A Blistering, Rambling, Entertaining Attack on the Biomedical Disease Model of Depression

How did we get to this point, this point in our history where it is common, if not mandatory, to think of our unhappiness as a disease?

That's the big question in Manufacturing Depression: The Secret History of a Modern Disease. Gary Greenberg has written a blistering, rambling and entertaining attack on the biomedical disease model of depression. It's the story of how advertising, pharmaceutical companies, and psychiatrists packaged unhappiness as a medical disease to be treated with antidepressants.With nearly thirty million Americans taking antidepressants at an annual cost of 10 billion dollars, Greenberg is David armed with a slingshot, careful research, and clever one-liners.

Greenberg wants to shake us up. What genre is this? His book mixes together personal memoir, case histories (he's a practicing therapist), intellectual and business history, and guerilla journalism (he shows up as a mischievous patient in a clinical trial).

He shakes us up by jumping around in his narrative His lyrical history includes detours into germ theory, the transformation of German synthetic dye companies into pharmaceutical industry titans, and the numerous turf wars between psychiatrists, psychologists, and neurologists over what is mental illness and who gets to diagnose and treat it.

Greenberg also keeps the reader busy. We have to track that he is making several different cases against the biomedical disease model.

There's the historical case. The disease model was not foreordained or inevitable, but represents the coming together of big pharma and the cultural needs of the late 20th century. He delights in the irony that discredited treatments in the early 20th century such as insulin coma therapy and lobotomy set the stage for the magic pharmaceutical bullets.

There's the scientific case. Greenberg hammers home the differences between depression and bona fide diseases cancer, diabetes, or flu. Unlike the latter, there remains no reliable biological marker of depression, or a validated theory of the biology that produces its symptoms. He covers the sad history of failed attempts to establish a biological basis of depression, from black bile to serotonin.

There's the clinical case. Greenberg points out that medications don't work well enough to be considered magic bullets. For example, the antidepressants beat placebo in only about half of clinical trials.

Finally, and probably dearest to Greenberg, there's the humanist case. He objects to DSM's one-size-fits-all checklist - how the diagnoses rendered with this system stunt the experience and expression of psychological suffering. Where is the place for experience in the biomedical model that treats consciousness as "merely the steam rising off the amino-acid-rich neurochemical soup that roils in dumb silence in your head?" As a practicing psychotherapist, he objects to how the disease model preempts the potentially redemptive power of self-exploration. He worries that if we call our misery a disease, we won't bother to try to fashion our past and present troubles into a coherent narrative. He worries that calling pessimism the symptom of an illness leads us to turn over our discontents to the medical industry and to surrender perhaps the most important portion of our autonomy, especially if our feelings of pessimism are "an ally at a time of crisis?"

This isn't your father's antipsychiatry. This isn't Peter Breggin railing against drugs that are rotting your brain, the chemical straightjacket. Greenberg has nothing against using psychiatric drugs to change feeling or perception, just as long as you don't call it treating a disease.

Greenberg is temperamentally a skeptic, and he is satisfied if he can help us understand what depression is not, not a disease. Given the history of muddled thinking on this topic, that is enough, for now. We must tear down before we can build. In the end, his book is more than a dizzying, dazzling critique of the biomedical disease model of depression. It is probably the most thoughtful book on depression ever written for a lay audience.