Manufacturing Depression (The Secret History of a Modern Disease) - Gary Greenberg

Despite the author's claim that the book deals in doubt & uncertainty, this is a determined polemic against the definition of depression as an illness that can be treated without taking account of the patient's inner life - "the pathologising of emotion for profit", as one reviewer describes it. This is a definition that needs to be examined because it is "an idea about our suffering, its source, and its relief, about who we are that we suffer this way and who we will be when we are cured."

In one of his frequent historical digressions, Greenberg states that in 1850, "to the extent that physicians were successful they relied not on knowledge of how their remedies acted biochemically to cure a disease but on luck, on trial and error and, perhaps above all else, on the placebo effect." Much of the rest of the book is devoted to demonstrating that in the case of depression, this is still accurate today. He does, however, make the interesting point that "a good working definition of disease" might be "not a condition with a specific biochemical cause, but a form of suffering that a particular society deems worthy of devoting health care resources to relieving" - in which case depression does qualify...

Much of the book is devoted to accumulating evidence against the idea that depression is a well-understood biologically-based illness which modern anti-depressants are able to cure by targeted action within the brain. The current diagnostic model of checklists and questionnaires as laid out in the psychiatric profession's manual was described (by an insider) as having "100 percent reliability but zero validity" - in other words, it accurately describes a set of symptoms, but provides no evidence that they correspond to / are caused by a single coherent disease, and confusion still reigns about the causes of depression and the mechanism(s) by which antidepressants have their effects. An interesting point about the ineffectiveness of antidepressants is that US law permits drug approval based on "substantial evidence" rather than the "preponderance of evidence" - so one study showing a drug's efficacy is enough even if many other studies suggest otherwise...

I was particularly interested in the chapter on cognitive therapy, in which Greenberg attends a course run by Aaron Beck's daughter Judy, and concludes that the approach's open intent to persuade the patient to "embrace the model" is one of the keys to its success as it explicitly harnesses the placebo effect (which Greenberg sees as a positive and valid therapeutic tool, resulting from "a patient's entering into a caring relationship with a healer"). He quotes some research to support this theory: Luborsky's confirmation of Rosenzweig's finding that "all must have prizes"; analyses of cognitive therapy trials that point out limitations such as the unreality of the control treatments or the failure to count drop-outs as failures; and Jacobson & Dobson's attempt to examine the effects of independent components of Beck's manual, which found no difference between complete or partial implementations of it.

Ultimately, Greenberg rejects the medicalisation of depression, and it's hard to disagree with the conclusion he draws from his own experiences of emerging from bleak periods (once through experiencing deep love while taking Ecstacy, once through building a house) that "the redemption of despair lies in involvement in the world and engagement with others - to put it briefly, in love".