psychologist Marvin Seligman defined as a root condition of depression. Or they may have childhood trauma, or a genetic predisposition, or any combination of these.
The core fact is that to invite someone to recategorise themselves as ‘depressed’ is to ask them to recategorise themselves from subjecthood to objecthood. In other words the response to a condition whose principle characteristic is the absence of meaning is to have the person redefine themselves as a thing, as a point of relationship between different systems — social, chemical, linguistic, etc.
This criticism has been made before, by writers such as R.D. Laing and the anti-psychiatric movement in the 1960s. But much of that work came to be seen as no longer useful due to the excessive claims that it made for a totally humanistic approach that had no biological component. The later tendency of such writers to sometimes celebrate ‘schizophrenia’ as an excessively sane response to insane social conditions was also taken up by its opponents. Despite the fact that Laing and others never ceased to insist that mental illness was frequently a tormenting condition that was in need of alleviation, the general reaction to all things sixties that set in in the late seventies swept any form of critical psychiatry into the tidybin of history. Increased findings of possible evidence of a genetic predisposition to schizophrenia — the jewel in the crown of psychiatry — gave medical and systemic models a crucial increase in legitimacy. Although many of the insights of Laing and others into the ‘politics of experience’ were incorporated into diagnosis and the practice of the psychotherapeutic session, the broader criticism of diagnosis as a political and social act was forgotten.
In the rush to establish depression as a social problem to be recognised and addressed, the surrender of full personhood has been encouraged for a variety of reasons, credible and otherwise. Pundits such as Lewis Wolpert, author of the book and TV series Malignant Sadness, have mounted substantial campaigns to frame depression as an ‘illness’, ostensibly to relieve the sense of shame felt by those who see it as individual weakness and failure. The line is that it can ‘happen to anyone’ and that it is important to pass through the experience as efficiently as possible — to cut it out of one’s life as one would remove a diseased appendix from the body. Such an approach locks in easily to a ‘human capital’ approach to self, especially in the intellectually trained professions where the minimum level of cognition and focus required for effective performance may be higher than in other spheres. The intellectually trained worker is thus a valuable piece of equipment whose continued functioning must be ensured at all costs. Increasingly businesses have become aware of the need for a flexible approach to depression and stress, largely because they’ve been losing too many highly trained and experienced staff. The intellectual property lawyer who bails out to open a muffin shop, the IT genius who takes off to ride around Australia … twenty years ago ‘burn out’ was largely restricted to professions such as advertising and social work, where the work practice entailed free-form creative and emotional responses being channelled into specific and routinised tasks. Increasingly the management of the psychological mechanisms of individual workers has become a vital task in managing the production process and business has sought to incorporate the therapeutic model into human capital management. In 1999, for example, the Business Council of Great Britain devoted much of its lobbying budget and campaigning time to persuading the government to retain tax deductible status for stress counselling and psychotherapy for work-related issues, both for the individual employee and the company providing them. Mental health had become as significant an economic issue as trade union legislation, tax regimes and the like.
The current Australian initiative is in the same mode. There was an initial fuss when it was discovered that major pharmaceutical corporations were possibly to be involved in the funding of the inquiry — in the same way that they’re involved in the funding of numerous conference and research programs across the psychiatric field, often as not focussed on the relative efficacy of chemical and non-chemical treatments — and this link was severed. Nevertheless, the personnel of the inquiry will predispose it to models of depression which are systemic and non-contextual, rather than those which have an existential and social-historical perspective. Aside from athlete Nova Peris-Kneebone and actor Garry McDonald — the latter there due to his much publicised breakdown — the personnel of the initiative is tilted towards the medical and the psychiatric. There is no philosopher, no social theorist or sociologist, no historian to give a more reflective and wide-ranging consideration of the multidimensional social phenomenon.
Whatever more immediate commercial motives some of the participants in the initiative may have, there is no doubt of the sincerity of the majority of its participants in their desire to address the issue. Yet it is precisely because their thinking about the issue is constrained within the ‘biopsychosocial’ model — depression as social problem, rather than depression as social symptom — that such initiatives threaten to be more about increasingly sophisticated processes of social control, rather than liberation. Any genuine inquiry into the complex social phenomenon known as ‘depression’ would generate a degree of reflection on social life that would question the widest possible range of assumptions.
For if there were to be any short answer to the question of the causes of the ‘depression epidemic’ the answer would be ‘just about everything’. Many of the particular features of contemporary life in information-industrial societies serve to take human beings out of their comfort zone, from sunlight deprivation to lack of muscular exercise to the increase in periods of isolation throughout the day. The neurobiological mood maintenance system evolved to predispose humans to seek out these things, and contemporary life has removed them. Closed systems of meaning — religion being the primary example — that framed life and gave a sense of imminent presence to its most chaotic aspects — have collapsed under the impact of the scientific world view. Without such legitimating overviews — and in the absence of a ‘heroic’ style left movement which would give meaning to struggle — poverty and social exclusion have come to be seen as mere and total deprivation, an unameliorable helplessness and denial of the pleasures and powers of a consumer society. The extension of the market into every aspect of life has drained everyday life of much of its particular and sensual character …
One could go on with this, but there is little need. The particular critiques of contemporary life have been widespread and generally known since the 1960s, yet they’ve received the ‘Chesterton’ treatment — found difficult and not tried, honoured more in the breach than the observance. To read a book like Earth in the Balance — Al Gore’s passionate plea for a sustainable world and its trenchant and detailed critique of instrumental rationality, you would think that the Frankfurt School had finally found their political champion — were you not aware of Gore’s record as an unfailing agent of US corporate power across the globe. The shelves of self-help books take for granted the cultural problem of the collapse of religion and the rich structures of tradition, yet authorise the belief that such meanings can be rediscovered by the use of the particular artifacts and atomised rituals of such practices. In other words it is the limitations of the tradition of classical sociology — including Marxism, and the critique it offered — that now stand in the way of the cultural dilemma of which the ‘depression epidemic’ is the harbinger.
Depression may look like an individual predicament, but this is clearly the surface structure of a deeper event — the collapse of social meaning within the depressed person. That can and does occur in most cultures. All cultures, even the most myth-girdled of kinship societies, have some concept of something like depression or spiritual disturbance — often rendered as someone ‘not being in their right head’ or a similar sort of phrase.
What may be new now is that the collapse is occuring both within and without, for larger numbers of people. If people are increasingly less bound up in each other — in networks of obligation, co-operation, familial relation — and less bound up with specific meaningful places and things, then the burden of making a meaningful world falls back wholly on the self, who is obliged to be the point at which a whole world is held together. This is now taken as second nature by most people, and an era in which one was defined largely by class, church, nation, association, order, brotherhood and so on falls away. The oft-heard phrase — ‘only you know what’s right for you’ — is a measure of this attitude, and of the contradiction it carries within it. If the only thing that makes the meaningful world for person X is that person X has chosen it from the remorseless stream of images, persons and possibilities that characterise contemporary life, then person X is caught in a process of diminishing returns. In such a precarious existential situation, the slightest stumble — a lost job, a failed relationship, the normal disappointments of everyday life — can precipitate a fall into the abyss.
The contemporary person has less of a ‘ground’ to them, and when they fall they’re more likely to fall for ever. Hence the newest and most numerous victims of the ‘depression epidemic’ are those whose selves are under construction — pre-adolescents of the ten-to-twelve-year-old range, for whom a number of anti-depressants are now manufactured in orange and lemon flavours. This is the substructure of depression as a social form, and why adversity and difficulty increasingly present themselves to people not as hardship, or as ill-fortune, or as oppression, or as woe, but as partial or total subjective collapse and shutdown.
Furthermore, the cultural cycle can be a vicious one. As more people commit themselves to the chemical technology of anti-depressants or the social technology of psychotherapy, the degree to which encounters between persons are actual encounters between situated, authentic people responding to their present world diminishes. The sense that the other may not be a present person, but a chemically transformed series of reactions adds to the general sense of social non-meaning. Once again, this is something that people understand as part of the round of social life with more visible drugs, à la the expression ‘it’s the beer talking’. The idea that psychotherapy is a ‘social technology’ is less well understood. Clearly some forms of therapy open people up to a more real and authentic relation to the world. Others — such as neurolinguistic programming (NLP) — rely on changing people’s behaviour in order to adjust them socially, without opening out to a less circumscribed relationship to the world. In that respect, the division between chemical and social techniques for social adjustment can be seen as partial. They are both processes for putting the world ‘in brackets’ as a way of dealing with problems of meaning associated with it.
The number of people for whom this process is necessary has been vastly overstated — in a social debate about depression in which every aspect of the condition has been thoroughly worked over, except that of a widespread and growing feeling of meaninglessness.
Marxist approaches — from the visionary social analysis of the 1844 Manuscripts through the sixties works of Marcuse and Fromm — have emphasised that the subjective ‘alienation’ felt by many people is an expression of the ‘objective’ alienation — of labour and self — that occurs within capitalism. But the hope that a society in which alienated labour has been replaced by free life activity will have substantially solved problems of personhood and meaning is a hope based on the assumption of a ‘whole’ human being who will leap, entire and of herself, from the alienated shell of the distorted and crushed personalities produced by capitalism. In fact a post-scarcity communist society would find the creation of meaningful frameworks of social and psychological life one of its major challenges. Marxist social critics rightly accuse psychotherapy of adjusting real human beings to an unalienated world. Yet the Marxist critique too — one that has become a staple of mainstream Sunday colour magazine treatments of such issues — fails to go deeply enough into the way our selfhood is put together by deep, abiding and irreplaceable forms of obligation and social connection. These social forms could not be maintained within a society whose sole maxim was that ‘the free development of each is a condition for the free development of all’.
Such rarefied discussion might seem abstruse in the face of this ‘biopsychosocial’ phenomenon. But if the WHO figures are correct and depression is trending upward in all postmodernising societies, then that discussion cannot be avoided forever. The scattered and fragmented social phenomenon of depression will become a, perhaps the, major social phenomenon to be addressed. Just as the natural world became the ‘environment’ in the 1960s — at the point when it was on the way to ceasing to be any sort of environment capable of sustaining life — so the ‘inner nature’ of social and psychological life will become the focus of sustained social attention when it is starting to become unsustainable on a wide scale. Like salinity carried in a river system, the problem of social meaning in a culture of hyperindividualism and disconnection deposits grain by grain until one day it is suddenly clear that the land has become salt.