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The Big Divide in US Psychiatry

And like the San Andreas Fault Line, it's getting wider.

Peter Kramer, a psychiatrist and professor at Brown University, is well-known for writing Listening to Prozac in 1993. He has just published a new book, Ordinarily Well: The Case for Antidepressants (Farrar, Straus, and Giroux). The book is fluently written, interestingly argued, and deserves wide attention.

I just reviewed it in the Washington Post, and have been getting some reactions to my review, positive and negative. It is clear that a great fault line runs through American psychiatry on the subject of mood disorders, and that the fault line, comparable to the San Andreas Fault Line in California’s earthquake territory, is getting wider. A big quake may be coming.

On one side of the fault line are those who agree with DSM that there is only one form of depressive illness, major depression. On the other side are people, such as myself and some other truly distinguished figures who say there are at least two depressions, as different from each other as chalk and cheese.

One is melancholic depression.

The other is a mixture of anxiety, dysphoria, fatigue, insomnia, and somatic symptoms—once called “nerves,” later “psychoneurosis,” “reactive depression,” and today “non-melancholic depression” or “community depression.”

I don’t mean to make this second depression sound trivial. It’s certainly not for the patients who have it, who deserve relief and are legitimately ill.

But it’s not melancholia. They aren’t necessarily suicidal; they are not completely lacking in any source of joy, nor are they filled with psychic and somatic pain. William Styron gave a penetrating description of melancholia in his book Darkness Visible: A Memoir of Madness. He didn’t have psychoneurosis.

This brings us back to Peter Kramer, who sits on the one-depression side of the fault line. The tendency in American society to dumb-down depression, by considering it a kind of sour disaffection rather than a brush against the threshold of madness, began with a distinguished American psychiatrist named Gerald Klerman in the 1970s. There is a kind of walking track that links together Harvard, Yale, Columbia, and the National Institute for Mental Health in Bethesda, Maryland, and Klerman was a familiar figure on this track, scuttling back and forth.

Klerman’s students were highly influential, and two of them have made history. One is the late Robert Spitzer, the disease designer of DSM-3 in 1980. The other is Peter Kramer, who has a big international reputation and whose book on Prozac had a large impact on opening up the SSRI antidepressant market. This is the American psychiatric establishment. They occupy the commanding heights, and they have, more or less, imposed their views on much of the world with the ongoing success of the DSM series, which has been translated into many languages and is the world “bible” of psychiatry. The bible says one depression.

Sulking in their lonely citadels are the two-depression advocates, who rigorously distinguish between melancholia and community depression as two separate diseases, as different as mumps and tuberculosis; both infectious diseases but not the same. Nor are melancholia and non-melancholia the same. There is a biological test for many melancholic patients, the dexamethasone suppression test (DST). Clinically, someone like William Styron is totally different from the legions of “depressed” young female undergraduates on every campus. That doesn’t mean that these young women don’t have legitimate psychological difficulties, but they are not Styron’s issues, who lay coiled in a fetal ball on his bed.

The difference between these two schools was brought home to me just now with an email from an internationally distinguished psychiatrist known for having helped reintroduce the idea of melancholia to medicine. He said, “I visited Gerry Klerman when he was in his last months but showed great courage about it all. He was very warm in the conversation but observed something along these lines, “[real name], I’ve never agreed with your push for melancholia.”

Klerman, no longer with us, speaks for American psychiatry today. But is it the voice of science?

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