This reading group guide for Manufacturing Depression includes an introduction, discussion questions, ideas for enhancing your book club, and a Q&A with author Gary Greenberg. The suggested questions are intended to help your reading group find new and interesting angles and topics for your discussion. We hope that these ideas will enrich your conversation and increase your enjoyment of the book.INTRODUCTION
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is psychotherapist Gary Greenberg’s look at how we came to have the common belief that depression is a biochemical illness. It starts with the revolution in medicine set off when doctors first discovered that drugs could target the molecular causes of disease, continues through the accidental, drug-fueled discoveries that led scientists to surmise that serotonin imbalances caused depression, and culminates with pharmaceutical companies' shrewd and wildly successful efforts to spin these discoveries into a theory that unhappiness is a disease for which they have the cure.
The author details the way that doctors and drug companies advanced their chemical imbalance theory despite a lack of evidence, and how even now, when most scientists agree that depression is not a simple biochemical glitch, they continue to tell their patients that it is, and urge them to take antidepressants for the same reason that diabetics take insulin. He also traces the idea that deep unhappiness is caused by a malfunction within the individual to its roots in one of the earliest stories of Western civilization, the Book of Job, in which a man who has lost everything wonders “Why give light to a man of grief . . . Why make this gift of light to a man who does not see his way?” (29) only to hear his “therapists” tell him that there is something wrong with him for feeling this way. He details his own bouts with depression and his various attempts at a cure, including his enrollment in an experimental trial of an antidepressant. He gives a firsthand account of what it is like to be depressed and subjected to the mental health industry. TOPICS AND QUESTIONS FOR DISCUSSION
ENHANCE YOUR BOOK CLUB
- How does the concept of “On this medication, I am myself at last” (35) make you feel? Can taking medication make you yourself, or does such a dependency negate that?
- According to the Diagnostic and Statistical Manual (DSM), a mental disorder is only an illness if it “causes you clinically significant impairment or distress.” This means, the author says, that “for the most part, it’s up to you to decide if you are impaired or distressed; a mental illness is an illness only if it is a problem for you” (170). How does this definition of disease compare to yours? Are you concerned about subjectivity in making medical decisions? Are you concerned that doctors must make their diagnoses based on what patients tell them, rather than on what they can determine from medical tests?
- Consider this: “If you’re a psychiatrist or a drug company [you will place great emphasis] on dividing up the territory, on separating your chemicals from theirs, on making sure that yours are medicine and theirs are drugs, that you are treating illnesses while they are abusing substances” (174). Should people be allowed take drugs simply to feel better, rather than to cure a disease? If depression isn't a disease, then how can we distinguish antidepressants from recreational drugs? What are the implications for the drug war, which is waged primarily to prevent people from taking drugs merely to feel better?
- Have you ever felt “consciousness without an I” (176)? What is it like to be outside of yourself?
- “As many as 70 percent of people taking SSRIs suffer from sexual dysfunction” (348). Why do you think so many people are willing to “trade in their sex lives for antidepression”?
- Reread the advertisement transcript on page 275. Can you pick apart the ways in which the ad is targeting everyone? Do you think it’s effective? How many times have you seen an ad like this one on television or in magazines? Do you think ads like this lead people to think of themselves as diseased rather than unhappy?
- "‘Depression strikes one in eight,’" says the Prozac TV ad. The number is 17 million in the print version, 20 million in the Zoloft ad, and 20 percent of women on Paxil’s website—a whole lot of fellow citizens,” writes the author (276). Are those numbers higher or lower than you imagined them to be? What does the disparity in the numbers stated suggest to you?
- Where do you stand on this statement (339)? “Your depression is a flaw, in you but not of you, that causes you to see the world as darker and meaner than it really is and that can be corrected with a quick trip to the drugstore.” Do you think that there is “an authentic self, waiting to emerge like a sculpture from a slab of marble” (351)?
- As the author is discussing the history of depression and antidepression drugs, he adds stories about his own siege of depression. Does this help you see depression in a clearer light or help you sympathize with the author’s case? Does his personal story clarify or hinder his argument?
- If someone in earnest told you that he or she thought you seemed clinically depressed, how would that make you feel? How would it affect your life and decision-making process? Do you think you would see a doctor regarding depression? Would you be more inclined to take medication for it?
- In the United Kingdom, it’s not permitted to have drug advertisements on television or in magazines. Yet in the United States, drug advertisements are ubiquitous. Do you think this is a problem? Are there benefits to having consumers/patients know about particular drugs? Are there downsides?
- Given that so much interpretation is up to the psychiatrist and patient, do you think psychiatry will ever be considered a hard science—like chemistry or physics? Do you want it to turn into “clinical neuroscience” (317)?
- Did anything regarding the history of depression and how it is classified shock you? What would you like to see done differently in the future regarding depression and its treatment? How do you feel about calling depression a mental disease? To you, does that imply there is a cure?
- If upwards of 30 million Americans are taking antidepressants at an annual cost of more than 10 billion dollars, is there any way to abate this trend, or do you think depression will always be a part of America’s culture? Do you think that our society’s significant use of antidepressants is in part because of the gap between our expectations of happiness and what we can actually achieve?
A CONVERSATION WITH GARY GREENBERG
- Read a book on depression/madness, like William Styron’s Darkness Visible, Virginia Woolf’s On Being Ill, Ken Kesey’s One Flew over the Cuckoo’s Nest, or Andrew Solomon’s Noonday Demon, and discuss how you would treat their ailments. Do you think the deceased authors, if living today, would have had a different experience? If they had the drugs that we are privy to, do you think they would have fallen into such darkness?
- Talk to a local psychiatrist about his or her perception of depression and the pharmaceutical industry. Attend a lecture at a nearby college in the psychology department. See if their findings and experience match with what Greenberg posits in his book. Why do you think there are so many opinions on the matter of depression?
- Try to think of different ways to help ameliorate someone’s depression without the use of drugs. Have you had a family member or friend whom you had to care for that experienced such pain and didn’t use drugs? Come up with anecdotes to share with the group and have each member discuss how they would handle the situations.
- Have everyone research a particular drug that has been created to fight depression. Cite the pros and the cons, and see how long the list of side effects is. Look at how the drug developed and how many cases it has been used in. Discuss, using facts, whether or not you would “recommend” this drug to anyone else.
What was the most fascinating fact or anecdote that you came across in your research for this book? How did it change or bolster your perspective on depression?
The fact that surprised me the most was the widespread agreement among knowledgeable doctors, especially psychiatrists, that depression, whatever else it is, is not
a simple deficiency or imbalance in serotonin (or any other brain chemical). This doesn't stop doctors from telling their patients that it is, however, which can only hurt the already suffering credibility of psychiatry. In the course of your practice, was there a pivotal moment that got you interested in depression and its history?
In the early 1990s, patients started coming to me with “clinical depression,” a condition that I'd barely heard of before, and for which they were taking drugs. At around the same time, I noticed I was hearing more and more about this “disease” in casual conversations and in the mass media. It was hard not to see this as related to the sharp rise in antidepressant use, and to the more general tendency in American society to reduce complex phenomena to simplistic formulas. Is there anything you would personally like doctors or professors to tell people when they’re teaching others about depression?
The truth—that depression is a complex, multi-determined human experience that each person must understand in the context of his or her own life, and decide to treat accordingly.Is diagnosing depression one of the more difficult aspects of your job? Do you think you’re able to spot when someone has or doesn’t have it?
I don't spend a lot of time worrying about diagnoses. Most therapists will tell you that diagnosis is irrelevant to treatment. Of course, it is important to know which symptoms might point to others—for instance, that people who are having trouble sleeping and are not feeling interested in their usual activities might be suicidal—but you don't need an official diagnosis to do this. How do you feel about the concept of advertising drugs on television and online in the United States? In the UK, it’s not permitted. Do you think that the US should move toward not having advertisements?
Drug companies, along with hospitals and doctor’s practices, should be prohibited from being for-profit enterprises. That answers the advertising question, as well as many of the other problems my book gets at, which is that when people’s suffering becomes the occasion for someone to make money, the patient’s welfare becomes secondary to the bottom line.Should the government regulate the drug industry’s business practices? Is the government even the right choice as an overseer?
The government already is deeply involved with the drug industry—not only as a regulator, but as a provider of intellectual property. Much of the basic research on which Big Pharma relies is done at the National Institutes of Health. The government should simply extend its reach and take over the drug companies completely. At the very least, the government should license intellectual property developed with its money to drug companies and use the money to develop a strict regulatory scheme that functions independent of the industry. Is there a particular narrative regarding depression that you particularly think is a must-read for the layman?
Andrew Solomon's The Noonday Demon
and William Styron's Darkness Visible
are probably the best.Was writing about depression cathartic in any way for you, as you yourself have experienced a bout of depression firsthand? Did it bring back any memories that you wish hadn’t returned? Did writing this book make you more resilient to depression?
As with any memoir, writing this book changed my understanding of myself and my history. I had to consider, for instance, why I hadn't thought of myself as sick when I was depressed, and I had to rethink my first marriage in order to provide a fair account. That wasn’t a very happy memory. As to the effects of the book on my health, mental and otherwise, in the two years I spent writing it, I had a couple of major surgeries and a couple of illnesses, all stress related, plus the usual emotional chaos of a writer’s life. It hasn’t been long enough to know if the book will make me more resilient, but so far, being done with writing, it has reduced my trips to the doctor’s office. As many artists are considered to have experienced depression, do you think that there is a correlation between depression and the creative process? Did undergoing depression yourself help you with writing this book?
I think that there is a point of diminishing returns when it comes to depression and creativity, or any kind of productivity. No doubt depression, like any other intense emotional state, can fuel the creative fire. But sometimes depression becomes disabling, and then it’s only useful, if at all, in retrospect. My own experience was more useful in this fashion—as material to write about when I wasn’t so depressed. On the other hand, as I say in the book, I had some depression-like experiences as I wrote that helped me make connections between aspects of depression I hadn’t previously seen. Has writing this book changed the way you interact with your patients? Are you more careful in suggesting diagnoses for them?
I’ve always been pretty circumspect about diagnosis. The dirty little secret of therapy is that diagnosis is mostly meaningless. Diagnosis has some value—thinking of a patient as depressed, for instance, reminds you to be on the lookout for suicidal thoughts, and a diagnostic label is a nice shorthand when talking to my colleagues. But for the most part, the diagnosis is rendered for only one reason: to satisfy an insurance company’s requirements.Have your patients queried you about your findings in this book? If they feel that they are depressed, are they nervous about undergoing a drug treatment?
Some patients who have read my book have had to rethink whether they want to be in therapy with me. The book shows a side of my life that they don’t see, and it reveals some attitudes that, while they are implicit in my treatment, are disturbing to them when laid out explicitly on the page. Others find comfort in the fact that I am not interested in reducing their experience to a random biochemical event. And still others are greatly relieved by the fact that I don’t come out against drug use, but rather suggest that drugs be used mindfully and without the “cover story” that the disease model provides. What are your hopes for the treatment of depression in the future? Do you think that researchers are taking the rights steps in attaining these goals?
I hope that the diagnostic category of Major Depressive Disorder is carved up into much smaller, and more precise, diagnoses. In particular, I hope that the relatively small population of people who suffer from depressions caused by biochemical accidents (and I believe there are such people) can be isolated and identified, and drug treatments discovered for them. I think some doctors are pursuing this goal, but there’s not as much money in it as there is in expanding the diagnostic umbrella, so I don’t expect results anytime soon.What’s the best piece of advice you can give someone who thinks he or she is suffering depression?
Use all the resources at your disposal—medical, psychological, social, and otherwise. Put yourself in the presence of people that love you. Use your depression as an opportunity to understand yourself and the world around you, and remember that you’re not alone. Millions have suffered in the way that you are suffering, and nearly all of them got better. Like nearly everything, depression is temporary. It just doesn’t feel like it at the time.