American Melancholy

In this thought-provoking, short book, Laura Hirshbein, a psychiatrist and historian of psychiatry, presents compelling evidence that depression, as we know it, is in part a relatively recent American construct which makes depression, in large part, a disease more prevalent in women than men.  She relies on many studies in the psychiatric literature but also bolsters her argument by examples from the popular press -- and especially women's magazines -- to demonstrate her thesis and also the cultural context surrounding the development of the modern diagnosis.

          In her introduction, Hirshbein begins with a consideration of the current ubiquity of depression and its promulgation as a disease, its extraordinary prevalence throughout the world, and its two-to-one female to male ratio.  She reviews criteria for the diagnosis, usual treatments, campaigns to educate the public, and the big business aspect of the marketing of antidepressant medicines.

          The author makes it very clear that this is not the book about the venal manufacture of a syndrome -- she stresses the unity and continuity of depression over many centuries and across cultures, but she also stresses the expansion of the syndrome:  "But the modern label of depression --- also refers to individuals who are not sure what they want in their lives, are not entirely happy, are in difficult home or work situations, or who would like to feel better than they do."

          She then provides a chapter, "prelude to depression", in which she explains the historical prodromes of the modern syndrome as well as a very truncated view of the history of psychiatric nosology.  She links several syndromes -- melancholia, of course, but also neurasthenia, as an excellent example -- to modern depression.  She provides a dry but important chapter on the development of the Research Diagnostic Criteria and the DSM-III, with their links to the increasing diagnosis of depression, including many major and still-cited research studies.  The next chapter examines the "consumer" effect on the diagnosis.  Many popular magazines featured this disorder from the 1960's on, with advice to consumers about how to diagnose oneself as well as approaches to treatment, with a significant emphasis on pills -- though there were even a couple of advertisements for electroconvulsive therapy!

          The next chapter explores the issues of gender and depression, with more depth than most of the rest of the book.  It is a long and tightly-argued chapter, with some fresh insights.  Hirshbein does an excellent job of delineating gender bias in such useful and commonly used tools as the Hamilton Depression Scale and the Beck Depression Inventory.  She points out the oft-forgotten fact that the very influential Boston-New Haven Collaborative Depression Project was based on a sample of 150 depressed women, with no men.  The findings were often explicitly generalized to men, without any evidence.  A partial outgrowth of this study, Interpersonal Therapy, based on disruptions in interpersonal relationships in the depressed women in this study, was developed and is widely used in both genders.  In this chapter, Hirshbein also describes culturally based, changing values of society and its psychiatrists regarding expected and desirable roles of women.

          Hirshbein bolsters her assertion that depression was largely viewed as a syndrome of women by examining a fascinating study from South Carolina which explored rating scales in men with substance abuse.  Several rating scales suggested a high comorbidity of depression and substance abuse (which is viewed as very true, today), but these were rejected as false positives, and the rating scales were rejected and replaced with clinical interviews which showed a low comorbidity of depression and substance abuse in men.  This excellent chapter is in many ways the heart of the book.

          The next chapter attempts to link depression with modes of relating and feeling, thought to be unique to or more common in women.  It is far less satisfying than the previous chapters in part because these purported ways of relating and feeling lack evidence and have not been confirmed.  In fact, they have largely been rejected.  Her stress on Scarf's work and hypotheses seems unfortunate, because they are not essential to her argument.  Her emphasis that "the language of feelings" is largely a feminine trait may be overstated.

          She does make a very important point in this chapter, reinforced throughout the book:  "Women did not seem to perceive this diagnosis as an expression of patriarchal physician authority.  Indeed --- a number of writers -- including women physicians -- argued that depression was a disease of women and that treating depression was an important issue for women."

          The final chapter, an epilogue, is entitled "Real Men, Real Depression", which is provocative until one realizes that it was the title of an NIMH campaign to educate men about depression.  This campaign stressed differences between men and women's experience of depression.  It stressed that depression is a disease, with some focus on its chemistry, "with the implication that diagnosis and pictures of molecules can better convey the disease to men".  This campaign also suggested that men might have some symptoms not listed in the DSM.

          The last two pages of this epilogue take on a different tone, absent from the rest of the book.  First, there is a comment about how American concepts of depression are not applicable in a cross-cultural setting.  This seems to disagree with previous comments Hirshbein has made.  And her question on the last page of the book is inconsistent with the tone of the rest of the book:  "The ubiquity of depression in our culture raises the question of whether women -- or men if the NIMH campaign succeeds -- are capable of living without having their lives propped up by chemistry --  Why, in a nation of abundance, opportunities for social mobility, and economic and religious freedoms, would there be large (and growing) rates of mental disease?... Maybe it is our relentless individualism -- in the pursuit of happiness, including the pursuit of psychiatric treatment -- that fuels our particular American melancholy."

          The book concludes with comprehensive footnotes and a well-constructed index.

          I found many aspects of American Melancholy admirable.  The author researched the topic thoroughly, and her voice is that of both a historian and a psychiatrist.  Up until the last two pages, there are no "bad guys" in the book, which is refreshing.  And she clearly supports and demonstrates her thesis that the concept of depression has been intricately tied to society's views of women's affects and roles.

          I especially admire the depth and insight with which she addresses important studies, such as the Boston-New Haven Collaborative Depression Study, whose 150 subjects were all women, but whose results were generalized to men, without data.

          I think that this book has some problems, though none of them truly undermine Hirshbein's central thesis about women and depression.  She does not sufficiently demarcate the loose and popular use of the term, depression -- "individuals who are not sure what they want in their lives, are not entirely happy, are in difficult home and work situations, or who would like to feel better than they do" -- from the psychiatric use of the term.  I certainly do not know any psychiatrists who diagnose depression solely because an individual is not sure what she or he wants in life.

          The historical background Hirshbein provides is necessarily incomplete.  The disputes about the need for a universal nosology in psychiatry go back more than 150 years and were not just a product of the twentieth century.  Some of the older aspects of this dispute are very relevant to the author's thesis.  Her account of perceptions of mental health in popular magazines through various time periods are fascinating and could well be expanded.  She has old quotes which support her arguments about cultural bias toward women -- most notably one from a superintendent of the St. Peter State Hospital -- but one can find similarly biased quotes about men, from the same era, which ascribe their psychiatric disorders to masturbation and drunken ancestors.  (And, of course, our putatively scientific pronouncements today will seem similarly ludicrous and biased in a hundred years.)

          Hirshbein cites such studies  as the Boston-New Haven one but does not emphasize the fact that in psychiatry and indeed all medicine there were hundreds of studies conducted entirely on men, with results generalized to women.  This has been a major point in feminist critiques of medicine and may have deserved more discussion in this book.  In discussing this study she makes the important point that Interpersonal Therapy (IPT) in part evolved from it, but does not mention that excellent research validates its efficacy for both genders.

          I think Hirshbein places too much emphasis on views that women define themselves through relationships and "the language of feelings".  This concept has been highly debated in recent years and remains unvalidated.

          Her view of the "Real Men" NIMH campaign focuses on depression being presented to men, but not to women, as a molecular, neurobiological illness.  While the presentation of the campaign may merit some criticism, media advertisements today clearly make the same pitch to women.  The author's statement that depression in women is still conceptualized as "disordered internal experience" is certainly not universally true.  In her review of this NIMH campaign and its argument for more criteria, the author does not describe the conflict between the NIMH and the DSM about criteria for diagnosis, and a brief account of this situation belongs here because it helps inform the proposal of additional criteria.

          A minor irritation is the role of chronology in the book.  Hirshbein jumps everywhere with it, so one is reading about the 1950's and then the 1980's.  Her chronology provides very helpful data, but it would be useful to have, in addition, a more rigorous chronology.

          Hirshbein seems to contradict herself about transcultural aspects, at one point writing that there is widespread convergence about depression across cultures and at another place writing that there is discontinuity.  This book deserves a much broader discussion of transcultural issues.

          The roles of insurance and managed care in the diagnosis and treatment of depression might also warrant more exploration.

          The last two pages of the book are powerful, well written rhetoric but seem to me a bit inconsistent with the limited claims and sound reasoning of the rest of the book.

          Over all, this is an excellent book, which I recommend to psychiatrists, psychologists, historians and philosophers with an interest in psychiatry.  It is one of the few books I have read in recent years which should be longer!  There is much to validate Hirshbein's view, some of which she does not cite.  For example, the work of Kendler and colleagues which shows equal heritability for depression in both genders indirectly bolsters her thesis.  This is a rich book which could be even richer!

© 2015 Lloyd A. Wells

Lloyd A. Wells, Ph.D., M.D., Emeritus Consultant, Department of Psychiatry and Psychology, Mayo Clinic, Rochester, Minnesota