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Apr 2, 2015

Rundle: 'depression confessional' culture obscures the true nature of mental illness

Mia Freedman's original confessional on her anxiety, coupled with her supporters' follow-up commentary, display a profound lack of understanding of the historical and social causes of depression and anxiety.

Good God, when you go to war with Mia Freedman, everyone piles on. Your correspondent made a comment on la Freedman’s piece “I’m finally ready to talk about my anxiety“, and suddenly everyone was there, from la Freedman herself to her Dad to Ageistas-turned-Guardianistas, to (ha) Paul Murray, one of Sky News’ resident shock jocks. It was like a Wes Anderson movie, you keep expecting Owen Wilson to come through the door in a silly uniform.

So let’s try and get a bit more light than heat from this conversation, shall we? First off, depression and anxiety are a real thing, individually and socially. Despite being compared to Mark Latham by Freedman (of which more later), I’m emphatically not of the “pull yourself together we didn’t have this in the 1950s” school.

But there are different types of depression and anxiety. Manic depression/bipolar disorder seems a fairly separate condition. Serious or clinical depression, which leaves people unable to function, is separated off (in various different ways, by various categorisation systems) from a more common-or-garden variant. There are various types of anxiety, but one particular type appears to be related to depression — which is why it responds to SSRI (selective serotonin re-uptake inhibitor) drugs that were originally marketed as anti-depressants (whereas other types, which respond to other drugs such as Xanax and Valium, do not). “Standard depression” and anxiety appear to be on the rise in contemporary society. But are they?

The question is not easy to answer. Some types of subjective disorder/mental illness appear to occur in all societies. The condition we call “paranoid schizophrenia” appears to be constant, with a 1% occurrence in all societies — and is identified as a disorder, even in societies that believe in magic and supernatural forces (which is one thing that marks schizophrenia in a secular-scientific society). Serious clinical depression appears to have a degree of universal occurrence, too — stories of people falling “into a melancholy” lasting for years appear to be a record of this.

But what appears to be new are distinct forms of depression and anxiety spreading over an ever-wider area of social life. For a century or so, a form of anxiety — known for a number of decades as “the nervous breakdown” — has been current. More recently, it was joined, and to some extent superseded by, a persistent form of depression that leaves people functional but feeling utterly hollowed out inside — feelings of meaninglessness, obsessional negative thinking about self, disconnection, lack of pleasure, low energy, fuzzy mind, psychosomatic illness, etc. A certain type of anxiety has a similar structure of circular thinking — extreme hypochondria, panic, etc — to the obsessional negativity of depression.

Whatever the occurrence of other types of subjective disorder across cultures, this condition appears to be very specific to our culture, that of prosperous consumer-oriented, media/image-dominated mass society. Cultures based around smaller intimate societies, pre-capitalist forms of production, strong religious or traditional beliefs, may have all sorts of problems, but they don’t have these ones, by and large. From within the sociological/social-psychological discipline that suggests a root cause — meaningful life in such societies is founded on shared meaning, a lesser role for individuality and choice, and a common belief system. That puts a ground beneath people’s feet. Sadness, even misery, occurs, but they do not become that vague, cloudy but tormenting, depression/anxiety that many modern people recognise.

“The argument that mental depression could create a persistent physical depression pre-existed the rise of the market for SSRIs, but it was effectively cemented in place by their success.”

Further to this theory of the psychology of depression/anxiety is a theory of physical changes created by it. This is the “cortisol hypothesis” — the argument that the long-term occurrence of such feelings elevates levels of the fight-or-flight hormone cortisol, which is eventually depressive in itself, and also lowers the levels of the brain chemical serotonin. Playing a role in many functions, serotonin has a role in regulating mood, chiefly by allowing us to gain pleasure from the presence of trusted others (the “loved-up” effect of MDMA/ecstasy, which creates a serotonin flood, may be, in effect, causing one to identify strangers as loved others). The suggestion would be that persistent depression gets people “stuck” in a physical-mental rut, from which it is difficult to get out of by an act of will or self-determination alone.

Chemical anti-depressants have been known since the 1950s, but they were fairly crude in their effect. In the 1970s, fluoxetine was discovered, the first SSRI. Serotonin fills the “synaptic gap” in the brain — the space between synapses, the brain’s many billions of connection points. The cortisol hypothesis suggests that in depressives, it is reabsorbed too quickly by the “receptors” (like little drains) budded on the synapse. SSRIs have a chemical structure similar to serotonin, but they are not absorbed by the receptors — so they “plug” some of them, and serotonin stays in the gap longer. This appears to produce an immediate lift in many users of SSRIs, but the main effect appears to occur three to five weeks later, when a sustained lift out of depression often (but not always) occurs.

From the time Prozac, produced by Eli Lilly, came on the market, every other Big Pharma company started to bud off variants. Zoloft and Paxil were the two major ones, and Lexapro, the variant Freedman was spruiking, one of the minor leaguers. Such drugs are all minor molecular variants of each other, and they have a 17-year branded patent (after which they can be sold generically by anyone). However, the corporations producing these drugs can extend the patents if they can argue that they treat other conditions — thus Lexapro had its patent life extended as an anti-anxiety drug, and Zoloft was applied as a treatment for “social phobia”, a pretty amorphous condition that the manufacturers argued was a hard medical condition. In one particularly audacious move, Zoloft’s manufacturer tried to have “shyness” defined as a medicable condition.

SSRIs took off in a way that no drug ever had to date. By the 1990s, they were the most -prescribed drugs, earning Big Pharma billions, hitting prescription levels of 10-15% of the population. They were in use for about five years before people began to notice that they were changing the culture, our idea of selfhood — and the actual materiality of the selfhood of people taking them. The argument that mental depression could create a persistent physical depression pre-existed the rise of the market for SSRIs, but it was effectively cemented in place by their success, their vast marketing campaigns, and the capacity of Big Pharma to fund research that tracked in certain directions.

But as SSRIs spread and governments cut back funding for more expensive talking-therapy approaches, the mental-to-physical theory of depression and anxiety began to fall away , and a simpler de facto model took over — depression and anxiety were treated as purely physical/neurological functions, to be directly adjusted by drugs. GPs had preferred to refer troubled patients to psychotherapists, to apply a mix of talking and drug therapy; increasingly GPs themselves began to prescribe the drugs with very little follow-up. They had initially been presented as taking three weeks to work, but it was clear to many that an immediate effect was occurring in many people. GPs want to alleviate suffering, large numbers of depressed people came through their doors, the drugs seemed to work, and GPs tend to be practical types, not prone to cross-cultural analysis. Though other people tried to emphasise the complex nature of depression as a social/psychological occurrence, the de facto physical theory started to win out.

The approach was also attractive to many sufferers too. Depression has many factors, and some of its particular occurrence may have individual factors — dysfunctional childhoods, bad adolescences, physical/sexual/emotional abuse, personality traits useful in some societies (e.g. mildness, gentleness, introversion) that make life difficult in an individualist, market-based society. Committing to therapy offered a longer, more difficult path, one that involved admitting a lack of success in negotiating parts of life, and confronting things that the depression or anxiety might have been an unconscious strategy to avoid. Not only do SSRIs offer an immediate lift, they also offer the idea that one is afflicted with a random physical condition. It not only absolves the sufferer from a more difficult struggle, it gives one the status of the ill, a degree of special dispensation.

“The physical theory of depression ignores the stark fact that many societies that do not have our characteristics simply do not have the levels of depression and anxiety we are experiencing.”

But this ever-widening acceptance of the physical approach to depression occurred at the same time as some contrary indications. While it was clear that SSRIs altered the chemical processes of the brain, several studies suggested that there was no difference between SSRIs and a placebo in alleviating depression and anxiety. This in turn has thrown doubt on the serotonin/cortisol hypothesis. This isn’t unusual in this area; for more than half a century, lithium has been used to treat bipolar disorder, yet there is still no authoritative theory of how it works. The placebo effect disturbed many practitioners, which they dealt with by ignoring it (no profession is more practiced in psychological defences than psychological professional practice). There was no real theory applied, but the simplest one would be from anthropology — the pill is a gift, a material exchange of reciprocal connection between doctor and patient. Effectively, it’s an invitation to magical thinking that relieves the patient of the burden of their own afflictions, and thus allows their energy to flow outwards to the world again. “Pick up thy bed and walk” — Jesus, by using a touch of the hand, was one of the first documented short-term psychotherapy providers.

SSRIs have been so lucrative for their patent-holders that they have gone to extraordinary lengths to maintain the market. This has meant playing down some of the serious side effects. Earlier anti-depressants had had general side effects — they left users feeling sluggish and fuzzy. SSRIs had particular side effects — they left most users without side effects, but caused a very dire one in a small number (1-2%) of users, which was a sudden and overpowering surge of suicidal feelings. The simple enough theory of that was that depression had the effect of depriving very troubled people of will (and was thus to a degree protective). Recharged by an increase of energy and purpose, but with none of their psychological issues dealt with, the combination supercharged the drive to self-destruction. There has also been an argument that SSRIs promote homicidal behaviour, for related reasons, and Big Pharma fought court cases all through the ’90s to try and head that off at the pass.

Proportionally, these were relatively rare occurrences — though given the numbers of people taking these drugs, the raw figures of suicidality are quite high — but in the 2000s another issue began to emerge, that of habituation and neurological damage from long-term use. SSRIs had been marketed on the claim that they wouldn’t have an effect on people who didn’t have depleted serotonin, wouldn’t diminish in effect over time, and wouldn’t cause receptor damage. But none of this had been tested prior to FDA approval and only emerged after the drugs had been in use for a decade or more. The dangers are obvious — prolonged use could reduce the effectiveness to zero, damage the mood “hardware” and leave sufferers in a worse state than they began in, and with resistance to the drug in question.

That SSRIs are beneficial, life-saving in some instances, and an effective treatment for deep-seated and resistant depression and anxiety seems well-established (though some would disagree). But the level of prescription that goes with the “physical” theory of depression/anxiety is vastly in excess. No one really advanced the simplistic physical theory of depression, bald and unvarnished; it has simply grown up around practice — and then it started to steer the practice and exclude alternatives. But the physical theory of depression ignores the stark fact that many societies that do not have our characteristics simply do not have the levels of depression and anxiety we are experiencing, especially the levels of it in adolescence and childhood.

When we approach it from the other end, the social end, we can say something different about depression and anxiety — that we have a depressogenic society, creating depressed people who would not otherwise be so, and creating a vast amount of unnecessary suffering. But what is it about our society that is creating this depressive excess? As I noted, the clear division is between societies “grounded” by abiding others, shared purpose and work, mutual obligation in close networks and a relatively concrete belief system. Modernity, of any character, is the factor most likely to increase these conditions — scattering villages into cities, replacing traditional culture with mass culture, allowing people to become isolated and disconnected — but that only goes part of the way. After the “great transformation” when we went from “communities” to abstract societies, both the working  and middle class re-assembled community in the form of neighbourhoods, associations, congregations, etc.

But, in the 1960s, those worlds were subject to a fresh break-up. A consumer economy, class mobility, liberal social revolutions and a new centrality for mass media put the individual at the centre of social life — with the increased risks of collapse that individualism creates. In the ’80s and ’90s a further break-up of social networks occurred with the extension of the market into all areas of social life and the absolute dominance of a culture based on a vast stream of images. Beneath this all, a master process ran — working life ceased to be about production for a local community, for each other, and became commodity production, work to produce something with no particular meaning attached to it, to sell on the market.

The result is a society that is supercharged, dynamic, often exciting, and liberating. But it is also competitive, setting people against each other, hyper-individualistic, repeatedly dissolves grounding meanings — where you grew up, how you lived, etc — and all of it driving many people to work very hard with no meaningful purpose. When the going is good, it’s great, when it’s not, you can fall for a long way. It is also afflicted with what one might call the “precursor” of depression and anxiety, narcissism — a see-saw of manic (and defensive) overvaluation of self and a sense of crushing insignificance amid the global image gallery.

That way of life can create outbreaks of depression and anxiety everywhere, but it tends to hit two groups hardest. The first is the powerless — those with little control over their lives, victims of under-resourced education, abusive backgrounds, working-class worlds from which work has been removed, rural areas in serious decline (where community has become attenuated) and the like. Depression and anxiety in these cases are what Martin Seligman called  “learned helplessness” — when no choice you could reasonably make could make a difference, you collapse into a vicious circle of defeated and depressive mood.

The other group that seems to be afflicted by depression and anxiety are at the other end of things — culture and media producers. Levels of depression and anxiety appear to be very high amongst this group, judging by the number of articles written about it in media for affluent consumers. There are many particular reasons for this. Culture/media producers work in a world of images, disconnected texts and relentless production of content with no great meaning. It’s like working in a hall of mirrors. Unless you understand that you’re in a hall of mirrors, you are bound to be disoriented. Then there is the particular form of the work. Whatever the many advantages of such work over factory labour, the latter doesn’t ask for your continued passionate engagement; many people in culture and media circles find themselves sucked dry by the continued demand for ideas, opinions, performance, etc. Increasingly this demands a mobilisation of self, drawing on personal experience and attitude to create material for sale. Within an overarching purpose for doing it — political, for example– many people will simply find themselves out of gas. That is particularly so in our era. The great era of liberal media is over, when large organisations were willing to put capital in the service of truth and inquiry. With honourable exceptions, media are now content mills, and media and culture can feel, for many people, a ghastly parody of what they went into it for.So, many people have a desire to believe that their depression or anxiety is nothing other than a physical illness, and a whole medical system is willing to agree with them. But there is also an interest the system itself has in maintaining such a false and simplistic belief. To really address these issues. we’d have to start thinking about social and cultural change — rebuilding a way of life in which there is more possibility for people to live in meaningful interconnection, less set against each other in an isolating manner, and less dominated by commodities, and images. Those who have an interest — even an unconscious one — in the current world continuing are those who have an interest in selling meaning back to a general populace one piece at a time. Such interests cannot but shape their worldview.

In the wake of last week’s article, the critic fielded a number of criticisms, all of them easily dealt with. A persistent one was that “I was not a doctor”, so couldn’t speak. Well, first of all I wasn’t advocating a course of action. Freedman was, pushing a line pretty strongly pro-SSRI, and implicitly suggesting indefinite use. I merely pointed out the side effects. Freedman’s doctor either didn’t point these out, professionally remiss, or Freedman didn’t pass them on, and she was remiss. More broadly, however, the idea that only doctors, or those channelling them, can speak on the topic is to pre-decide the issue as a medical one, and depression/anxiety as a physical disease, which is pretty circular. The most extreme form of that was the argument that to suggest that people with such conditions, think about whether factors in their life might be contributing — like living in the vortex of media-entrepreneurial mania — was to be “patronising”. This seems about the most bizarre application of the medical “physical” model of depression/anxiety around; that you should entirely abandon any sort of reflection on how you live, and simply jack into your brain with a chemical. This is the denial of autonomy and self-determination at its most confused.

Secondly, was the suggestion that a personal article should be above criticism, especially a “brave”, confessional one. But, of course, it wasn’t just a personal article — it was evangelising for a certain type of drug, so to claim immunity would be perverse. And how brave is it to publish another mental illness memoir, really? Nor is contacting the author for more information a feasible option. If you’re going to advocate a debatable course of action based on your own experience, it becomes a public object, to be debated with robustness.

Depression and anxiety have become major topics in the contemporary world because they’ve become major challenges in many people’s lives, either directly or through people they’re close to. But the depression/anxiety memoir, etc, has also become something else — a heroic narrative, something that lifts the reader out of the mundane and tells of overcoming the odds. Frontier narratives for a built-out world, inward ho! They make people feel alive in a deadened world, which is why they are endlessly repeated. Without pushing back against this on a collective level, it will only get worse. It will be worse for your kids, and it will occur in a context not of expanding opportunity and prosperity, but of the narrowing of such. The crisis will come, best prepare for it.

Australia has become a world centre for this. Whether we have more depression and anxiety than elsewhere is hard to quantify, but we sure love to talk about it. We’ve gone from true blue to Beyondblue in a couple of generations. One reason why that might be, is that our culture was so thin in the first place. With old value systems like imperial mission or cultural nationalism gone, we’re just a big suburb on the coast, swamped by the new anti-culture, anti-social media, etc. Depression confessional has become the centre of our cultural life. Politicians, footballers, writers, etc — it never stops. There was a point to it early on, but now it is part of a cultural predicament. And also of diminishing returns, as the discussion never moves forward to what it needs to do, which is to talk about this issue as a social and historical phenomenon. Ultimately, to make the decision to ring-fence a part of your own behaviour as pathological is to make a separation between self and world that can’t help but put your whole subjectivity “in brackets” as it were. For some it may be necessary; for all it should be a last resort. Better to try and avoid the trap altogether than to hack your leg off to get out of it.

Books from which this article was drawn and further reading for those interested:

  • Rick Ingram (Ed) Contemporary psychological approaches to depression: Theory, research, and treatment;
  • Peter Kramer, Listening to Prozac and Against Depression;
  • Peter Breggin, Toxic Psychiatry;
  • Joanna Moncrieff, The Myth of the Chemical Cure; 
  • Martin Seligman, Helplessness: On Depression, Development and Death;
  • John Cornwall, The Power To Harm;
  • Erich Fromm, The Sane Society and On Being Human; 
  • Susan Pinker, The Village Effect; 
  • Christopher Lasch, The Culture of Narcissism;
  • Pierre Bourdieu, The Weight of the World: Social Suffering in Contemporary Society; and
  • The depression-anxiety film club! Three films by Adam Curtis: The Century of the Self; The Trap; Watched Over By The Grace of Loving Machines.

Over to you, Mia.

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30 thoughts on “Rundle: ‘depression confessional’ culture obscures the true nature of mental illness

  1. Daniel Retward

    A good account.

    In my limited experience of those on anti-depressants, one of the side effects is loss of emotional intimacy with family and friends.

    It would be interesting to see if depression is more contagious when being treated by anti-depressants.

    For myself, there is much to be said for gardening, bush walking and pets for normalising the human psyche.

  2. lethell

    I did think your original article was a bit harsh but this more thoughtful expansion of it is well worth reading.
    Strange irony: Jeff Kennett as spokesperson for Beyond Blue yet as a politician a paradigmatic exemplar of the sort of neoliberalism whose explicit aim is the destruction of a sense of obligation to the community in favour of the hyper-individualistic economic concept of value that is a leading cause of depression.
    (Like Fraser, in his post-political life agitating against the very conditions he helped to create.)

  3. KennyB

    Similar, my reactions to SSRIs were similar to many others during the 90s and early 200s, eventually a case of “don’t care”, and quite numb distanciation from “things” and people also perhaps because any path or goals seemed to have been removed.

    To say nothing of sexual disfunction cause by SSRIs – not getting it up, then not being able to come. I think this is much more serious than many allow for it. In the short term the drugs were moderately useful, but only ever for short terms. I was and remain concerned about the situational side of one’s life and what sort of circumstances and behaviours and perceptions I needed to solve “issues” or remove triggers for gloom. I decided to do over a year of relatively “soft” semi-Freudian psychiatry (because I particularly wanted this form of therapy, and I knew a practice who did it.) I found these interactions were far more useful as ongoing therapy.

    I would not wish to use SSRIs again, frankly. But they can work for some, although the longer term use issues aren’t being addressed properly.

    As for Freedman, I couldn’t care less what she did and how she felt. I have no time for “single solution” proponents to anything whether fad diets or Voodoo homeopathy or mental health. I thought Guy was being far too gentle with Ms Freedman.

  4. parrick

    The cure for this ill is not to sit still,
    Or descend in the SSRI mire;
    But to take a large hoe and a shovel also,
    And dig till you gently perspire;

    And then you will find that the sun and the wind,
    And the Djinn of the Garden too,
    Have lifted the hump —
    The horrible hump —
    The hump that is black and blue!

    With apologies to Rudyard Kipling

  5. Colin James

    It’s always a tad confronting to read almost anything written by Guy Rundle because he makes me realise how shallow and opinion led is much of my cogitations on matters social, political, economic and otherwise. I had long surmised that Australia did not have a depression epidemic just an unhappiness one. Being unhappy implies some responsibility. Pathologising unhappiness to depression removes accountability and medicalises the state. And that’s where my thinking stopped. Guy takes us into the layers of substrata and historical contexts that navigate the transition from true blue to Beyond blue with his usual dexterity. Bastard.

  6. burnmuthaburn

    it’s all about failure (perceived or real).

    trust me; i am a failure…………

    if only i could know if my failure was perceived or real…….

    (i’m not shitting you……. this is deadly serious)

  7. puddleduck

    Thanks Guy for a thoughtful and thought-provoking article.

    While not (yet) in a worse state than I was before I was prescribed the first of three different types of SSRIs, I am worried about the habituation and neurological damage that may result from now 15 years on these things, not to mention the health effects of the additional 25kg I’m carrying as a result.

  8. puddleduck

    PS I can recommend Andrew Solomon’s “Anatomy of Depression”.

  9. David Barrow

    When Guy Rundle writes:

    “This in turn has thrown doubt on the serotonin/cortisol hypothesis. This isn’t unusual in this area; for more than half a century, lithium has been used to treat bipolar disorder, yet there is still no authoritative theory of how it works. The placebo effect disturbed many practitioners, which they dealt with by ignoring it (no profession is more practiced in psychological defences than psychological professional practice).”

    Does he mean lithium has a placebo effect? Or the wider “serotonin/cortisol hypothesis”?

    Lithium was not a placebo effect for me (I’m sure).

    October 2014, in a defamation trial against Andrew Bolt (of the NewsCorp stable), I publicly disclosed for the first time that that I have a bipolar condition well-managed with medication since 2007.

    One ‘benefit’ (sort of) from having an illness that was raging untreated for so long is that I have some lengthy comparative time periods with and without medication.

    Here’s my timeline:

    1989: age 19 onset of bipolar symptoms: disruption to relationships, career and finances due to manic and depressive moods. This raged for the next 18 years.

    2005: age 36 first bipolar medical diagnosis after attending psychiatric sessions for 6 months. Diagnosis confirmed through second opinion of world leading psychiatrist Prof Isaac Schweitzer.

    29 March 2007: after 2 years of resistance I finally started taking Lithium. Very positive results stabilising moods which enabled me to work the regular hours of a job again. Since then have taken Lithium daily for 8 years and added Lamotrigine in Dec 2007 to give more protection against depression. It should be noted that these bipolar medications can have serious harmful side-effects; although I have not suffered any that I am aware of or have shown up in regular blood tests.

    Summary: 19 years with no symptoms; then 18 years bipolar raged without medication; then 8 years on bipolar meds and have achieved mood stability.

    I would recommend people with disruptive moods seek out an opinion, or a couple of them, from a healthcare professional, and also consider medication. For me it has been a miracle and perhaps it will work wonders for you as well.

    For all the insight and empathy-awareness that came from the 18 years between 1989 and 2007 of whiteknuckled, untreated rapid-cycling bipolar chaos, I would have preferred that someone encouraged me to explore medical help earlier. In my case, it would have saved me much needless suffering.

    David Barrow

  10. Catherine Scott

    A few facts. Antidepressants are snake oil and snake oil at that with sometimes deadly side effects. Apart from all the other stuff that can go wrong they are implicated in suicides and homocides. And no better than placebo
    http://www.scientificamerican.com/article/antidepressants-do-they-work-or-dont-they/

    Mental distress of all types increases as inequality increases.

    In countries like Japan where both positive and negative emotions are accepted as normal and not things that should be controlled but just observed and let pass reactive anxiety and depression occur much less frequently.

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