When should sorrow be considered sickness? Historian Jonathan Sadowsky ponders this question as he explores the remarkable history of depression treatments.
As someone who has suffered bouts of depression on and off for decades – and has benefited from both psychotherapy and medication – I have wrestled with the philosophical question of how it is possible not to be depressed, given the state of the world and the existential threat climate change poses to the viability of life on the planet. Indeed, depression is sometimes thought of as a largely modern affliction, or one greatly exaggerated by the pharmaceutical industry’s profit motive.
With these questions in mind, I picked up Dr. Jonathan Sadowsky’s new book, The Empire of Depression: A New History, with great interest. I was curious to see how Sadowsky, with his historical perspective, would address these issues. A professor of history at Case Western Reserve University in Cleveland, Sadowsky specializes in the history of medicine, and psychiatry in particular. He’s the author of well-received books about colonialism and mental illness in Africa and the history of electroconvulsive therapy. I recently talked via Zoom with Sadowsky from his home office in Cleveland. As we introduced ourselves, we were surprised to find that not only had we both grown up in Queens, but that my mother and his father had known each other through their work in local politics. I also learned that his father, an attorney who had served for 24 years as a progressive city councilman, had recently died. The issue of mourning arose as we discussed The Empire of Depression, as did a thorny, long-debated question: At what point should sorrow be regarded as sickness?
The interview has been condensed and edited for clarity.
As a historian, what led you to write The Empire of Depression?
There’s been a lot of attention to the problems created by the avarice of pharmaceutical companies and the ways in which depression is – in the overused academic phrase – socially constructed. And I think those are legitimate issues to raise. I don’t dispute the avarice of the pharmaceutical companies, which have sometimes engaged in terrible behavior. Nor do I deny that we have to look at how cultural ideas resonate and influence what’s considered depression.
But what I thought was missing in a lot of the history was real consideration to the pain of the sufferers. I felt that people who feel helped by their medicines and therapy deserve to be heard. They deserved a voice in the history. The historical profession, when it looks at psychiatry, is often relentlessly negative. It sees psychiatry purely as an oppressive force. I’ve studied many of the abuses of psychiatric power, so I know that is real. But there is another side to it, and that is this: For many people, psychiatry and therapy and treatments relieve suffering. And it’s this that is left out of so much of the history, to an extent that outsiders to my field might find bizarre.
When did the word depression first begin to be used as a clinical term?
You know, there are some uses of it as early as the 18th and 19th century. But in those times, for the most part, the older word melancholia was used to describe illnesses characterized by extremely low mood, dejection, social withdrawal, etc. I don’t think there was one moment that suddenly changed things overnight. The two words came to be used interchangeably at first for a few decades. By the
middle of the 20th century, “depression” was gaining ground and “melancholia” was pretty much gone. What does exist now is so-called “melancholic depression” as a subtype of depression.
One of the big questions you talk about is trying to come up with a boundary between sorrow and the normal human experience of sadness, loss and grief on the one hand and what we would now call depression. Could you reflect on that boundary, and why it’s so hard to construct?
I suspect we will never know because I don’t think there is any a clear line dividing the two. You do have clear-cut cases of people with frequent suicidal ideation or extreme lethargy where they literally can’t get out of bed, commit self-harm or just have an extreme lack of motivation and loss of interest in things. In those cases, most of us think, well, they probably need some kind of medical intervention.
But there is a gray area in between sadness and grief and depression – actually, it’s not a line; it’s a field. Let’s take grieving. I mean, I’m grieving right now, and sometimes it hurts. It feels bad. There are days when it’s okay, but there’s other days when it feels very desolate. My father died only about a week and a half ago, so no one on the planet would find it odd that I would feel bad. If I were feeling desolate about that a lot of the time three years from now, most people would say, ‘You know, this seems like maybe you need to get some help for that.’
But how long should the period of bereavement be? It varies from culture to culture. Some people think, in a month or so you ought to be back on your feet. Some people, a year or so. It’s not like many infectious diseases where there’s a blood test.
What I’d like to stress, though, is the fact that depression has blurry boundaries and is hard to set a limit on doesn’t make it not real. Instead of treating the blurriness or the fuzziness as an indictment of the entire category of depression, as too many people do, I would say let’s treat it as inherited wisdom. We’ve been trying for at least 2000 years now to decide how much is too much. We haven’t come up with objective criteria and probably won’t. Let’s continue to discuss it, but we shouldn’t start rejecting the whole illness category because it’s a complicated one.
We have a linguistic issue, too – we use the word “depressed” day in and day out. It can be very hard, I think, for some people to make a distinction between “I’m depressed today because I couldn’t buy whatever” and “I have depression.”
Yes. William Styron, who initiated the big efflorescence of memoir literature on depression, complained about the weakness of the word and how it doesn’t really convey the deep suffering of clinical depression. Another memoirist, Tracy Thompson, put it this way, in language very similar to yours. She said, “You know, ‘I’m depressed’ can mean anything from ‘I had a fender bender this morning’ to ‘I’ve been considering killing myself for months on end.’ So yes, there is that kind of linguistic slippage.
Could you talk about social inequities that can lead to depression, and what we could do about that?
There is a lot we could do. Universal health care, for example, would not only help people with depression get into treatment, but would alleviate many factors that lead them into depression in the first place. It’s barbaric for a society to have such abundant medical resources and deny them to people who are unemployed or uninsured. My father was a politician and staunch advocate of social welfare programs. He was all for taxing the rich. He saw that the claim that doing so would stifle the dynamism of the economy was a rationalization for upward distribution of wealth when it was being fiercely advocated for in the late 1970s and 1980s.
At that time, many on the left were saying, if you cut social programs, and cut taxes on the rich, and wage war on union organizing, what you will actually get is simply increased inequality. And that’s exactly what we’ve gotten. The precarity of everyone outside the very rich now is unconscionable. We have abandoned even the pretense of striving for shared prosperity. With more economic security, I am sure there would be less depression. This is true even though many affluent people get depressed, and many poor people do not.
Also, virtually every axis of inequality – race, gender, LGBT status, for example – can increase the risk of depression for those on the lower end of the hierarchy. It’s easy to feel some resignation about those problems because they feel stubborn, intractable. We should remember though that history shows many instances where social attitudes changed, sometimes very quickly. It takes work, and we have to be willing to do it.
Your book goes back to the ancient Greeks and tracks parallels to what we would call depression from then to the modern age. Can you take us back to this issue about what’s normal sorrow and what’s excess sorrow — how was that handled in the past?
In antiquity, a model of disease called humoral theory emerged — the idea that there were four principal substances in the body and ill health was caused by an imbalance of them. In the case of melancholia, the idea was that there was too much black bile and the goal was to correct that imbalance. To be considered illness, depression – or in this case, melancholia – needed to be out of proportion to the events surrounding it. You see that in ancient Greek writers, you see it in Renaissance writers, and you see it in Freud.
And there was also stigma about the illness back then?
Yes. A late-Renaissance-era author named Timothy Bright really wanted to show that melancholia was a physical condition to destigmatize it, so people would stop seeing it as a failure of will. And then hundreds of years later, in the pharmacological revolution of the 60s and 70s, many had the same hope that if we could show that mental illnesses were physical in their origin and had physical treatments, they would be considered real illnesses and therefore destigmatized. The irony here, though, is showing that something has a physical dimension or cause doesn’t necessarily dispel stigma; it simply changes the nature of the stigma. It can increase perceptions that it’s something inherent to the person rather than an illness that comes and goes, for example.
Depression also is a treatable condition and it’s often recurring for people, but we do have a robust repertoire of treatments, including insight-oriented therapy, behavior-oriented therapy, cognitive therapy, drugs, and electroconvulsive therapy. For most people, something’s going to work. Some depressions are very hard to treat; some are very, very stubborn. But the very fact that we have a category now called “treatment-resistant depression” represents a lot of progress. Because 120 years ago, it was all “treatment-resistant.” There wasn’t much you could do for anybody.
As someone who has benefited both from psychotherapy and from medication, I don’t really get why people think it has to be one or the other.
Sometimes the dogmatism on either side of this really baffles me. Many people find themselves helped by both, and the data show that antidepressants and psychotherapy do work best together. Where did this dogmatism come from? Starting in the 19th century, the wider field of medicine began to change what anthropologists, medical anthropologists and historians of medicine called biomedicine. It’s an extremely powerful paradigm that’s led to a lot of advances in human health, but it does tend to be biologically reductionist.
Take the germ theory of disease. One of the most prominent physicians of the 19th century, Rudolph Virchow, was very worried about the germ theory of disease triumphing, because he was afraid that it would leave out attention to the social factors of disease. He was actually right. It’s not that people didn’t recognize that things like poverty and social inequality contributed to ill health. But those factors receded into the background, and the biological mechanisms became the shiny object of medical attention as biomedicine grew and psychiatry aimed to emulate it. And people on the other side replaced that with a reductionism of their own.
There are also professional social factors in this – let’s face it. There’s some turf war going on here between psychiatrists who want to focus on the biomedical aspect of it, and psychotherapists who want to look at the psychological and social dimensions of it. But I think the core of the issue is that as biomedicine grew in power and prestige, it’s reductionist and not really workable for something that is as multifactorial as depression.
When I started treatment for depression years ago, you didn’t tell anybody you were on antidepressants. It felt sort of shameful, especially when I was in my 20s. Why did Prozac and other SSRIs became so popular when they aren’t any more effective than earlier drugs? Why did it become such a cultural phenomenon and reinforce the chemical imbalance narrative?
It came at a cultural moment that was primed for it. For one thing, it followed decades of increasing interest in depression. In the medical community, and through the 1970s and 1980s, the number of publications on depression began to mushroom. So the medical profession was paying more attention to depression. In addition, a lot of the anti-anxiety medications that were popular in the early post-war period, like Xanax and later Valium, were starting to show some ill effects that people were trying to get away from. There was a real fascination with the brain and brain science. Peter Kramer, the psychiatrist who wrote the book Listening to Prozac (first published in 1993), noted that the cultural attention to brain science and mental illness outstripped any scientific advance being made. I think we can understand that even better now.
But Kramer also described people who took Prozac and suddenly were vibrant for the first time in their memories.
Yes, and those stories should be taken seriously by psychopharmacology’s many critics. One reason Prozac was exciting to clinicians and maybe to patients at the time was that many people didn’t respond that well to the older tricyclic antidepressants, even though we know that those drugs are very effective. I think an a probably unhelpful idea Kramer put out was that Prozac could be a kind of enhancement treatment for people who weren’t actually sick. This has not panned out at all, but you could see that this would be very exciting to people – if I could perform better by taking a pill, why wouldn’t I want to do that? That debate about Prozac as an enhancement just fizzled out.
What about the domains of wellness that some experts recommend to reduce the risk of depression such as exercise, mindfulness, getting enough sleep, spending time in nature, having a strong network of friendships or even cutting back on social media?
All of those measures can help to both prevent depression and alleviate it. It’s also important to remember, though, that for many people, they may not be enough. Putting a severely depressed person in a forest isn’t going to cure them, and there’s anecdotal evidence that even the very fact of being in a beautiful, natural setting and being unable to enjoy it can be a torment to depressed people. By all means, use these measures, but psychotherapy and medications also help, and for many, they will be necessary before working out or mindfulness is going to have much effect.
A final word about social media. Like most technology, it’s double-edged. I don’t doubt that its use can increase feelings of isolation and anxiety. I try to stay off social media after going through my Twitter feed at breakfast, and I don’t use Facebook or Instagram anymore, because I think that company is a menace to society. (Facebook bought Instagram in 2012.) I also think that internet use is probably eroding people’s capacity for sustained concentration, and that worries me. But social media does fulfill its promise of social connection for many people. Some people who might have been otherwise isolated have a means of creating community. Let’s be alert to the problems social media can cause, without turning it into an easy scapegoat for mental health problems that have multiple sources.
What are your predictions, if any, for future treatments?
I predict that we will have new treatments that will help people in ways that they haven’t been helped before. I also predict that new treatments will be overhyped so that their limitations, disadvantages, and adverse effects will be underrated and will only emerge in time. Why do we know this? Because it’s happened every time. Every single treatment for depression that’s been developed over the past 120 years has been overhyped and then led to a period of disillusionment. Then, in the period of disillusionment, people have emerged who call the treatment completely worthless, which it wasn’t. I predict this will happen again. My other prediction is that we will continue to have debates over the precise borders of this condition and that those debates will not be resolved.
Is there anything else you’d like to say about depression?
Yes. Just because the disease disproportionately affects people who are facing adversity doesn’t make it less of a disease or an illness. We know, for example, that poverty and oppression are risk factors for tuberculosis, AIDS, and COVID-19. And for COVID-19, for example, we don’t say, ‘Let’s not give these people medicine; let’s simply fix the social inequalities.’ We should fix the social inequalities – of course we should be working on that. But as I put it in the book, people who are depressed shouldn’t have to wait for us to bring about a perfectly egalitarian and harmonious society to get relief from their trouble.
The second point: This idea of “empire” is that there are lots of ways of describing the cluster of symptoms that seem to go along with depression. The term “empire of depression” is not necessarily an indictment or an endorsement. It’s that the word depression has come to refer to a widening range of unhappiness. It has gone by other names, both in the West and in a non-Western context.
When I talk about an empire, I’m really talking about a kind of linguistic colonization in which the word depression, not just in the West, but globally, is being used more and more to describe many forms of distress. When I say that, I’m not as convinced as many of my peers that this is entirely a bad thing, I don’t want to imply that there are no possible losses. There may be downsides to this. I just think the upsides ought to be considered as well. If people who would have previously been described as having a nervous breakdown are now called “depressed” and going into treatment and getting things that are making them feel better, is that really so bad?
— David Tuller, DrPH, a journalist who has written for Health Affairs and The New York Times, is a senior fellow in public health and journalism at UC Berkeley’s Center for Global Public Health.