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.
"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"
ReplyDeleteMy 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.
DeleteYes 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
Related to this, I found a very interesting article from the New York Times about depression is being "overdiagnosed on a remarkable scale"
ReplyDeletehttp://well.blogs.nytimes.com/2013/08/12/a-glut-of-antidepressants/?ref=ronicarynrabin&_r=1
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
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.
ReplyDeleteThanks, 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
Delete