Are You Depressed?
Sociologist Allan Horwitz discusses psychiatric diagnosis in the late 20th Century, and our changing perceptions of “sadness” and “depression.”
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BRIAN BALOGH: You know, Peter, for better or worse, the story of the asylum in America it doesn’t end there. In the 20th century it morphs yet again. We called up Alan Horwitz a sociologist who has written a lot about the history of psychiatry, and he explained what happened next.
ALAN HORWITZ: For most of the 20th century, mental hospitals were at the core of the psychiatric profession. And most psychiatrists practiced in inpatient mental institutions. Really it was psychoanalysis that made the major change, where they pretty much thought mental problems we’re just extensions of ordinary kinds of psychosocial problems.
PETER ONUF: In addition to the psychotic, who had long been institutionalized, psychiatrists began to focus on the neurotic. People who weren’t in danger of being committed, but who needed help, nonetheless.
ALAN HORWITZ: So that instead of the sharp dichotomy between people who are basically considered crazy and those who are sane, what you get is a much more gradual transition between sanity and normality.
PETER ONUF: These gradations were laid out in a document the American Psychiatric Association released in 1952. They called it the “Diagnostic and Statistical Manual” or DSM.
BRIAN BALOGH: A second edition was published in 1968. Like the first one, it was intended as a compendium of the range of mental disorders and their probable causes.
ALAN HORWITZ: So for example, this is the entire definition of depression in the DSM II. And it’s, quote, “This disorder is manifested by an excessive reaction of depression due to an internal conflict or to an identifiable event, such as the loss of a love object or cherished possession.” That’s it.
BRIAN BALOGH: Wow! They violated my elementary school teacher’s rule. Never define something with the thing you’re defining.
ALAN HORWITZ: Right. Exactly. When it says that manifested by an excessive reaction of depression, yes, it’s quite circular.
BRIAN BALOGH: Psychoanalysts were OK with these broad definitions. After all, they were mainly interested in the distinctive details of the patient’s unconscious lives. But, says Alan Horwitz, there was a problem.
ALAN HORWITZ: The major problem was that it’s not a very medical way of thinking about things. That it didn’t give you sharp diseases.
BRIAN BALOGH: It was in this context that psychiatrists went back to the drawing board. And in 1980, they released a third version of their manual, the DSM III. Alan Horowitz says, it was nothing short of a paradigm shift.
ALAN HORWITZ: DSM III really medicalized psychiatry. The criteria, say, for depression, you have five symptoms. If you have fewer than five, you don’t have the condition. So you have the kinds of discrete categories that you have in other medical disciplines, that you didn’t have before the DSM III.
BRIAN BALOGH: The new paradigm was a real win for research psychiatrists who had pushing for years for a more uniform way of talking about mental illness. And for pharmaceutical companies, who could now use that checklist to pitch specific symptoms to doctors and patients that they should look out for.
PETER ONUF: Psychoanalysts, on the other hand, weren’t so happy. Because the new focus on symptoms left no room for considerations of root causes.
ALAN HORWITZ: With the single exception of bereavement, there’s no context in it, at all.
BRIAN BALOGH: What we’re left with, says Horowitz, is a system that does not distinguish between real depression and the kind of temporary sadness that is the natural human response to a range of life events. Both are now lumped together into one diagnosis, which in turn, frequently results in a prescription for drugs.
ALAN HORWITZ: I think that psychiatric researchers are finding that the paradigm they’ve been using since the DSM III just hasn’t worked very well. That it hasn’t produced the kinds of breakthroughs, regarding the treatments for conditions, that they expected it would have. And I think there’s a growing recognition that it’s the current DSM system itself that is almost holding back progress. And many of the proposals that you see for changing it, really do hearken back to systems that were more common before the DSM III in 1980.
BRIAN BALOGH: In other words, getting back to root causes. But these days, those causes are more likely to be seen in the chemistry of the brain than in uncovering the deep history of a person’s mental suffering. It’s time for another short break, but stick around. When we get back, a psychological test that promised to identify people who threatened American democracy.
PETER ONUF: More BackStory coming up in a minute.