Greenberg has many problems with the depression industry: one is that the drugs don't work on the majority of patients (he says that 70% of patients prescribed anti-depressants stop the course in the first month because of the side-effects - of which one is a loss of interest in or ability to perform sex); another is that the idea that depression is mere chemistry and says nothing about the world one is living in or the way one lives in it, robs our emotions of meaning.
I'm glad to read a professional saying that the drugs don't work and I'm not going to quibble. If it takes a large-scale PR campaign (only OTC medicines can be advertised in the UK), biased "research", confidentiality clauses, a huge sales force and all the other tricks to shift the stuff, that's because the companies know that word-of-mouth, BBC documentaries, not to mention the consumer-created websites, are going to be telling a different story. Potions with names ending in 'statin', 'formin' and anti-depressants are being hyped. Nobody needed to hype Miltown in the 1960's or Valium in the 1970's: both were taken recreationally. Indeed, according to Greenberg, word-of-mouth loved Miltown so much it got banned: it was being used as just another high.
The thing about disease and meaning is a little trickier. Cholera is a disease and it is mere chemistry, and it told the Victorians (eventually) that the water was infected and they needed to get some main sewage and a clean water supply going. They could have decreed that there was nothing wrong with the water, and blamed the patients or looked for something to cure the sufferers. Blaming the patients is always good when the no-one has a clue about the problem or a cure - fixing the patients makes sense when an actual solution would be a tough sell to funding agencies. When someone gets a disease that makes a mess of them it always says two things: there's something out there, this patient is susceptible to it, and that person seems to be immune to it. (There are a few people who seem to be able to shrug off HIV, don't forget.) After that, it's a matter of economics: is it cheaper for the taxpayer to solve the problem or to solve the patients? You can ask another question as well: is there more profit in solving the problem or solving the patients? What's profitable for Big Pharma may not be so cheap for the tax-payer.
What I'm not so sure about is that depression is always existentially meaningful. Not if we mean serious will-sapping depression anyway, rather than the depression-lite that Greenberg rightly points out is passed off as a disease.
A little diversion into some autobiography. As yet another relationship was falling apart in the 1980's, one of her final shots was the suggestion that I might be or was "clinically depressed". She was a PR who specialised in, you guessed, pharmaceuticals, but this was in the pre-Prozac days. I was a great many things back then (jerk, prick, asshole, bad-mannered, lacking self-confidence, incapable of doing fun, relationships or making good career judgements, and sophomore alcoholic to boot) but no matter how low I felt, I was never depressed. Every frakkin' day I woke up and ground it out, through insomnia that would have sent you begging for sleeping pills, through emotional upsets that left me hyperventilating, through painful physical loneliness and endless emotional puzzlement, and every day I showed up, ready to fight and fuck, however badly I might do it. Duvet days are for the weak, and pills for the pathetic. A long-term AA colleague is a pill-head more than a drunk, and while we have much in common, our diseases are different. The defiant alcoholic in me could never let himself lie down on the couch and fade away - unless it was to sleep off a drunk. I had all the symptoms of depression but not the disease. And under the DSM-IV rules, a doctor should have hesitated to diagnose me as depressed because I had a drink problem and DSM-IV prefers to deal with the substance abuse first. Which is what I did, and I felt better about myself and the world in early recovery than I ever did when drinking.
This experience makes me believe that there are genuinely depressed people, who have an anomalous body chemistry, and will eventually be helped to feel like a normal person when Big Pharma starts making drugs that don't make you want to kill yourself or feel like you're a stranger in your own body. The rest of the world just have lives that suck, either because they aren't living right (as I wasn't) or because the objective circumstances of their lives actually objectively suck. Starting the day by standing on a cramped train, having a bullying or incompetent supervisor, inadequate tools to do their job, a wife who can't cook and uses sex for reward-and-punishment, a couple of kids who ooze resentment and demands for money, the ever-looming threat of redundancy, debts, a car that needs fixing and to make it all worse, an endless stream of fatuous preaching about how they should be "eating less and exercising more" and stories about how this or that nebbesh turned their life around by doing something one-off and unrepeatable. Anyone who can bear that with good cheer is delusional, and most people aren't.
Most people whose lives suck aren't depressed. They have existentially meaningful emotions and states such as: hungover, withdrawn, sulky, snappy, irritable, resentful, aggressive, passive, resigned, lacking energy, unable to get to sleep, waking up too early, lack of enthusiasm and a hundred other things no two of which add up to an attractive personality. These are meaningful because they have specific causes, even if the sufferer doesn't know what yet. It's this stuff that should be treated in Dr Greenberg's therapy room and should not be eased by drugs. What most people whose lives suck need is a different life: a change of job, wife, children, salary, neighbourhood, sex life, friends, acquaintances, hobbies, sports and pastimes. Their problem is that there are no jobs to go to, divorces favour the wife, they can't dump the kids because they are not a "deadbeat dad", the employer isn't giving out pay rises and hasn't for the last three years, and between the job, the commute and the chores, there are about eight hours a week left in which to have a life.
This doesn't make for someone who works and plays well with others. Employers want malleable, can-do, don't-mind peons; mothers-of-two want husbands with jobs, who pay the bills, don't make un-natural demands (like sex), aren't going to leave and don't need worked around or managed; friends and acquaintances would rather have cheerful companions than glum ones. I'm with Greenberg that Western post-modern capitalist economies are great at producing lives that suck. But one look at the inspirational literature and snake-oil of the past will convince you that most people's lives have always sucked. Big Pharma isn't producing anti-depressants because it helps the machinery of post-modern capitalism. It's one thing for Juan Trippe, President of Pan Am to be sitting next William Allen, the President of Boeing, and say that if Boeing could build a 400-seater he would buy enough to make it worthwhile, as it would bring international air travel to the masses who could afford the cost of a seat on a Jumbo but not a 707. (That conversation actually happened). It would be another entirely for the CEO of (say) AIG to say to the CEO of AstraZeneca "If you can make a pill that turns my workers into docile worker bees, I'll make sure it gets funded by our medical insurance arm. And I think I speak for all the other guys as well." That conversation is never going to happen.
Big Pharma does produce serious psychotic-grade anti-depressants. The market is small and the drugs are so awful no-one can buy or sell them in the cafes in and around big hospitals that are the scene of the secondary market in prescription drugs. Big Pharma is not going to get rich making drugs to deal with actual medical conditions. Big Pharma is producing anti-depressants because ordinary people want to get out of it and always have. They may call it "taking the edge off", but it's the same thing. It's a nice side-effect of contemporary anti-depressants that they make people more accepting, malleable and prepared to accept the stuff that "life" in the guise of the HR Department, the wife's lawyer and the train company throw at them. There's no doubt it helps with the acceptability of these drugs that people on them put up with a crappy supervisor rather than suddenly discovering to give him a sound thrashing in a stairwell.
It isn't Big Pharma and existentially-shallow doctors who want to give people drugs to allow them to accept their lives. It's the people who want to take them: what do you think alcohol is? Not all of them, not even most of them. 70% of the people prescribed anti-depressants stop within a month, presumably because they would rather be irritable than sexually impotent. Of course that leaves 30% who carry on, either because they do prefer being impotent to irritable, or because they really are better on the drugs, or because the drugs make them better at dealing with this crazy world. Greenberg would rather that people didn't get out of it, and that they examined and re-evaluated their own lives. That's my preference for myself as well, but it doesn't suit everybody, just as the drugs don't suit everybody. The shocking thing about ordinary people is that no matter what circumstances you drop them into, they will come up feeling happy. Make them rich or poor, take away limbs or lovers, they will turn out happy. Or rather: they will be content with their circumstances and not see them as being worth trying to get the Fifth International started. And if their circumstances are so bad their natural happy-equilibrium mechanism breaks down, then they will look for pills and potions to help it back. Ordinary people don't do living examined lives. I don't know what they do do, and I hope I never find out.
What's really scary is that one day there may be anti-depressants without nasty side-effects. Then nobody will stop taking them once they start, and this time the pharmaceutical Calvinists (as Greenberg calls them) won't be able to ban it. They didn't ban Viagra, and that's only taken for one reason.
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