And then there were pills. Like many discoveries in the history of psychopharmacology, antidepressants became antidepressants quite by accident. The earliest prototypes were developed as tuberculosis drugs in the United States in the early 1950s. They weren’t particularly effective at treating TB, but, doctors observed, they bestowed on certain recipients a conspicuous boost in mood. Patients who received them at one hospital in Staten Island were described as “dancing in the halls” of their ward. Why not, then, try the pills out on a class of patients who had confounded doctors since time immemorial? That would be the sad ones. The hopeless ones. The ones who said they felt no pleasure, just “emptiness.” The ones who couldn’t necessarily explain why.
By the late 1950s, though these first-generation antidepressants were becoming more widely prescribed, psychoanalysis still dominated American psychiatry, and pills were a controversial choice for an illness with obvious psychological features. A famous case turned on this dispute: that of Rafael Osheroff, a doctor, who, suffering from depression, checked into Chestnut Lodge, a psychoanalytically oriented hospital. His doctors there denied him medication, believing pills would simply mask his illness and that only talk therapy could address depression. Osheroff became more and more debilitated. At last, he switched to a different hospital, was prescribed pills, got better, and sued Chestnut Lodge, successfully.
Other doctors, like the psychiatrist Nathan Kline, had been searching for something exactly like what the new pills seemed to offer: what Kline called a “psychic energizer.” Kline, from his office in midtown Manhattan, was, by the 1970s, enthusiastically prescribing, perhaps to as many as five thousand patients. At least one of his patients wasn’t helped by the new treatment for his old disease. Mark Rothko, painter and depressive, committed suicide while under the care of Kline, who did little but prescribe the newfangled medication that Rothko had hoped would finally provide the elusive cure.
These new pills would soon be joined by the later pills, the updated pills, the pills that defined an era. When Prozac came out in 1987, it caught the cultural imagination in a way that the earlier antidepressants hadn’t. “I can’t escape the icky feeling I get every time I’m sitting in a full car and everyone but the driver is on Prozac,” writes Elizabeth Wurtzel in Prozac Nation, published in 1994. Now, it’s more likely that the driver, too, would have a prescription. Between 1988 and 2008, rates of antidepressant use in the United States increased by almost 500 percent, according to the National Center for Health Statistics. Prozac worked in a new way—by altering the level of serotonin in the brain—and inspired a new theory of what caused depression, leading to an increased diagnosis of the condition. With the drug’s apparent success, it became common to define depression as a “chemical imbalance,” specifically, one involving too little serotonin. The biological model had triumphed. All across America, doctors scribbled on their prescription pads; Freud was duly pronounced dead, yet again. Who needed to hear about unconscious conflicts, about “anger turned inward,” now that we could simply swallow our pills?
This is the familiar arc that Jonathan Sadowsky traces in his new book The Empire of Depression: A New History. But Sadowsky, a medical historian at Case Western, aims to show how the Western notion of depression is making its way around the globe, threatening to displace other conceptions of the disease. “Western psychiatry often treats anxiety and depression as separate things that often occur together. In many places, though, anxiety and depression are seen as part of one thing,” he writes. And the sense of what causes depression differs significantly, too. Whereas in the West, depression is most often understood as having a physical reason, be it genes, or chemistry, “globally, it is more common to consider depression to be at once psychological, social, and physical.”
The Western model even threatens to stomp out others’ subjective experiences. Sadowsky points to the Punjabi idiom, “sinking heart,” a condition which overlaps with depression, but is not quite identical to it. “Sinking heart” includes unhappiness, yes, but as well, faintness, dry mouth, and trouble breathing. It “manifests in the chest.” “If you simply call it depression, you lose aspects of how Punjabis see the problem.” Sadowsky warns of the potential losses that could come from imposing one monolithic vision of depression as universal. And besides, as he persuasively illustrates, the shine has begun to come off the purely biological story as it has become clear that antidepressants, while helpful, are not a definitive cure. We still do not understand what causes depression. “A depression illness narrative will always have some chaos to it, because any reflection on the causes will leave the sick person stuck in the swamps of the unsettled science,” he writes.
Sadowsky’s project is to illuminate the thorny problem of depression and the persistent questions still attached to it. Anyone who steps into this space is instantly wrestling with the shadow of Andrew Solomon’s definitive work, The Noonday Demon: An Atlas of Depression, which, though it was published in 2001, remains at once as authoritative and poetic as it did twenty years ago. Indeed, when reading about depression, one somehow wants more than what Sadowsky offers, something that touches the texture of life itself. But he is an able writer and a careful thinker, as he considers some of the most important questions about depression, past and present.
One complex problem for doctors and patients alike has long been: When is sorrow sickness? In the West, Sadowsky says, there is a preoccupation with “proportionality.” Do life’s hardships justify the extent of one’s sadness? Of the many ambiguities surrounding depression: it is both a mood state that nearly everyone passes through in the course of a single day, and a disease that separates its sufferers out from the rest, designates them as having too much, without “enough” reason. In The Noonday Demon, Andrew Solomon pointed to the delicacy of these boundaries. “The present tense of mild depression envisages no alleviation because it feels like knowledge,” he writes.
Sadowsky stresses that the decision of how and who to diagnose has been a source of debate for millennia. Before there was the crisply clinical sounding Major Depressive Disorder, there were other names, other stories. There was acedia, a term used by fourth- and fifth-century monks to capture the particular downbeat listlessness of their monastery-bound lives. There was neurasthenia, invented around the turn of the nineteenth century by the neurologist George Beard, to describe the shock of modernity. There was dysthymia, to talk about mild depression. Before any of the rest, there was melancholia, originally explained as caused by its own kind of “chemical imbalance”: too much black bile.
The inquiry “When is sorrow sickness?” hits differently now, in the plague winter of 2021, when it can be difficult to steer oneself through the day on the best of days, when so many are struggling with unemployment, loss of loved ones, and social isolation. By February, two in five Americans were reporting symptoms of anxiety and depression, a significant rise from the year before. Yet the sorrow is nothing new: the World Health Organization estimates that 300 million people are affected by depression, a figure which soared 18 percent in the decade between 2005 and 2015. Sadowsky asks why. What is accounting for this worldwide colonization by depression diagnosis? Are we detecting new cases where we weren’t sensitized enough to see illness before? Are we calling more things depression? Or are we just more depressed? For his part, Sadowsky takes the position that it is unlikely that more of us are more miserable than we ever used to be. “While the world we live in is upsetting, it is not obviously more fertile for mental illness than the world of the first half of the twentieth century,” he writes.
Sadowsky’s text is, in fact, a counterargument to the idea of depression as something uniquely modern and uniquely Western. As he shows, depression as an exclusively Western phenomenon has a frankly racist and imperialist history. During the Atlantic slave trade, captors observed a “severe melancholy” among the enslaved, an observation which ran counter to the stereotype of “carefree Black people, immune from melancholy and mental illness.” That stereotype served to dehumanize the enslaved and perpetuate the new economic system based on their exploitation: “Depression, these observers thought, was not just an illness, but a capacity held by more civilized people.”
Even centuries later, that kind of racist apportioning persisted. In the twentieth century, depression was a “quiet” diagnosis often reserved for white patients. When the jazz musician Charles Mingus was admitted to psychiatric care in 1958, he was initially thought to have paranoid schizophrenia, a diagnosis disproportionally given to Black men, especially those with “social grievances,” as the psychiatrist Jonathan Metzl has shown in his own work. To this day, Black patients are less likely to get prescribed antidepressants than white patients whose depression is equally severe. For the poor and the marginalized, “depression has a politics,” Sadowsky writes, “a politics of inequality.” He is critical of the so-called “happiness industry,” a movement that has produced such arguments as the one encapsulated in a 2015 New York Times column by Arthur C. Brooks: that practicing gratitude is the key to promoting personal happiness. Sadowsky coolly points out that “Brooks was the president of the American Enterprise Institute for nine years. The Institute is a right-wing think tank, generally opposed to government programs that help the poor. This seems relevant. Let them eat gratitude.”
Is depression a quirk of brain chemistry or a response to life’s circumstances? Is it a pointless debilitation, or, as Carl Jung believed, purposeful pain, the psyche’s way of flagging trouble? Who deserves the label, and who gets shut out from compassionate care? The Western vision of depression is a conflicted one that seems to have abstained from answering these deeper questions. On the one hand, the disease is an individual problem that one has cheer oneself out of; on the other, it’s a biological malady that only big pharma can address. Sadowsky warns that much will be lost if the world adopts our paradoxical view of this serious disease.
Casey Schwartz is the author most recently of Attention: A Love Story.
