How Everyone Became Depressed

The rise and fall of the nervous breakdown

Struggling in the Trenches

It's difficult for GP/psychotherapists to apply a diagnoses to unhappy people

I gave a talk the other day to a group of GP/psychotherapists. They’re the closest to the old time family doctor that it gets. They look after their patients’ medical needs and at the same time offer counseling to those who are in distress.

And many patients are in distress. This hasn’t changed in a hundred years. I have a photo of an old-style family doctor in Texas around 1940. He’s holding his pipe in his hands and looking reflectively at the camera. Men and women such as this were local heroes, venerated by the population – not because they could cure terrible diseases because in 1940 there was very little they could cure. But because they listened patiently to the stories of their distressed patients and occasionally offered advice, though of the two functions, listening is the more important.

Just being listened to by someone you admire and look up to is very therapeutic. And often that’s what GP/psychotherapists do today. There’s nothing practical they can do for their patients, who need new husbands, more money, teenagers who aren’t assholes.

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So they listen. But when they submit a bill to the insurance company it has to have a diagnostic code on it. Here’s where the trouble starts.

There is no DSM code for “terribly unhappy and upset, life a mess.” So the GP/psychotherapist codes “major depression.”

Hey, all of a sudden your problems have been converted from being irritable and upset to a big-time mood disorder. Major depression is a very heterogeneous diagnosis, and a piece of that basin is patients who were once diagnosed as “melancholic”: unable to eat, unable to sleep, no joy in life, suicidal.

One GP/psychotherapist said, “When I read DSM, I don’t see my patients.”

Maybe your patients are in the Anxiety chapter, doctor?

Let’s see. Generalized Anxiety Disorder: “difficulty concentrating or mind going blank.”

Nope. Not that. She’s always found it difficult to concentrate because the kids are always yelling at each other.

Sleep disturbance? Nope, not that. She falls into bed at night exhausted.

We have trivialized something like depression but it’s actually a serious psychiatric illness. You need to be treated for it. The GP/psychotherapists’ patients aren’t really depressed in any meaningful sense, even though everyone throws that term around because it’s so meaningless. One size fits all.

So at this session, where I spoke, the GP/psychotherapists were supposed to be familiarizing themselves with the new DSM-5. I told them much of it was rubbish. Filled with diagnoses that lack a firm scientific basis and were really just someone’s bright idea. “Major depression” was someone’s bright idea. It didn’t exist before DSM-3 launched it on its historic course in 1980 to become the world’s most popular disease.

I was a bit worried before I gave the talk. Maybe they all loved the DSM diagnoses. Nope. Hated them. There were big smiles and hearty handshakes afterwards.

“Finally, someone is telling it like it is.” (They’d had a procession of psychiatrists telling them patronizingly that the DSM “was really meant for research in the field.”)

So the GP/psychotherapists are struggling today. They’re committed to making their patients better, just like the old-time family docs. But if talk therapy needs to be supplemented with meds, the meds available to them – the Prozac-style “antidepressants” – are not very effective. And most family docs feel uncomfortable with the treatments that are effective, namely the tricyclic antidepressants and electroconvulsive therapy.

And they’re struggling to apply psychiatric diagnoses to unhappy people. Unhappiness is not an illness. It’s a structural problem. But so many patients have it. They’re wretchedly unhappy with their lives and they’re seeking counseling, the wise old family doc in Texas who looks out at the camera through the wisps of smoke from his pipe.

Edward Shorter, Ph.D., is the Jason A. Hannah Professor in the History of Medicine at the University of Toronto.

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