Gary Greenberg is a psychotherapist who joined a clinical trial for an antidepressant at a time when he was mildly depressed. He was diagnosed as severely depressed, got better, and found that his pill was a placebo. His book contains a major attack on antidepressants, and he blames the drug companies for the false advertising of their positive effects. He is also very critical of the concept of depression itself.
He is right that quite a lot of random clinical trials have failed to demonstrate the effectiveness of antidepressants – as opposed to placebos – in curing depression. However, he ignores the evidence that, for severe depression, they really can help. He accuses the drug industry of downplaying the numerous side-effects, such as the 774 papers showing their effect on sexual performance. In addition, he argues that the industry has successfully campaigned to persuade doctors and the public that they suffer in enormous numbers from a disease called depression when in fact they might not. Only someone who has not been seriously depressed could accept that. He suggests that those who benefit from antidepressants that raise serotonin levels might instead be thought of as suffering from Prozac-deficit disorder.
His main thesis seems to be that depression is not a disease or an illness. When a doctor says to a patient that he has depression, "He couches his judgments in the language of sickness and health rather than sin and virtue, which means he is cloaking his morality, even from himself, in science." Impenetrable.
Greenberg devotes much space to tracing the history of ideas about depression, going back to Hippocrates, who identified melancholia as a distinct disease. He gives much attention to Emil Kraepelin, who believed the chief origin of psychiatric diseases to be biological and genetic malfunction. These are not ideas that he accepts: he views them as neurological tautologies. Psychiatry, he thinks, has been led astray by attaching itself to science, thus losing sight of humanity.
He is very critical of the Diagnostic and Statistical Manual of Mental Disorders, which is intended to help diagnosis by listing key symptoms, or scoring the answers to questions. This, he says, is "a way for the doctor to keep his eye on his notebook and not on the patient". He is right that there is no unequivocal diagnosis of depression, and psychiatrists may quite often give a different diagnosis for the same patient. However, he does not point out how being depressed can in many cases render people unable to work, and ignores the fact that severe depression can result in self-harm, plunging the individual into a world unrelated to anything in everyday life. Nor does he mention research showing that almost all people who end their life by suicide have a mental illness, most commonly depression.
Severe depression is a terrible experience, as I know. William Styron, in Darkness Visible, describes his thought processes "being engulfed by a toxic and unnameable tide that obliterated any enjoyable response to the living world". Greenberg's advice to those who think they are depressed is to stop looking for a cause in their brain, which is just a story, but "to tell your own story about your discontents".
There is no mention of sadness in the book, or the possibility that depression is an extreme form of sadness. Sadness is a universal human emotion, programmed by our genes, and its evolutionary function is to restore loss of some kind. This loss can be in a child left alone, break-up of a relationship, loss of a job, loss of money. It has been argued that mild depression is useful as it makes individuals reconsider their problems and perhaps give up certain goals that they are having great difficulty achieving. Mourning is clearly triggered by a serious loss, but is not necessarily depression.
It is clear that depression results from changes in the brain, because it can be induced by chemical means such as high concentrations of the hormone cortisol, or the drugs reserpine or alpha-interferon.
Depression can be thought of as sadness becoming malignant for a variety of reasons, not least genetic factors. Heritability of depression is more than 50%. Greenberg is very suspicious of ideas about the cell biology of depression, such as its being due to low levels of the neurotransmitter serotonin. He also ignores the evidence that a gene that lowers serotonin has been linked to depression.
He is not keen on psychoanalysis because it is not possible to verify its ideas, but he seems to accept the virtues of cognitive therapy, developed by the psychoanalyst Aaron Beck in the 1960s. The essence of this is to discuss with the patient their negative thoughts and to see if they are valid, then train them out of negative behaviours. Yet he attributes its success largely to the placebo effect. He is also very sceptical about the explanations that brain imaging have offered – but to take these seriously you have to believe that depression actually exists.
I found the book most unsatisfactory. While Greenberg writes very well and has a nice sense of humour, the arguments are often far too long and discursive, even though there is a lot of information buried in the text. Finally, I remain unclear as to what he thinks depression is, and how and if it should be treated. This book will not help either those who suffer from it or those who wish to understand it.
Lewis Wolpert's books include Malignant Sadness (Faber).
