Transcription
Hi, I'm Dr. Yosef. During it's my pleasure to be joined by Alan Horowitz. He's one of the authors of a really excellent book called "The Loss of Sadness." And today, he's going to be talking to us about how depression, uh, the idea of depression has changed over time. And then we're going to talk a little bit about how the current conceptualization of depression has influenced mental health care, you know, in in the modern era. So, Alan, thank you so much for agreeing to come and have a chat with me about this. And and and let's just dive, dive right in. Talk, talk to us about, uh, the the history of depression over time.
Right. Well, I would say depression is probably the single mental illness that has been described in remarkably constant ways for thousands of years. And the ancient Greek philosopher Hippocrates, uh, spent a considerable amount of time describing depression in ways that are just remarkably like the current definitions of depression. And but unlike current definitions, Hippocrates, Hippocrates clearly separated symptoms of, um, normal depression, I mean, when people ought to feel sad, um, from depressions without cause. That is, depressions that aren't grounded in some kind of loss that people are experiencing. And it's only those, um, depressions that are, in his terms, without cause. And they didn't really necessarily have without any cause, but were either disproportionate to what's happening in the person's actual life. And and you can really see great similarities between the symptoms that Hippocrates described and the current DSM, um, definitions of depression.
And I mean, throughout history, I mean, there's a, um, very famous book by the 16th century English, uh, he was actually a vicar, Robert Burton, "Anatomy of Melancholy." So he called what depression, melanchol, Melancholy, or Melancholy, and our pronunciation, um. And again, what Burton describes as depression is virtually the same as Hippocrates' and very similar to current definitions. And so you have this remarkable consistency in definitions across thousands of years that really only changes when, um, Sigmund Freud developed his, um, system that became tremendously popular towards the end of the 19th century and into the 20th century. And while Freud probably wouldn't disagree with anything that Hippocrates or Burton talked about, he emphasized anxiety much more than depression. Indeed, for Freud, depression was just a particular form of, um, of anxiety. So for the period when psychoanalysis was dominant in psychiatry, you know, rough, very roughly, the first half or first six decades of the 20th century, much less attention was given to depression than to anxiety. Indeed, you also see, really in the 1950s, the development of the first, you know, very widespread drugs to treat what would then have been called neurotic conditions. And they're called anxiolytics. They're not called antidepressants. And they are tremendously popular. Everybody at the, there you know, were as well known in the 1950s, 1960s culture as the antidepressants are today.
And so, just, just to kind of contextualize, to say, so there's a couple of things. I do remember that in when I was learning about Freud, they don't talk about depression, they talk about neuroses. You know, and it's that, that, yes, that idea. And anxiety is the key to the neuroses, not depression. And then, um, you know, when you talk about the 1950s, are you talking about, I guess, the development of meprobamate, you know, "Miltown's Little Helper," and maybe Librium, uh, and entering the market, the first benzodiazepine, right? Okay, right. And sort of the first sort of drug scandal hits at around that time. Really, in the early 1970s, you have, um, thalidomide, which wasn't given for psychiatric conditions, but it caused really horrible birth defects. It really led the Food and Drug Administration to crack down on advertisements for the anxiolytics and really made drug companies prove their effectiveness with some particular condition. You couldn't, um, do as they had been advertising. I mean, you would see things like children leaving home and the elderly parents, you know, taking these anxiolytics because of their situations. And just these very general, common conditions. This no longer was permissible in terms of the FDA, the Food and Drug Administration regulations. And that, so what you get is sort of a gap in these, um, medications. The anxiolytics, the anti-anxiety drugs are sort of stigmatized, but there's nothing that has emerged in their place. So then when a whole new class of drugs, which work on the, the serotonin system, is developed in the 1980s, it made a lot more marketing sense to call them antidepressants because depression didn't have the same kind of negative connotation that the anti-anxiety drugs had garnered.
So to recap, you know, it's like the, uh, the anxiolytic medications, the benzodiazepines, they kind of had their heyday from the '50s up to maybe, you know, into the '70s, and then they became stigmatized because people recognized there were a lot of safety, dependence, addiction issues with them. And so when the new group of drugs came onto the market, they wanted to kind of separate themselves, say, you know, we're not anti-anxiety meds because we don't want to be associated with that, with those risks. We're antidepressants. Yeah, exactly. And in fact, the so-called antidepressants don't have anything more to do with depression in particular than the anxiolytics had to do with anxiety in particular. They work across, or don't work, whichever you think, across very, very broad conditions. So that, you know, as you just said, it was much more a question of marketing than of, you know, how the drugs actually work.
And, um, I want to, because this, there's a little that, there's a stage before, you know, there's a stage kind of before we get to, I guess, the late '80s when Prozac hits the market, where we have a couple of drugs which are the traditional antidepressants. I'm thinking about drugs like imipramine and the monoamine oxidase inhibitors, like the MAOI type drugs. And they were used, you know, in depression, but, and correct me if I'm wrong, but more so back then, this was used in, I guess, what people used to call melancholic depression, or vital depression, or endogenous depression, you know, the kind of words that we use to signify, you know, an organic cause to the, to the depression, or at least they did back then. And it's this very, oh, oftentimes a very kind of lethargic, hypersomnolent state where there can be a lot of, you know, they stop eating, they stop moving a lot. And it's a really, you know, a really almost heading in the direction of catatonia. But, um, and so could you tell us a little bit about about that phase? How, how depression transitioned from being this kind of niche thing that maybe was treated in asylums with these MAOIs and tricyclic antidepressants, like how we got from that small group of, you know, technically like endogenously, you know, depressed or genetically depressed, or however you want to say, to the group that became a lot broader, you know, following the, you know, at the start of the '80s and into the '90s?
Yeah, no, you're absolutely correct that the MAOIs, the imipramine, um, these were used really serious melancholic depressions. I mean, they certainly were not suitable for a broad range of the population. That is, no pharmaceutical company would see those as appropriate to try and market to a, the general population. They're really for more almost psychotic, um, conditions than, um, for your run-of-the-mill depressions. So when the new, the SSRIs, which hadn't existed before the 1980s, really, are developed, it made the drug companies didn't want to call them anti-anxiety medications, even though they're pretty much replacing Miltown or the other, you know, benzodiazepines. Um, it just hit on a genius marketing thing, and certainly helped by Peter Kramer's, um, you know, "Listening to Prozac," which was an enormously influential book. And he's promoting them, I mean, not just as, you know, a relief for any kind of psychic problem, but they make you better than well. And, you know, who doesn't want to be better than well? And so Kramer's book had a, um, tremendously influential impact on the, um, marketing of of these at the time, new, uh, drugs. And the other major development was before, um, roughly 1998, I might not have the exact date correct, that drug companies couldn't advertise to the general public. That is, they could only advertise within medical journals. Um, yeah, they could have their promotion people visit, you know, psychiatrists or general physicians in their offices, but there were no say, television ads. Um, there was no widespread promotion of these because it was prohibited. That changes at the end of the '80s, just as the SSRIs are coming onto the market. And there's just a barrage of advertisements that are directed at the general public to promote these drugs. And often even using Kramer's imagery of, you know, better than well. And, um, you know, certainly bringing a whole new category of drugs to the attention of the general public. And they are just hugely successful. And they're called antidepressants. And they're certainly prescribed for depression, but among many, many other kinds of, oh, yeah, like PTSD, generalized anxiety disorder, obsessive compulsive disorder, just to, just to name a few.
And, um, I think the other thing that, you know, just a comment that that happens as well, is, you know, the drugs have a much more, I guess you would say, in a way, favorable safety profile. You know, when we look at the older antidepressants, you know, with the tricyclic class, uh, they were fatal in overdose. It's very difficult to overdose on SSRIs. So again, the safety kind of increases there. And then with the monoamine oxidase inhibitors, you have to avoid cheese and wine. And so, you know, there's these kind of risks of those drugs that sort of ends up being, you know, making people think, oh, you know, we really need to use these in people who are more sick. Um, but when, when Peter Kramer comes out with "Listening to Prozac" and he starts talking about cosmetic psychopharmacology, I mean, now, now we're not talking about a drug for a serious illness. In many ways, we start talking about almost like a lifestyle drug, a lifestyle drug where you could be kind of perkier, you could be a little less anxious, a little, a little more disinhibited if you wanted that. And hey, you don't have to worry about changing your diet. You know, your doctor doesn't have to worry about prescribing you small, you know, days at a time because he's worried about you overdosing on them as well. And so, and then also there's that marketing piece. You know, it seems like it then it really takes off.
Okay. So the first DSM, um, is published in 1952. Right when the psychoanalysts are dominant in psychiatry. The second edition was published in 1968, when there's still this psychoanalytic, um, dominance. And both of these manuals reflected really a strong analytic perspective and emphasized anxiety as the overwhelmingly powerful condition among the neuroses. Depression was a relatively minor part of the DSM-1 and DSM-2. Okay. Well, the research psychiatrists who were led by Robert Spitzer, who was the editor of the Third Edition of the DSM-3, really wanted to create a revolution in psychiatric diagnosis. And they did. And their idea was, the first two DSMs were really based on an ideological model, that is, what causes the condition that is under study. And they would generally find the causes in sort of unconscious motivations and other, you know, analytic kinds of concepts. They wanted to abolish that completely and develop a symptom-based, um, manual where they would have a list of very precise symptoms. So, depressed, the nine possible symptoms of depression. And if you have five of the nine, you get the diagnosis of depression. Doesn't matter what the cause might be.
And, and may I add, and I'd like you to comment on this as well, um, you know, my understanding of why they, they shifted from a causal-based, well, actually, here's my first question. When, in the first two DSMs, you know, they had neuroses, which was much more linked to intra-psychic conflict, or, you know, you could just say, you know, stress, stressful interpersonal things, or, you know, troubles in your life that you couldn't overcome. And that was intra-psychic conflict leading to neuroses. Did they draw a distinction between that kind of, uh, neurosis or depression that is more causally related to, you know, stresses in your life, and, um, endogenous type depressions, which were thought to come out, like, did they have those two categories in the first two DSMs?
Yeah, well, they did have the category of, you know, sort of what we now call endogenous depression. So, yes, that was, there was not a common diagnosis, but it was certainly in the manual. Yeah. But the, in terms of ordinary depression, the major goal of the DSM-3, the researchers who were behind implementing the system, was really to destroy anxiety. That is, because anxiety is so tied up with the analytic perspective. So what they did was, they make anxiety, they divided into nine distinct conditions. I mean, so there's generalized, there's, ah, social and specific phobias, there's obsessive compulsive disorders, there's all these distinct sorts of anxiety conditions. There's just one kind of depressive condition that's not a psychotic condition. And this is defined by symptoms of being sad, or, um, you know, having losing your appetite, having problems sleeping, just extremely common symptoms of in the population. And what happens is, when the DSM-3 definitions are applied in epidemiological studies, that is, studies of mental illness in the general population, as opposed to treated patients, you get huge prevalence of depression. Oh, my God. Depression is by far the most common, um, kind of mental illness. Roughly 20% of the entire population experiences, um, being depressive, you know, enough depressive symptoms to meet the five symptom criteria. And so all of a sudden, depression, because of the changes that the DSM-3 made in diagnoses, that becomes probably at the center of the mental health professions. Yeah, yeah. Because, yeah, the, um, it's so easy to diagnose, um, at that point.
I want to, um, share kind of my understanding of, um, of kind of why the shift from the, um, the causal model to the list model, which I think does provide some kind of context and why the need to move away from psychoanalytic to terms like neuroses. So my understanding was that psychiatry, there was a lot of embarrassment in psychiatry at the time because they were doing studies where several psychiatrists might interview the same patient. And that, you know, the, at least in DSM-1 and 2, the, it was so subjective. You know, every psychiatrist could just say, oh, I think this is a neurosis versus I think this is, you know, a depression. Because no one could decide supposedly whether, you know, this is due to intra-psychic conflict or maybe this is more biological in nature, like an endogenous one. And so there's, there's this, um, um, you know, this this push to kind of make, to kind of take that thought out of it. You know, we don't want you, we don't want to be making our diagnoses based on, you know, our subjective interpretations. We want to be like internal medicine doctors diagnosing rheumatic heart disease, where we have, you know, a list of, you know, symptoms there. And that, and that's, you know, much more scientific. If we just do the symptoms. And then the other thing is, psychoanalysis is kind of falling out of favor at that time. You know, there's this general sense that, you know, that model has taken us, you know, to the extent that it can. And maybe some of the interpretations are getting a little bit wacky. You know, some of the things like penis envy, and some of the things we all kind of laugh about now. But there was this, I think there was a shift away from, you know, that way of kind of conceptualizing or mental illness as, you know, Oedipus complex, or, you know, some kind of, you know, problems within the family. And the model just wasn't working. And so there's also this sense that, you know, to evolve, we need to move away from such a, a Freudian-based kind of model of diagnosis. Is that your understanding as well, or maybe you could elaborate and add some things?
Oh, absolutely. And pretty much basically after 1980, when the DSM-3 comes out, psychoanalysis becomes just pretty much a small subculture within psychiatry. That is, very, very few psychiatrists go into analysis. It becomes more the province of a subculture of say, clinical psychology or social work. Is actually one of the, um, now major bastions of of analysis. But so just the whole client, the type of person who goes becomes an analyst, really is transformed from psychiatry to the other mental health professions. Although in general, it falls out of favor also in, just in the general culture. It's just not, analysis is no longer a major presence at all. And I think to a large part, that is because of the changes in the DSM-3.
You know, I want to, I'm going to pick up on on a thread that you mentioned previously, because I think it's important to maybe get some of this context before we go into the impact of the new DSM criteria and the growth of depression. So I'm going to go back to something right at the start of when we were talking about it, um, Hippocrates. How did he differentiate endogenous depressions from reactive depressions? In that meaning, biological versus ones that are based in life? Was there some kind of criteria that he used? Did it look different in some way? Do we have that level of detail from his early writings that there were, you know, how he thought about those two being different?
The major criteria that Hippocrates used was the term "without cause." That is, depressions, um, that just seem to come out of the blue, or just seem, you know, wildly disproportionate to, you know, what the person is experiencing in their lives, um, are the ones that he would have considered to be true mental illnesses. Whereas depressions with cause, that it's somebody dies, or it's natural that people would become depressed, it's not a mental illness. Even if you have the same symptoms, it really depends on the relationship of the symptoms to what's happening in the person's life. And it's that basic distinction that continues for thousands of years, right up until 1980 in the, the DSM-3, where it's almost abandoned. The one exception is the bereavement exclusion. That is, that the DSM-3 does say, well, if, you know, the person has suffered a recent loss of a loved one, shows these symptoms, they shouldn't be diagnosed with depression unless it's long-standing, by which they defined as two months. I mean, you can argue that's not, you know, not long enough, or if it has truly, um, severe symptoms, symptoms. And it's, it's interesting, you know, that they have that carve out for bereavement. And it's almost, in many ways, it's like, I think it was a concession to the more psychoanalytically based, you know, members of the group who said, hey, what about if someone dies? And they said, okay, we'll let you have that, even though we don't really want to, even though we want to move away from a causal definition. Because I mean, there's having a carve out for bereavement, it's, you know, why not have a carve out for catastrophic economic loss following a job loss, or from a divorce, a particularly brutal divorce, perhaps, where you lose the children, or something like that. Um, you know, it's interesting that that carve out bereavement when there's several things that anyone could think of that could be just as significant as losing a loved one.
Well, I think you've hit on exactly the important question. And to go back to the DSM-3, there's one influential member, Polly Clayton, who had actually done studies of bereavement. And what she found was that a huge proportion, you know, half of people who had suffered a recent loss of somebody close to them, the death of somebody close to them, would meet the criteria for depression. But if you look, say, three months later, most of those people were starting to get better. And by say, six months, almost, you know, very few would still meet the criteria for depression. So I think it was because of Clayton's work that the DSM-3 had carved out this exception. I mean, you could make the same kind of point that, you know, I know the study wasn't done, but maybe people bounced back, you know, three to six months after a job loss, you know, if they're really sad.
Yeah, well, I mean, actually, um, my collaborator, Jerry Wakefield, and a couple of other people, we did a study which was attempting to get at exactly the issue that you raised, which is, well, is bereavement isolated? Is it a special kind of loss? Or what about people who just lost their job? What about people who are getting divorced? That is, that there might be a broader category of loss that also should be excluded from the, um, depression criteria. That, um, you know, was published in the American Journal of Psychiatry. And upset a lot of people because, I mean, depression is the core condition. And if much of what's getting diagnosed as depression is really just a normal response to loss, I mean, that's pretty threatening to psychiatry's core condition. And our results suggested that there really wasn't that much difference between bereavement and other kinds of losses.
One thing that I want to ask you about is, um, so when, when the, you know, when the, when we move from two to three in the DSM and we get rid of cause, you know, we're not interested in cause anymore, except for this like little carve out that we have for bereavement, which by the way, doesn't exist anymore. And the fifth DSM, I'm sure you're aware, you know, they finally got it out. But the, the DSM clearly states, you know, we are a causally, you know, neutral manual. Like, we don't really care if it's caused biologically or caused in reaction to social, to social stresses. However, even though they say that, and that's what's in there, that's not how it's used. Well, that's not how it's perceived, both by a lot of the times, the practitioners, psychiatrists, and family medicine doctors, and by the public. And so when you get given a major diagnosis, a major depressive disorder diagnosis, a lot of people start thinking that they have, um, biological problems. And, and, and I think that's kind of, uh, you know, something that I really want to get your perspective on, because, you know, it's not, the DSM never says that, but that's what the kind of the social contagion starts being after the DSM-3. That's the, that's how a lot of people start seeing. I don't know if you agree with that. I mean, that's kind of my perspective being a practitioner. And I'd like to get your thoughts on that.
Yeah, well, there is actually, in all of the DSMs since DSM-3, including DSM-5, a very short general definition of what it means to have a mental disorder. That is, it's not particular to depression, it could, it holds for any condition in the DSM. And basically, to condense it, it means, well, something has gone wrong in the way people are responding to, um, you know, some mental mechanism, whether it's emotional or cognitive, or, you know, that it, it's not working as it's been designed to work by evolution, um, in responding to to the world. So that, the, what the bereavement exception was saying is, well, this isn't anything gone wrong. It's normal for people to respond to, you know, the death of a close, um, you know, family member with serious depression. I mean, even, um, you know, apes and chimpanzees, um, respond this way. I mean, this is built into our hardwiring. But it's not a mental disorder, it's the way that humans are designed to be. And the same thing for, you know, undergoing, you know, painful divorce, or losing a valued job, that there's, you know, many kinds of loss responses that are absolutely normal and not, um, signs of mental disorder. And so that's what we were trying to show empirically, that bereavement was not a singular exception, but an example of a much broader category of, um, of loss responses.
So this, of course, is enormously threatening to, um, the psychiatrists who are developing the, well, the latest edition, the DSM-5, which, as you mentioned, well, it's now the, I guess, the 5TR, but when it was just the plain old five, came out in 2013, it pretty much abandons the bereavement exclusion. It does, it now becomes a footnote that's very ambiguously written, and it's not part of the diagnostic criteria any, any longer. So even bereavement is no longer an excuse for, um, not giving a diagnosis of major depression. And it's interesting because, um, you know, so much of it, [Music] I feel like so much of it is in the language that you use. Uh, because major depressive disorder, you know, when you hear "disorder," you think, at least for me, is something malfunctioning. You know, and, and I know that's, you know, because I read the DSM, and that's not what they're not trying to say something is malfunctioning biologically. Although that's how everyone interprets it. You know, it's just saying, you know, you could, you know, at least they want to say, oh, you could have, I guess what they're trying to say is that you could have, um, these symptoms from, you know, social stresses or psychological stresses, and it's still a disorder because it's impairing your ability to function. You know, you could just as well have it coming out of the blue. But that's, um, and and so I guess their perspective would be something like, why do we need this carve out for bereavement when, you know, we're not even, um, you know, we don't, yeah, it's, it's, who cares? It's a disorder, you know, is what they're saying. But it actually, it it matters a lot, um, because it matters a lot in how people see the illness, you know, as if, if they see it as something which is, I'm passive in my recovery, I I need to take the medication as the doctor has prescribed, and that's how I need to recover because I'm disordered in this way, as opposed to, um, maybe a different word or a different way of putting it where it's where it's more empowering, where it's more like, well, actually, have we looked at your diet? Have we looked at how you, um, function in relationships? Have we looked at your ability to succeed, succeed economically? Are there things holding you back? I mean, there's this, there's this thing that happens, you know, when you start telling someone that they're sick, um, and I feel like the kind of the contagion that got out there, at least the idea that was has been pumped out for a long time with, and you could go to talk about, you know, the chemical imbalance, uh, hypothesis for mental illness and depression and such, was that as soon as they got rid of the terms such as like neuroses, which or bereavement, which more anchored in causal things going on, they started to really promote kind of depression or major depressive disorder solely in biological ways. And, and, I mean, the one part of me says that that's probably because it was very helpful in selling drugs. You know, is to say, you know, you've got this deficit, and, um, now, um, you know, it's not your fault, and this is medicine, you know, it's like insulin for diabetes, type of thing. And so I wonder if, um, I mean, my, my perspective is that, you know, if there is a financial incentive to kind of, um, um, share one version, you know, or to promote one idea, you know, depression, biological, serious mental illness, you know, medic, antidepressants, or like insulin for diabetes, that that's going to be the, the idea that takes hold, especially if there's a lot of, um, you know, finances and and things kind of going into it. And so, I mean, that was my perspective, I think, going through it and reading back of kind of how this thing that's meant to be neutral, you know, major depressive disorder, is just, it's just symptoms, it's meant to be neutral, but it changes and it gets seen in a different way by the public. I, I don't know if you could kind of comment on that, and or, or maybe, maybe I'm right, maybe I'm wrong. I'd love to to get your thoughts on how this thing evolves.
Yeah, oh, well, I mean, to my mind, you're entirely right. I mean, I think you have, you summarize the situation exactly. That is, if you call someone sick, and even if the reason they're sick is because they're acting the way we would expect anybody to react to a serious, you know, loss of relationships or jobs or, you know, the death of a close family member, um, well, if you're saying they're disordered, well, the natural reaction would be, we have a pill for that. You should take, you know, antidepressant, uh, medication. And it was a, you know, wildly successful. I mean, I mean, successful beyond what the, the drug companies initially, you know, envisioned in the, in the late '80s and, you know, through the rest of the century, until, as is pretty much the case now, they lost the patents on on the, um, antidepressants. And it doesn't seem as if they've been replaced. However, just because there's nothing really new on the horizon.
Well, one thing we could tack on to the end of this, and I could talk to you about, is the psychedelics. And I think that was, psychedelic, yes. The whole psychedelic model is, is so different from, um, that take a pill every day model. And I think it'll be interesting to see how these two clash. Because if MDMA, which is now, you know, MAPS has completed their second phase three study and they're applying for a new drug application as we speak, you know, potentially with an approval by the end of the year, if that comes onto the market, there's a whole new model. Because the idea is that you have PTSD, and, um, you know, things aren't working out well for you, and you go and you see a therapist who's trained in helping you prepare for the session, you know, what are the things that you want to change in your life? How are you hoping this is going to help you? They go through this experience on the medication, and then they have to integrate the insights from the experience. So it's more drug as a vehicle for insights, you know, it's not something like drug you take every day. We do this, it's like, it's putting it back on the person and the therapist to say, how are we going to integrate these new experiences? And this is going to be such a vital clash, I think, between the two models. And you're going to have some really well-financed players who are going to come into the market and start having some very ideas about some some different ideas about how do we want the public to perceive depression that may be beneficial to us. And, you know, and what we're doing. And, and so I think that the conversation may change, you know, as more money kind of flows into this space, you know, backing a different model. And I'm really eager to see that.
Yeah, especially interested to watch these developments because, I mean, I went to, um, as an undergraduate at the late 1960s, and of course, yeah, well, I guess ecstasy hadn't quite yet arrived, but psilocybin, um, magic mushrooms, LSD, I mean, these were the sort of deviant subcultural drugs that had, you know, I mean, nothing to do with medical practice. I mean, you would never get these from a psychiatrist or any kind of physician. I mean, it's a huge, you know, underground market. And people would take them for the often very exciting and, you know, insightful insights you would gain from from tripping, although they also had a lot of risks because bad trips were, you know, you know, a major possibility. And but just the notion that these would be incorporated in some kind of a medical setting would have just been seen as absurd at that time. And now you're saying, you know, all of a sudden, there's this revival of these old psychedelics as medicine, promising new, although I would question the newness, you know, tools to, um, you know, to, um, to help people. And although PTSD might be one, um, condition where they, I think we might have something special value. Oh, they're going for depression as well, you know, number two and three through the gates is going to be, I think it's compost, and then Usona pursuing psilocybin for major, uh, treatment-resistant depression, and then, uh, Usona just for normal depression. And but I think those ones are a few years behind, you know, we may need to wait until 2025 to see if they, they kind of, they come through.
Another, you know, question I don't want to get away from, which, um, you know, because you've read so much of the literature about, um, old forms of depression and such, you know, when people hear the word depression nowadays, they, they kind of think about, um, I guess what everyone thinks about with depression, you know, low mood, feeling guilty, restless, you know, low motivation, you know, a lot of self-critical thoughts and things like that. That's really what most people think of with depression. But could you describe how endogenous depression was described? You know, because that was how people used to use that word, you know, they talk about depression and they talk about someone who had endogenous depression. I was wondering if you could talk about, you know, when, you know, how is that being described in the literature in the past, you know, the, the depression of the '50s, kind of before it all changed? Because I think that's interesting to kind of contrast as well, is that that these two things were very, you know, were pretty different.
Depression would be, I think, just a much more serious form that often shows, say, instead of just, you know, just kind of feeling down in the dumps or feeling sad, you know, vegetative. That is, you just can't, you might just stay in your house, stay in bed, you know, all day. It's just a much more severe sort of condition. And in certain ways, would be comparable to depression because it does have the same symptoms or similar symptoms, but it's just a far more severe kind of of condition, often accompanied by suicidal thoughts, um, or suicidal actions, um, and so on. And so on the one hand, it's just a matter of severity, but at a certain point, becomes so severe, it almost becomes a different kind of condition.
Mm-hmm. And I've, and I've, I've seen these folks during my residency and it, at least at the very severe side of it, the neuro-vegetative side, it is it can be quite shocking sometimes, you know, they're just in bed, you know, hardly able to talk, you know, and sometimes with psychotic symptoms. And then they require ECT or some other kind of fairly heavy intervention in order to get out of it. Um, and, um, I'm trying to think, is that, I think there's an author, is it William Styron or something? Uh, yeah, "Darkness." Um, oh, um, yeah, yeah, no, I, I actually, there's two words, and "Darkness" is one of them, because, yeah, to me, that that seems like more of this endogenous depression, you know, when you read his book, I mean, it's just this wave that comes over him, you know, and just completely depletes him and tortures his mind, you know. And, um, I think about, you know, that constellation of symptoms of something seemingly coming out of nowhere in a cyclical way, you know, knocking someone over and then just putting them in the deepest despair ever. Um, and then it's so different from, um, I guess how everyone thinks of depression these days. And and so like the market of the idea of it has gone from being something that little to being something so big now.
Yeah, I think now when you read about depression, it's as of just a very common. It's almost always coupled with anxiety. It sort of goes back to the way it used to be described. But, you know, that you have just huge numbers of, of especially young people depressed and anxious, often tied to the use of social media, um, also often tied to the effects of the isolation during the COVID pandemic. And so depression now has, to a certain extent, shed its, um, its association with mental illness and is now just seen as a widely prevalent condition, especially among, um, you know, adolescents and young, young adults. And so as a sociologist, what is the impact of that? What do you, what do you think about what's kind of, um, happened? What impact has that had on, on the United States and maybe, maybe the world?
Well, I think probably the, I mean, it certainly brought mental health into a much more prominence than, um, it's been for, again, a long time. Whether that's a good thing, I'm not sure. Because, you know, defining is it the impact of social problems by their mental health effects as opposed to their societal kinds of impacts, it's, you know, it's hard to say what people are gaining by, uh, saying, oh, I'm depressed, I'm anxious. Um, but I, on the other hand, it's, I think it's good that depression and anxiety of someone, yeah, lost their stigma that they were once highly associated with. It's a good time.
Yes, there's two parts of it because you're right, you know, I mean, and I see the change even in my lifetime, you know, when I was growing up, no one talked about mental illness at all. No one talked about medications. It was something that you just would not mention. You know, this is me in high school. And now I think about how it's all over social media. Everyone's talking about it, you know, you know, what antidepressants certain celebrities take. And so just this comfort in kind of talking about it has grown. And and that impact, certainly could, you know, let's say someone is suicidal and they're feeling like a failure and they're feeling like, you know, it is a weak thing to do to kind of talk about that. You know, with this kind of general like acceptance of it and the openness about it, they may be more likely to, um, to seek help. But then on the other side is, you know, now we have a system that is so quick to medicate people. And, you know, many of these things, um, resolve spontaneously. And, you know, the problem with, um, dependence on antidepressants has has really grown, you know, where it's like, you could have someone who has a temporary problem become essentially on a drug for a long time because they, they can be very difficult to stop for a proportion of people. And, and so what's, what's the net gain? Is it net positive or net negative? You know, it's, it's, it's, it's difficult to know. I mean, I've worked with people who are drug injured every day. So I mean, my perspective is generally one where it is a more negative thing. But it's, you know, there's two sides of it for sure.
Yeah, yeah. And it, it also depends a lot on the particular person that you're talking about. Yeah. Um, and so one thing I wanted to ask you a little bit about is, you know, you, so much of your work has been about, well, I guess, um, you know, fighting for things like the bereavement clause and things like that, um, and getting the, uh, you know, keeping some of that causal reasoning in, uh, psychiatric diagnoses. What has it been like on the other side of that? You know, when you're, when you're advocating for these things, what are the things that that you used to get, you know, pushback on? You know, what was it like interacting with your other, you know, academic colleagues and the different people that were involved in the DSM? What was that, um, that jostle like for you?
Well, yeah, I mean, I'm a sociologist, I'm not a clinician. So it was sort of easy for me to be saying these things because, you know, um, the people that I'm basically arguing against, traditional, you know, psychiatric thinkers, um, are not sort of my own peers. I mean, so that, in a sense, it's easy for me to be a critic because I don't have to come in contact, yeah, face-to-face contact with these people. I can, um, sort of critique from afar. Although I have, I guess I have used to give some talks that, you know, American Psychiatric Association meetings and actually found quite a welcoming reception, uh, there. Yeah.
And, um, I guess the next thing is, um, I'm sure you're familiar with, uh, Allen Frances and his kind of about-turn after the DSM-4 out. What was that like for you to see, you know, someone who was so integral, kind of, uh, you know, after doing something like the DSM-4, kind of really aligning in many ways with, you know, with with your ideas and kind of, you know, the the awareness of overdiagnosis and how the the manual was getting, was being used in unintended ways? What was that like to kind of see that?
Oh, I thought it was terrific. I remember, a huge fan of, um, you know, Alan Frances. And I think he wrote a back cover blurb for my last book. And, yeah, um, you know, I think he, he saw the light. Yeah, I guess now he's, I mean, he's very active on Twitter. I get every day, um, he's great. Yeah, he's kind of like a wrecking ball. I really admire him and I I love the things that he says. So I, I did have the opportunity to speak with him not so long ago, you know, just just like we're, we're doing now, because, uh, he is someone I admire. Yeah.
Oh, and I would also mention that, uh, Bob Spitzer, who was of course the mastermind of the DSM-3, wrote a forward to "The Loss of Sadness" that I wrote with, uh, Jerry Wakefield, in which he basically repudiated what he had done in DSM-3 and says, hey, these guys are right. Yeah, that's great. Yeah. I, I need to have a look at that again. I, it's been a while since I read it, but, um, I think we're, you know, this is a probably a good time to wrap. I, I really want to thank you for, uh, you know, letting me talk to you about this and, you know, being able to learn from your expertise. So on the, on the history of depression, I, I loved your book. It's "The Loss of Sadness." It's been out for a while now, but it's still worth buying if you're interested. And, um, and, uh, is anything else you want to add before we wrap?
Oh, I, I would just say, yeah, I love, you know, exploring your website and you're doing terrific work and wish you all the best.
Great. All right. Thank you so much.