Tuesday, 13 August 2013

A plague of depression or sadness rebranded - what's the truth about capitalism and mental illness?

An essay, published a couple of weeks ago by the novelist Will Self, caught my eye because it embodies an interesting conflict between two differing left-wing critiques of corporate capitalism. They appear to be making diametrically opposite points yet both stem from an anti-capitalist viewpoint, or at least display a healthy scepticism towards the “truths” of our corporate society.

Self, who has previously been a psychiatric patient, was concerned to take on the psychiatric profession and  (as the stand-first puts it) its “disease mongering”. Unable to cure severe mental pathologies, Self argues, psychiatry has instead turned to treating “less marked psychic distress”. Aided and abetted at every stage by pharmaceutical companies, doctors now create diseases to fit the drugs available. What used to be ordinary sadness has been rebranded as depression, an illness that can conveniently be combated by the prescribing of anti-depressants  - a dispensing of billions of pills to correct an alleged chemical imbalance in the brain that coincidentally makes fantastic profits for big pharma.

“The sad are becoming oddly co-morbid (afflicted with the same sorts of diseases) with the mad,” writes Self.

Selfish capitalism and it discontents

Contrast this with the claim by Mark Fisher, author of Capitalist Realism, that neo-liberal capitalism is generating a “mental health plague”. Depression is now the condition most treated by the National Health Service in Britain, says Fisher. According to clinical psychologist Oliver James the “selfish capitalism” of Anglo-Saxon societies is causing an acute intensification of emotional distress ; an epidemic of depression, anxiety, substance abuse and personality disorder. James cites World Health Organization surveys: 26% of Americans experience an episode of “mental distress” every year. In Britain, the number is one person in five.

Here is James speaking:

So one side identifies a contagion of mental illness, while the other says it’s all a plot to uphold the prestige of psychiatry and supply pharma corporations with a steady profit stream. Who’s right?

At the risk of being diagnosed with an incurable case of fence sitting, it seems to me that both of these positions, on the surface utterly incompatible, may be true.

Depression x 1000

There is undoubted evidence for the veracity of what Self is saying. The arrival of Prozac and other SSRIs in the late 1980s coincided with a thousand-fold increase in the diagnosis of depression. It would be extremely difficult to honestly argue this had nothing to do with efforts of drug companies to market anti-depressants. And this initial anti-depressant spurt has since become a biblical flood. In 2011, 46.7 million prescriptions were written for anti-depressants by the National Health Service in England, an increase of 9.1% on the previous year, and an avalanche of pills compared to the 9 million prescriptions signed off in 1991.  But though “psychic distress” - to use Self’s term - has clearly been turned into chemically treatable depression, that doesn’t mean the distress was a fiction, or that the distress hasn’t increased, or that it was simply sadness given a medical name. There is, it seems to me, a large space between sadness and full blown mental illness. And a lot has been happening, in the last twenty or thirty years, in that space.

Ordinary and extraordinary sadness

Self himself makes the distinction. “But what has made it possible for someone recently bereaved or unemployed,” he asserts, “to have a prescription written by their doctor to alleviate their ‘depression’ is, I would argue, very much to do with psychiatry’s search for new worlds to conquer, an expedition that has been financed at every step by big pharma.”

Bereavement and unemployment are, I would argue, two completely different states. Bereavement is ordinary, though it doesn’t feel ordinary, sadness. It’s impossible to go through life and not be bereaved and feel its emotional effects. Unemployment is, by contrast, very much a socially constructed state. In the first place, unemployment has only been around for 200 years or so. Secondly, it’s much more acute now than it was forty years ago (from 1950 to 1973, UK unemployment averaged 1.6%). Lastly, its effects on an individual depend very much on how society treats it. Post-capitalist economists such as Richard Wolff and David Schweickart have argued that, in a more humane society, people that have to be laid off by enterprises would automatically be offered jobs or training elsewhere. This is everyday practice now in the Mondragon federation of worker co-operatives, comprising 256 companies employing 83,000 people, located in Northern Spain.

By contrast, what British society does is to make unemployment the personal responsibility of the person who is unemployed. Unemployment – a social problem if ever there was one - becomes an individual problem. The result is self-blame and, in a society that is intensely comparative, all the ingredients for mental distress, not just sadness, are laid. It is interesting that the root causes of the emotional distress identified by Oliver James in 2008’s The Selfish Capitalist (a book written before the financial crisis) – stagnating real wages, the growth of short-term, service industry jobs (see the rise of zero-hours contracts) and an exaltation of the consumer habits of the rich – have only become more prevalent. So why shouldn’t mental anguish have got worse?

Diseases, disorders and effects

The key to understanding what has happened, I think, is to separate social effects from their pathologisation, the turning of states of mind and behaviour into a “disease” which can then be treated by drugs. This pathologisation may be entirely unjustified, just suiting the need of pharma companies to make lots of money from selling pills, and indeed the pills may not actually work (Self says that the chemical imbalance theory of depression, on which SSRIs are based, is “essentially bunk” – he may be right, I don’t know) But all that doesn’t mean the social effects are not real. “The vast number of ‘hyperactive’ children in the US prescribed Ritalin is so well attested that it’s become a trope in popular culture,” writes Self. True, but I’m not convinced that labeling trends as a medical disorder, means that the trends themselves – difficulty in concentrating and impulsive behaviour in this case – are not genuine. Likewise, I don’t believe that the rise in mental distress is a myth.

Valium nation

To take a historical example, millions of prescriptions were written for the tranquilizer, Valium, a predecessor of anti-depressants, in the 1960s and 1970s. The drug quickly gained a reputation for being “the housewives’ choice”. It provided a release from the psychic consequences of an extremely restricted life. The problems for these women were pathologised and the symptoms they suffered from chemically anesthetized. But that didn’t imply that the underlying issues – a life limited to motherhood and caring and confined to the home – didn’t exist, or that doctors somehow created them, as most people, now the vast majority of women go out to work, would recognise. Why can’t the same be said for anti-depressants?

The book, The Spirit Level, provides persuasive evidence that Anglo-American societies have become more anxious, if not more depressed. The authors cite the work of American psychologist, Jean Twenge, who looked at 269 studies measuring anxiety in the US from 1952 to 1993. She found a continuous upward trend. By the late 1980s, the average American child was more anxious than child psychiatric patients in the 1950s. Anxiety, as far as I understand, is related to depression, though not as extreme. You can’t explain away these findings by saying it’s all down to doctors, egged on by pharma companies, discovering anxiety where previously it didn’t exist. Prozac was first released in 1988, just five years before the period of study ended.

I’ve little doubt that Self is right and psychiatry and big pharma, have, for different reasons, created diseases and pathologised distress. But that is only half the story.


  1. "Self says that the chemical imbalance theory of depression, on which SSRIs are based, is “essentially bunk” – he may be right, I don’t know"

    My chip-in on this point:
    There are certain cases where the imbalance theory is woefully inadequate, and cases where it is quite useful and predictive. That means that it should really be thought of as one part of a larger theory which remains unexpressed at the moment.

    I know it's a minor point, but I do like to note that psychiatry is still in its infancy, and is not at all helped by having to fight with economics. Imagine if physics had rich backers trying to make sure we believed in heliocentrism, and you get an idea of how awful it is.


    1. Yes I'm not equipped to judge on this point. I would say, though, that if what you say is right - chemical imbalance theory works in some cases but not in others, a large chunk of the money the NHS spends on anti-depressants, - at least £640m a year according to my calculations - is essentially wasted, and could be detrimental to patients. And people complain about public money wasted on homeopathy

  2. Related to this, I found a very interesting article from the New York Times about depression is being "overdiagnosed on a remarkable scale"

    But the article - in line with what I was arguing in the above post - does not say that those diagnosed with depression had no mental health issues, merely that they did conform to the criteria for labelling them 'depressed' and therefore suitable cases to be treated with pharma company pills

  3. Good, lucid piece. And generally a well-written and well-read blog. I personally am trying to shift to positive action and reflect on alternatives to what I agree is a crumbling inhumane system. Not an easy task of course.

    1. Thanks, and I agree it's not an easy task. While you desperately need the appreciation than an alternative is necessary and conceivable, so much energy has to go on defending what you already have against multiple onslaughts