Depression: Past and Present

I recently sat down with Jonathan Sadowsky, a Professor at Case Western Reserve University, to discuss his interesting new book, The Empire of Depression: A New History.

Thanks for doing this interview. I'll start with the simplest question I can think of: What's the empire you're referring to?

I’m referring to two things. One is the expansion of “depression” as a way of naming human distress nudging out other language. This expansion has been going on at least since the 1950s. The second is that depression, as a clinical term, comes from Western biomedical culture, and has spread to become a global idiom.

But “Empire of Depression” is not a long lament about over-diagnosis. As depression has edged out other names for distress there have probably been both gains and losses, and I think we should consider the gains, too. One gain may be that more people in distress are getting treatments that help them. Many writers on depression worry that we are turning all sadness into a disease, bandaging over the inevitable wounds of life without attending to their social and personal causes.

These are valid concerns, but I am not convinced we are medicating sadness away. Some people with depression actually welcome sadness, as a relief from feelings of numbness or emptiness. And while I believe both antidepressants and psychotherapy can help people with depression, I don’t think either of them can end sadness, even if we wanted them to. As for the social and personal roots of depression, I certainly hope I showed that those matter, both clinically and also as a matter of simple humanity. Exclusive emphasis on pills in treatment does risk inattention to the whole person, but this is far from a reason for a blanket rejection of antidepressants.

What should we all understand about the history of depression?

History shows that our current debates over whether to think of depression as a mind problem or a body problem are not new. And it shows that attempts to insist that depression is solely psychological or solely biological have led to dead ends. People who have advocated exclusively for mind or body in depression have both done a disservice to sufferers. Enough is enough. We have always had wise voices arguing for holistic approaches; it’s time for everyone to join them.

History also shows that when new treatments have come—from Freudian psychoanalysis to electroconvulsive therapy (ECT) to antidepressants to cognitive-behavioral therapy—their supporters often over-hype them. People under-estimate the flaws of the new treatments. Few treatments, in any area of medicine, lack limitations or adverse effects. Idealization of the new treatment also leads to over-zealous rejection of older ones. Then comes excessive disillusionment with the new treatment when the weaknesses become apparent. If we know this history of hype and disappointment, we can learn to assess future treatments with cautious hope, instead of reckless hype.

Of course, there’s a lot of discussion about depression these days. I recall news stories from mid-2020 suggesting that "the coronavirus pandemic is pushing America into a mental health crisis." So, it's obvious that you're contributing to vitally important current events/debates with your book. I don't want to be too presentist, but can you tell us more about the relevance of depression's history in 2021?

I was in the final stages of revision of Empire of Depression in March 2020, when the scale of the COVID-19 pandemic was growing clearer. My reaction, which I was able to note in the book, was that we were likely to see a lot of mental health problems, including depression—and some evidence suggests that we have.

I thought depression would be a growing risk for several reasons. One is that adversity increases the risk of depression. And epidemics cause adversity, both because of disease itself, but also the economic hardships that follow. Both of these have been made worse by the callous neglect of many governments, such as our own. In Empire of Depression, I emphasized that depression is a political problem because, like COVID-19, its distribution in society reflects and worsens existing social inequalities.

We need to look at the role of adversity in depressive illness with some care. Obviously, many people in adversity will have depressed mood, but that is different from clinical depression. Most people even in terrible adversity will not get clinical depression, but adversity does increase the risk.

Some, even among mental health professionals, conclude that since depression is a social and political problem, we should not treat it as a medical one. I disagree. This is another false choice. We should of course be trying to end the burdens caused by poverty, bigotry, persecution. But all illnesses have some social roots. Tuberculosis and AIDS thrive on poverty too, and they’re still medical problems. And people with depression shouldn’t have to wait for the social problems to be fixed to get relief.

Depression Essential Reads

How Depression Alters the Way We Experience Others

A Practical Guide to Major Depression

I’ve also been concerned about an uptick in depression from the pandemic because one of the only ways we have to stay safe from infection is to isolate. Depression feeds on isolation. Human connection isn’t a guarantee against depression, but it certainly helps.

What should American mental health providers and maybe even policymakers take away from the book?

I hope the book makes a case against one-dimensional approaches. Many clinicians are eclectic in practice, and value different expertise and approaches. Too much dogmatism and turf warring remain, though. It’s not just me who wants to see the whole patient treated. That’s what patients want, from the evidence I have seen—most of them want their biology, psychology, and social context all taken into account.

Psychiatry also has a bad record of not taking patient complaints about treatments seriously enough. Take electroconvulsive therapy. This controversial treatment is effective in relieving severe depression. But patients have been complaining about serious memory losses from it since it was invented in the late 1930s, and there are still providers and clinical handbooks that treat the risk as minor. There’s no clear scientific evidence that the risk is all that minor, though. In some cases, it may be a risk worth taking, but that hard decision should not be made without the possible losses kept in mind.

As for broad social policy—I could have underlined this more in the book than I did—but we need universal health care. This is right from a human standpoint, but it would also save resources. People with better health in other areas will have less depression, and people with less depression will have better overall health. And while I’m not a fan of our society’s hyper-emphasis on “productivity,” healthier people, and less depressed people, are better able to use their talents and initiative for creating the things we want and need. We are in a society where many celebrate ruthlessness, and call it “freedom.” I don’t think it’s freedom when people who are sick cannot get care.