Following her second appearance at the Democratic debates this summer, author and Presidential hopeful Marianne Williamson faced scrutiny for past comments regarding depression and the use of antidepressant medications. In a July interview on CNN, Anderson Cooper criticized Williamson for indicating that the distinction between clinical depression and sadness is defined arbitrarily and for implying that antidepressant medications produce a numbing effect. He pointed towards past tweets, including one from November of 2018, in which Williamson seemed to question the medical basis for depression diagnoses: “There is a blood test for diabetes. There is no blood test for depression. Anti-depressants [sic] are overprescribed…”
This summer, I was heartened to see Williamson’s arguments widely condemned as inaccurate and harmful. I applauded the dismissal of her fallacious claim that antidepressant drugs are linked to violence or “numb” individuals using them. However, there was something about the backlash which left me wary. An underlying assumption of many dismissals seemed to be that depression is solely and inherently a medical problem. Williamson’s comments about depression were in some response articles placed alongside a list of her “anti-medicine” and “anti-science” comments. A friend I spoke with about Williamson’s comments insisted that what she said was dangerous because it equated depression, which originates from issues within the brain, with sadness, which primarily arises from external forces. This assumption was perhaps most clearly demonstrated by Anderson Cooper who said during the interview: “Clinically depressed people aren’t depressed because the world is depressing, they’re depressed because they have a chemical imbalance.”
In the United States, depression is often understood as a product of brain pathology. It is common to hear depression explained as a “chemical imbalance” in the brain or likened to other medical diseases. For example, the nation’s largest mental health organization, the National Alliance on Mental Illness, has recommended that individuals fight the stigma associated with depression by emphasizing the similarities between physical disease and mental illness.
And even though most will acknowledge that depression is far more complex, this framing does not only affects the way we talk about depression. At the federal level, efforts to fight rising rates of depression tend to focus on the brain. Shortly before the publication of the most recent edition of the DSM, a guide used for the diagnosis of psychiatric disorders, the director of the federally-funded National Institute on Mental Health (NIMH) criticized the guide for not basing diagnoses on laboratory measures. In response, the NIMH developed the Research Domain Criteria Project (RDoc), a new framework for diagnostic models and research built on the assumption that mental illnesses like depression are fundamentally “biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior.”
Yet with depression rates rapidly rising in the United States, there is reason to turn a more critical eye towards the way we speak about, and conceptualize of, depression. As considerable historical and sociological scholarship indicates, the medicalization of depression has a long political history which cannot be disentangled from the emergence of industrial capitalism and the growth of the pharmaceutical industry. Moreover, an individual, medicalized conception of depression obfuscates how material conditions contribute to widespread suffering and rising rates of depression. We must shift from viewing depression exclusively as a problem of the individual brain, and instead embrace depression as a political issue—one that necessitates immense material change to be addressed.
In 2001, a series of commercials for the antidepressant drug Zoloft first appeared on televisions across the United States. Each ad featured a cute, squishy blob with a cartoonish frown and a looming cloud above it. As the blob slouched onto the screen, a voiceover rattled off the symptoms of “depression, a serious medical condition affecting over 20 million Americans.”
Then, a cartoon image of two neurotransmitters appeared with a sluggish stream of dots bouncing back and forth between them. “While the causes are unknown, depression may be related to an imbalance of natural chemicals between nerve cells in the brain,” the voiceover continued. The Zoloft logo flashed above the neurotransmitters and the dots began to flow more freely. The little blob’s face became a beaming smile.
The story of the development of this particular, medicalized view of depression is one of political and economic transformation during the 20th century. The medicalization of depression aligned with the interests of capital, which both covertly and overtly supported the medicalization process. This becomes apparent when looking at two instances in America’s psychopharmaceutical history: the institutionalization of psychiatry and the advent of modern antidepressants.
In the 2018 Jacobin magazine article “Medicalizing Society,” Zola Carr points to events of the early 20th century as laying the groundwork for the medicalization of depression. The article explains that in the decades following the Civil War, the rise of industrial capitalism and increasingly brutal conditions for American workers triggered a wave of working class militancy.
Progressive Era liberal reformers developed a new political vision for rectifying the unrest associated with industrial capitalism. Carr writes that reformers “offered a prescription of harmonious social integration” in which society existed as one integrated organism. This necessitated the “emotional adjustment” and “mental health” of the individual. The desires of capitalists to quell brewing working class radicalism, and the Progressive vision of social integration, meshed well with the incipient field of psychiatry. Early psychiatrists promised to help individuals adjust to their environments.
Leading industrialists provided a significant influx of cash for aspiring psychiatric foundations and psychiatrists, who in turn diagnosed labor discontents as not the product of material conditions, but of individual pathology. According to Carr, “the problems the new psychiatry aimed to solve were a medicalized gloss on the political problems of society itself.”
Just over forty years later, researchers at the pharmaceutical company Eli Lilly began exploring a potential link between increased levels of the neurotransmitter serotonin and alleviated depressive symptoms. After over a decade of research and testing, Eli Lilly developed the drug fluoxetine hydrochloride which promised to treat depression by regulating the brain’s reuptake of serotonin. The drug was approved by the FDA and in January of 1988, Prozac was available for prescription.
The drug experienced a meteoric rise and quickly became the most popular antidepressant ever released. By 1995, 15 million people worldwide were prescribed Prozac, and Eli Lilly netted over two billion dollars in profits from its sales. It introduced an entirely new class of psychopharmaceuticals, known as selective-serotonin reuptake inhibitors (SSRIs), appearing for consumers as Paxil, Celexa, and Zoloft, among others.
The success of SSRIs, however, was not always certain. In their history of the drug’s development, Eli Lilly researchers explained that they believed the market for antidepressant drugs was already at its saturation point and that Prozac would have only limited success. Indeed, by the late 1980s, there was considerable skepticism towards psychiatry. This was in part as a result of an anti-psychiatry backlash in the 1970s and 1980s, in which leftists argued that psychiatric medicine was a tool wielded to enforce psychological conformity and stifle individuality. Furthermore, there was particular concern about the over-prescription of psychopharmaceutical drugs to women. Throughout the 1950s and 1960s, antidepressant drug prescriptions primarily consisted of tranquilizers like Valium and Librium and, throughout the 1980s, spates of publicized addiction stories appeared in the media. “Innocent Addicts: Women Hooked on Prescription Drugs,” headlined one Women’s Day article in 1984. Exemplified by First Lady Betty Ford’s admission to a rehabilitation center for alcoholism and tranquilizer addiction, it became clear that many middle and upper-middle class white women were addicted to these drugs. The prescription rate for tranquilizers began to decline. Pharmaceutical companies intending to market SSRIs needed to ease public apprehension towards psychopharmaceutical drugs.
In response, they adopted a marketing strategy directed at both physicians and consumers which emphasized a neurological basis for depression. As David Herzberg explains in Happy Pills in America: From Miltown to Prozac: “Responding to fears of addiction and oppression, both biological psychiatrists and drug marketers produced a vision of technologically crafted drugs emerging from newly sophisticated brain sciences.” Thus, if depression was caused by a chemical imbalance in the brain, as advertisements would indicate, SSRIs could work with precision and address the disease at its root cause, rather than merely lulling sufferers into a haze.
Many SSRI advertisements throughout the 1990s and 2000s emphasized the biological nature of depression, putting forward versions of the “chemical imbalance” narrative that we recognize today. Zoloft magazine ads depicted cartoonish neurotransmitters, demonstrating how depression constituted a sluggish flow of serotonin. “Celexa helps restore the brain’s chemical balance by increasing the supply of a chemical messenger in the brain called serotonin,” wrote Forest Pharmaceuticals in a published FAQ about the SSRI.
Rather than offering a comprehensive history of the medicalization of depression, examining the institutionalization of psychiatry during the Gilded Age and the history of Zoloft demonstrates that understanding depression as a problem of the individual brain was not a product of scientific development alone. Instead, economic interests stood to directly benefit from a medicalized view of depression taking hold and worked to introduce such a view into the American mainstream.
Yet even if tracing the origins of a medicalized conception of depression requires looking at the role of economic interests, is there still reason to reject such an understanding? I long believed that describing depression in medical terms was important for fighting it, on the basis that doing so would reduce stigma. Yet by ignoring social and material causation, a medicalized conception of depression fails to grapple with the conditions that may generate it on such a significant scale.
Depression rates are rapidly rising in the United States. The increase is particularly acute among young people—a recent study found that over the last decade the rate of depression among teenagers increased by an astonishing 60 percent. If one believes, as Anderson Cooper stated in his interview, that “people aren’t depressed because the world is depressing,” one fails to grapple with the vast array of material factors contributing to these trends.
It is not difficult to develop a (far from exhaustive) list of examples of non-medical causes of depression generated by our current political and economic system. The link between poverty and a higher prevalence of depression is well-established, for example, yet routinely ignored when depression is understood in purely medical terms. Chronic stress and early traumatic life events (both in themselves linked with economic precarity and material deprivation) are associated with depression. Furthermore, it is not hard to imagine how the increasing drive towards atomization and competition which characterizes the neoliberal ethos may be linked to psychological pain. Many young people report intense loneliness—a 2018 survey found that over 20 percent of young adults always or often felt lonely.
And even ignoring for a moment the potential causes of depression, mental health care for individuals who are suffering from depression is, in itself, abysmal. The National Alliance on Mental Illness found that people in the midst of a mental health crisis are more likely to make contact with the police than to receive care. Austerity measures have left social services, including those providing mental health care, severely underfunded.
Less than a year ago, when I encountered the notion that depression should not be understood in solely medical terms, I found such a claim frustrating. I thought emphasizing the biological nature of depression reduced stigma and I refused to entertain the notion that most cases of depression were not caused by forces within the individual brain. In my mind, critics of a medicalized view of depression were those harboring stigma towards individuals with depression, parents refusing to vaccinate their children, climate change deniers, and essential oil peddlers.
Beyond that, the notion of a “chemical imbalance” in the brain seemed a comforting notion to me while I weathered my own bouts of depression. I was cripplingly sad, I reasoned, because of a crude biological destiny—my brain was wired for it. I quietly feared that looking for a culprit that was not serotonin would inevitably lead me to my own weakness. There was a strange comfort in the inevitability of my own pain.
I found an alternative in the writings of Mark Fisher, a writer and political leftist who struggled with depression throughout his entire life. In his Capitalist Realism, Fisher wrote:
“Instead of treating it as incumbent on individuals to resolve their own psychological distress, instead, that is, of accepting the vast privatization of stress that has taken place over the last thirty years, we need to ask: how has it become acceptable that so many people, and especially so many young people, are ill?””
Fisher calls not for the assumption that neurochemistry plays no role in depression, but instead emphasizes that its long-neglected social and material causation must be brought to the fore. He insists that we must view depression as a political issue, one demanding the extirpation of the conditions which generate widespread pain.
Of course, it would be absurd to argue that there is no biological causation for depression. According to Harvard Health, “There are many possible causes of depression, including faulty mood regulation by the brain, genetic vulnerability, stressful life events, medications, and medical problems. It’s believed that several of these forces interact to bring on depression.” Individuals with depression should not be dissuaded from seeking out all forms of help available to them, and antidepressant medications have proven to be greatly successful in helping those suffering with depression.
But we should not by default think of depression in medical terms that obfuscate its material causes. High rates of depression are not a biological inevitability—staggering numbers of young people do not need to be depressed. Rather than turning our attention to the individual brain and investing millions in technology to understand the biological basis for depression, we must turn our gaze outward.
The existence of widespread depression cannot be meaningfully challenged outside of the realm of politics—combating depression requires changing the material conditions which leave people chronically stressed, lonely, and alienated.
We must politicize depression.
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