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How Depression Went Mainstream: Interview with Dr. Edward Shorter

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Every year, more and more Americans are treated for complaints of depression and often do not derive relief from treatment for their symptoms that may include anxiety, fatigue, poor sleep, and physical problems.

According to acclaimed historian of psychiatry, Dr. Edward Shorter, the diagnosis of depression has increased steadily over the past forty years and, during our lifetimes, “one American in five will receive a diagnosis of depression.” That’s more than sixty million people.

In Dr. Shorter’s view, the over diagnosis, misdiagnosis and inappropriate treatment of depression is “a public health disaster.” In his new book, How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown (Oxford University Press), Dr. Shorter traces the history of the depression diagnosis over the past two centuries. He contends that most people who complain of depression do not have a mood disorder and are not “depressed.” Instead, he urges that they are “nervous” and, when they lose control, they suffer “nervous breakdowns” -- conditions described by pre-Freudian, biological psychiatrists in the nineteenth century.

Dr. Shorter cautions that today mental illness is often misdiagnosed and inappropriately treated with Prozac-style medication and other drugs. He blames much of the mistreatment on psychiatry’s abdication to the pharmaceutical industry leading to denial of proper treatment of misdiagnosed patients. Further, he attacks the official bible of psychiatric diagnosis, the Diagnostic and Statistical Manual [DSM], because its definitions of depression and other maladies, in his view, are not based on sound scientific findings.

Dr. Shorter’s provocative book has been praised for its lively review of history, thoughtful analysis, extensive research, and compelling narrative. Bernard Carroll, MBBS, PhD, FRCP, Pacific Behavioral Research Foundation, commented: "In this new survey of "nerves" Shorter recounts the shifting meanings and fashions over the ages concerning breakdowns, crackups, depression, anxiety, stress - what average persons thought ailed them and what the professionals thought. Labels come and go. Classifications come and go. Clear understanding waxes and wanes. Diagnostic boundaries come and go. Treatments come and go. Hard won insights are lost and rediscovered. Shorter brings it all alive with graphic historical and contemporary material. With his polyglot command of the European literature, there is no one better for the task. Through it all, Shorter keeps his focus firmly on the issues that matter to patients. This is a tale for everyone, not just the academics."

And Tom G. Bolwig, MD, DMSc, Professor of Psychiatry, University of Copenhagen, wrote of How Everyone Became Depressed: "Thoroughly and elegantly the reader is guided through centuries of ideas and concepts [and] Shorter's criticism of contemporary views on 'nerves' and 'depression' are sharp, but well-founded. This fine book deserves a wide readership - it should be mandatory reading for all professions working in mental health care."

Dr. Shorter, PhD, FRSC, is the Jason A. Hannah Professor in the History of Medicine and a Professor of Psychiatry in the Faculty of Medicine, University of Toronto. An internationally recognized as a historian of psychiatry, his books on the discipline include A History of Psychiatry; A Historical Dictionary of Psychiatry; Shock Therapy; and Before Prozac (2009). He has also published widely on the social history of medicine with histories of obstetrics and gynecology (Women’s Bodies), the doctor-patient relationship (Doctors and Their Patients), psychosomatic illness (From Paralysis to Fatigue), and sexuality (Written in the Flesh: A History of Desire). 

Dr. Shorter graciously spoke about his work and his new book by telephone from his office at the University of Toronto.

* * * * *

Robin Lindley: You’re a renowned historian of psychiatry. When you were a little boy, did you want to be a historian or a doctor?

Dr. Edward Shorter: I was interested in medicine and pharmacology ever since I worked as a high school student in a drugstore. But then I had an unfortunate encounter in an interview with my college advisor when I started college. He asked what I wanted to study, and I said I was thinking about medicine, and he said, “That must mean you’re very interested in physics and mathematics.” Of course, I wasn’t interested in physics and mathematics at all. I told him that, and he said [medicine] “is not a career for you then,” as though somehow a knowledge of physics and mathematics are important to the practice of medicine, which is certainly not the case. He was an economist.

On the basis of this erroneous advice of my advisor, I decided to renounce the study of medicine and went on to gain a Ph.D. in history.

Much later, after I came to Toronto, I decided I’m not giving up that easily, so I went to medical school for two years. I took all of the basic medical science courses and passed all of the exams and gained the basic knowledge of medical sciences that any physician would have.

What was you dissertation on for your doctorate in history?

My dissertation was on another subject and had nothing to do with medicine. It was implanted firmly in central European history. I did my dissertation on Bavaria in the early years of the nineteenth century and it gave me a feeling for what living in a traditional society was like before the advent of modern liberal thinking.

That was very valuable, and I’ve come back to touch on those insights in time and again in subsequent years. I was interviewed on Japanese television the other day and was asked if there was an increase in mental illness as the result of the transition to modern society. The Japanese are very alarmed by what they perceive as an increase of mental illness in their own society. And I said the rules of a traditional society are very different where community values trump individual values, and so forth. And I became very aware of this when I studied German history in the remote period. So even though I didn’t come back to that professionally, those insights remained, of course.

And you began your work in medical history with a book on women’s health?

Yes, that was my first book on medical history.

You went on to specialize in the history of psychiatry. What prompted your interest in psychiatry?

Obstetrics lends itself poorly to the study of the interaction between society and individuals, but psychiatry is much better because so much of the way people perceive their illnesses and the way physicians diagnose them is influenced by the surrounding society. Unlike [a discipline such as] cardiology, psychiatry is a subject that has an enormous amount of social weight on it. It took me a bit to arrive at that realization, but I did and since then the study of psychiatry and psychopharmacology has been enormously gratifying for me.

You’re a celebrated historian of psychiatry and you’ve written a magisterial history of psychiatry as well as books on the history of electroconvulsive therapy and your new book on depression and others. You actually make conclusions about the efficacy of treatment. How does your approach as a historian of psychiatry differ from that of a clinician in psychiatry?

Historians are well situated to appreciate how fragile current diagnoses are because you can see, over a long period, what psychiatry has considered to be the main diseases and also you get a sense over the centuries of the treatments that actually worked and were effective.

By contrast, you look at what’s happening in psychiatry today, and many of the diagnoses were created out of whole cloth in 1980 with the famous DSM III [Diagnostic and Statistical Manual III, meaning third edition].

I went back through the archives of the American Psychiatric Association, and looked at all the correspondence surrounding the DSM III. I was just amazed at how unscientific they were. The ideas were based on consensus, which implicitly is unscientific. Also, the whim of one man, Robert Spitzer, played an overpowering role in the creation of diagnoses such as bipolar disorder and major depression.

Over the years, psychiatry has gained an enormously powerful sense of what real illness is, and the DSM III flew in the face of that consensus. Major depression, for example -- which is probably the most popular diagnosis in the DSM III -- was simply put together by collapsing two very different depressive illnesses psychiatry always recognized: melancholic illness and non-melancholic illness. There is a lot of scientific evidence to back up that differentiation.

They flicked this aside in 1980, and said one kind of depression is the same as any other, so why make this distinction? It was a completely arbitrary, ruthless way of coming up with a diagnostic category. We’re paying the price for that today.

This is a concrete illustration of how knowledge of the history of something like diagnosis can give us an effective critique of current concepts.

Have you noticed any difference in the response to your work from historians versus psychiatrists?

Psychiatrists are very interested in the historical perspectives because they can see the obvious power that an understanding of history brings to appreciating the current situation.

Historians haven’t been so interested. Psychiatrists are centered on diagnosis and treatment, and those are the two aspects that are central to the practice of medicine.

Historians aren’t as interested because they aren’t intellectually equipped to study that kind of thing. Most of them don’t have a scientific background. They can’t get into detailed discussions of therapies because they aren’t well informed about the science, so they study such subjects as psychiatry’s attitude toward women or how is knowledge diffused in medicine -- by conferences or by medical journals? These questions are marginal but they are the kind of questions that animate the discipline.

What is needed in the discipline of the history of psychiatry is for more historians to do what I did: go to medical school and gain an understanding of the science that underpins the discipline so they can answer the really interesting questions.

I’m seldom invited to history meetings, whereas I’m widely invited to medical meetings.

I think historians have a lot to learn from the kind of history you write. I’ve audited courses on the history of science and medicine, and I hope we see more dialog between historians and those who study science and medicine.

I hope so too given that this is how I make my living but, at the moment, the trend is going in the opposite direction. The trend is not toward the study of science but “scientism” or pseudo-science, and to see how famous discoveries were really accomplished by sexist and ageist ways of thinking, and the whole line of investigation is of no interest at all to anyone outside the narrow corridors of the history of science departments, and almost certainly will not survive the test of time.

By contrast, what I do is of interest to wide circles of individuals.

Your book Shock Therapy on the history of electroconvulsive therapy (ECT) must have been surprising to many readers. ECT still probably has a tarnished reputation among members of the general public, but you note improvements in the technology and conclude that ECT is the most effective treatment for some forms of depression.

Once you look at the history of ECT, you realize the extent to which Hollywood images and the social prejudices of the flower children of the 1960s contributed to driving a highly effective therapy almost out of existence in the 1980s and 1990s. It was hanging on by a thread when a small handful of very dedicated physicians against enormous opposition managed to restore it. Now, ECT is certainly on its way back in psychiatry and is enjoying a renaissance in Europe and the United States.

And to think that One Flew Over the Cuckoo’s Nest was one of my favorite movies.

It’s wonderful entertainment, but it’s been a public health disaster. Who knows how many people were not prevented from committing suicide by having seen that movie and shunning ECT, which has very powerful, anti-suicidal properties. Families and patients didn’t want ECT because they saw the movie, and if the suicidal ideation couldn’t be reversed with drugs, the [patients] killed themselves. And there were many, many such tragedies.

And your new book, How Everyone Became Depressed, is also illuminating on misdiagnosis and failed treatment of depression. So much depends on the definition of the illness and, for me, it’s complicated. When you look at depression historically, how did we get to the present point of overdiagnosis and inappropriate treatment?

This is very straightforward. Psychiatry has always known that there are two very different depressions, as different as mumps and tuberculosis. They have very little in common with each other, even though they’re both called depression. The point is that they have different treatments.

Melancholia is characterized above all by deep sadness, also by the inability to experience pleasure, which is called anhedonia, and by hopelessness about the future. Melancholic patients also experience what is called “psychomotor change,” meaning that their thoughts and movements are either agitated, or slow and retarded.

Non-melancholic patients, by contrast, are not necessarily sad, though they may have one of the “D” words, meaning demoralized, disappointed, or dysphoric. Anxiety is very prominent for them. They also experience lots of phantom physical pains that come and go. And they tend to obsess about the whole package. And it is a package: These symptoms tend to occur together, just as hopelessness accompanies the sadness of melancholia.

Melancholic depression is effectively treated with the tricyclic antidepressant medications and with electroconvulsive therapy, also called ECT. Non-melancholic depression is effectively treated with benzodiazepines and, to some extent with the SSRIs [selective serotonin reuptake inhibitors] -- the Prozac-style drugs -- that also help with anxiety and obsessive-compulsive ideation that goes with non-melancholic depression, although the Prozac-style drugs are not antidepressants.

Given that we have two separate diseases, we have two separate treatments that are each appropriate for one or the other.

That sense of two separate diseases has been conflated now with the diagnosis of major depression, which is a very heterogeneous diagnosis that brings together the melancholics and non-melancholics into the same pool. Guess what? The treatment for major depression turns out to be the Prozac-style drugs, the SSRIs. And ECT tends to be stigmatized and tricyclic antidepressants have vastly declined in popularity. This means that patients with melancholic depression basically are getting the wrong kind of treatment. They are not being held back from the brink of suicide.

There has been an increase in American suicides over the last two decades. I believe this is a result of exchanging classes of medication that really are effective with classes of medication that are not so effective. That’s the real story behind this devastating increase in suicide in American society.

These matters have serious consequences for everyday life and it’s wonderful that, as a historian, I’m able to contribute to the understanding of these issues, but it’s horrifying that to see the wreckage that left by the false understanding of these issues by official psychiatry.

You write that it’s more appropriate to describe many patients as “nervous” rather than depressed. What symptoms would these patients exhibit? By a “nervous” condition are you suggesting a neurological condition? What is a “nervous breakdown”?

A nervous condition is really the same as non-melancholia, but the term nervous has disappeared from psychiatry. A nervous breakdown is a couple of pegs up from nervousness. You really become disabled, stay at home crying, think you are doomed, cannot see other people. Repeated panic attacks might qualify as a nervous breakdown, ditto an episode of psychotic illness. Melancholia, of course, is the quintessential nervous breakdown. ]

There’s also a tendency to treat unhappiness or dissatisfaction as depression.

Unhappiness is a separate issue, but it’s a very real issue. Up to now, we’ve been talking about genuine illnesses: melancholic depression and non-melancholic depression are real illnesses.

Some people get the diagnosis of depression who don’t have a real illness. Their problem is unhappiness. The general rule is that if your problems can be reversed with a check for five thousand dollars or with a new boy friend, you probably aren’t depressed.

So many people who are diagnosed with depression are the victims of medicalization in the sense that their problems have been given a medical description.

So you see a trend of diagnosis and then prescription of drugs for problems of living that are not illnesses?

That obviously is what happens. Psychiatry is a noble profession, and I’m not criticizing the motives of those who go into inspired by a genuine desire to serve the public good. But there is a tendency in psychiatry, as in every other area of medicine, to send every patient away with a prescription because that’s the way you feel you’re doing a good job as a doctor and prescribing for your patients. So the rule in psychiatry is that there’s no consultation without a prescription.

However, people who are unhappy won’t benefit from antidepressants, although they’ll get all of the side effects of them. This is an excess of goodwill in the sense that psychiatrists want so desperately to help everybody and they help them the only way they know how to do, by prescribing drugs for them. Most psychiatrists no longer do organized psychotherapy. So the caregivers end up doing a number of their patients a disfavor by exposing them to all of the side effects of drugs without any of the benefits.

You describe the arc of the history of depression and psychiatry, and how biological psychiatry in the nineteenth century was replaced by the psychoanalytical movement in the early twentieth century and, then in recent decades, biological psychiatry has displaced psychoanalysis with the rise of psychopharmacology.

Yes, that’s right. We’re in the second era of biological psychiatry and the first era happened in the nineteenth century.

In general, this is very positive. I’m certainly a fan of psychopharmacology in that it has the ability to help people who were not helped at all by psychotherapy or psychoanalysis. An illness like psychotic depression does not respond to psychoanalysis, and these people will kill themselves if they aren’t given a biological treatment such as ECT or a combination of an antipsychotic and another antidepressant drug.

We’ve made many important gains and the problem isn’t the concept of psychopharmacology. The problem is the DSM series. It’s such a blunt instrument. It creates artificial categories of illness such as bipolar illness, while in nature there is no separate bipolar disease. There are just affective disorders. Sometimes, if you have a serious depression, you may have an episode of mania, and sometimes you won’t. It’s not a big deal. Mania is inherent in serious depressive illness. To say this is a bipolar disorder and then treat it with different classes of medication makes no scientific sense and it’s a disservice to patients because it denies them the benefits of effective antidepressants.

It makes no sense at all to classify depressions on the basis of polarity because the depression of bipolar disorder is the same as the depression of unipolar depression. To insist that these are very different depressions that need separate treatments is just hocus-pocus.

You contend that the authors of the DSM rejected sound scientific evidence and diagnostic tests when they defined illnesses.

Yes they did. They simply dismissed them from the table.

Spitzer and the members of the task force had no interest in this at all. The problem was that, even though these people were not psychoanalysts, they came out of a world of psychoanalysis and psychoanalysis prepared psychiatrists very poorly to deal with the physicality of the body. The body is composed of physical organs that have a biochemistry of their own. This was something that psychoanalysts didn’t want to know about. They wanted to hear about intrapsychic conflict and the roots of the disease in childhood socialization and so forth. They had no interest in the rest of medicine.

Even though a new generation of physicians came along in the 1970s and 1980s that recognized that psychoanalysis was fraudulent, it was poorly equipped to deal with biology and, when you approach a biological test like the DST [dexamethasone suppression test], you have to understand quite a bit about medicine and endocrinology. Even though they were MDs and had done endocrinology 101, they didn’t have a real understanding of the [science], so they just flipped it from the table, and these are important parts of knowledge that they casually disregarded.

The DST today is out of psychiatry. Nobody uses it any more out of a colossal misunderstanding of how the body works, and how many different body systems are implicated in psychiatric illness. It’s not just the mind and the brain, but the whole body.

That gets me to another question about the recent advances in neuroscience and our growing understanding of brain function. It seems we’ve learned much more about brain anatomy and neurotransmitters and neuroplasticity. How do these discoveries affect psychiatry?

We are certainly making advances in the neurosciences, and I don’t want to dismiss that at all. But these advances have had almost no impact on clinical psychiatry. There are no drugs that are currently prescribed that originated as the result of new insights on neuroscience. There haven’t been any real innovations at all in psychopharmacology in the last 30 years -- no new compounds of any kind. And this has been very frustrating for people involved in drug development.

The point is that the advances of neuroscience have had relatively little impact on clinical psychiatry and how we treat patients. We now have a much better understanding of different areas of the brain that are involved in illness, but being able to address those areas pharmacologically is still a bridge too far.

When I worked as an attorney, I had the opportunity to review hundreds of medical records, including reports of psychiatrists. It seemed often that response to treatment steered the diagnosis, rather than the other way around. Have you seen that?

That certainly happens and it’s not necessarily illegitimate. If a patient is in a stupor and you want to find out if it’s a catatonic or depressive stupor, you can test that by giving anti-catatonic remedies such as the benzodiazepines, which are really not effective in serious depression but are effective in catatonia. If they respond to the benzodiazepine treatment, that means the stupors were catatonic in nature, and that’s an important piece of clinical information. But that’s been known since 1930. It’s not a new science.

How we can improve the diagnosis and treatment of depression?

The first step would be to get rid of the DSM because the whole approach to depression is entirely off base. They created major depression, which is highly heterogeneous and doesn’t represent a real illness at all. They created bipolar disorder and we talked about problems with that. They created a situational adjustment disorder that catered to psychotherapists who generally shy away from medication.

All of the present categories need to be rethought. They need to divide melancholic from non-melancholic illnesses. The non-melancholic illness has to include mixed anxiety-depression. Anxiety and depression appear so often together that it’s probably a distinctive illness of its own. Pure depression and pure anxiety are unusual and yet, in the DSM, there’s a firewall between depression and anxiety, so if the patient has both of them, the patient is then co-morbid for both, and requires two prescriptions rather than one.

These are good examples of how the current system needs to be completely rethought. But this will not happen as long as the American Psychiatry Association is guiding the DSM.

There’s not going to be a DSM 6. DSM 5 will be the last one. It will be thrown out as unusable and they’ll go back to square one. It will be some other organization such as NIMH or WHO that will come up with the next classification. It won’t the APA.

Didn’t you suggest that they adopt a diagnosis of mixed anxiety and depression?

I certainly did. Mixed anxiety-depression was probably the most common mood diagnosis in American psychiatry up to about 1980. If you had a psychoanalytic perspective, then you would use the term depressive neurosis, and depression for you was a kind of neurosis, not a kind of mood disorder. But for those outside of the sway of psychoanalysis, in community psychiatry, they made the diagnosis of anxiety-depression. And there were all kinds of agents that were suitable for mixed anxiety-depression, such as the barbiturate Sodium Amytal combined with an amphetamine. Smith Kline launched a barbiturate-amphetamine combo called Dexamyl in 1950 that was highly effective..

If you have mixed anxiety-depression, an agent for anxiety would be a barbiturate and an agent good for depression [would be] amphetamine. But the FDA decided that these drugs are too addictive to be properly prescribed, so amphetamines were withdrawn from medicine for everything but unruly adolescent boys with ADHD. And barbiturates are an effective class of sedatives, but they were displaced first by benzodiazepines . Then, after a scare about benzodiazepines, the door opened for the SSRIs that, in the treatment of depressive illness, are almost inert. So psychopharmacology has undergone this downhill plunge.

Does the drug industry, to some extent, drive the DSM categories?

No. The drug industry had nothing to do with the genesis of the DSM III. I know that because I’ve seen the correspondence. But DSM III and its successors have been an absolute gift to the drug industry by giving them diseases that they can shoot at.

With psychoanalysis there were no diseases. Everything was supposed to respond to psychotherapy, so what was the point of coming up with differential diagnoses of diseases? But once we threw out psychoanalysis and brought back diseases, that created drug targets to shoot at, and so major depression became a hugely lucrative drug target, even though it doesn’t really exist in nature. And anxiety became a hugely lucrative drug target. With ADHD, there’s enormous money to be made giving out these amphetamines to adolescent boys.

Even though the drug industry wasn’t responsible for diagnoses [in the DSM], they benefited from them to the tune of billions of dollars.

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