Article — From the May 2007 issue

Manufacturing Depression

A journey into the economy of melancholy

Doctor George Papakostas has some bad news for me. For the last half hour, he’s been guiding me through a catalogue of my discontent — the stalled writing projects and the weedy garden, the dwindling bank accounts and the difficulties of parenthood, the wife I see mostly in the moments before sleep or on our separate ways out the door, the typical plaint and worry and disappointment of a middle-aged, middle-class American life, which you wouldn’t bore your friends with, which you wouldn’t bore yourself with if you could avoid it and if this sweet man with his solicitous tone hadn’t asked. He’s been circling numbers and ticking boxes, occasionally writing a word or two in the fat three-ring binder on his desk, and now he has stopped the interview to flip the pages and add up some numbers. His brown eyes go soft behind his glasses. He looks apologetic, nearly embarrassed.

“I’m sorry, Greg,” he says. “I don’t think you’re going to qualify for the study. You just don’t meet the criteria for Minor Depression.”

“The Distraught Queen of the Butterflies.” Illustration by Ernst Kreidolf (1863–1956)/ New York Public Library collection

“The Distraught Queen of the Butterflies.” Illustration by Ernst Kreidolf (1863–1956)/ New York Public Library collection

Even if my confessor had gotten my name right, I would still be a little humiliated. I had come to his office at the Depression Clinical and Research Program of the Massachusetts General Hospital, insisting that I would qualify. I had told him that I figured anyone paying sufficient attention was bound to show the two symptoms out of the nine listed in the Diagnostic and Statistical Manual (DSM-IV) of the American Psychiatric Association — sadness, diminished pleasure, weight loss or gain, trouble sleeping, fatigue or malaise, guilt, diminished concentration, and recurrent thoughts of death — that are required for the diagnosis.[1] To explain my certainty and my interest in his study, I had told Papakostas that these days my native pessimism was feasting on a surfeit of bad news — my country taken over by thugs, the calamity of capitalism more apparent every day, environmental cataclysm edging from the wings to center stage, the brute facts of life brought home by the illnesses and deaths of people I love and by my own creeping decrepitude. I told him that I had more or less resigned myself to my dourness, that it struck me as reasonable, realistic even, and no more or less mutable than my short stature, my constitutional laziness, my thinning hair, my modest musical talents, the quirks of my personality that drive away some people and attract others. I told him that, as a therapist, I lean toward talk therapies for psychic distress, but I am not at all opposed to better living through chemistry. If the drugs offered by his clinical trial — Celexa, Forest Laboratories’ blockbuster antidepressant, and Saint-John’s-wort, an herb with a reputation as a tonic for melancholy — did what they promised, I might like that, and if I did not, at least I’d know what I was turning down. And, finally, I had told him that I was going to write about whatever happened, which meant that either way, I wouldn’t come away empty-handed.

[1] Minor Depression is a provisional diagnosis, listed at the back of the DSM-IV, where it awaits further study. Research that uses this diagnosis thus has a twofold aim: to provide another FDA-approved indication for a particular drug and to give Minor Depression medicine’s most lucrative imprimatur — the five-digit code that allows doctors to bill insurance companies for treatment.

Unless I didn’t meet the criteria.

But before I can get too upset, Papakostas has more news. “What you have is Major Depression.” He looks over the notebook again. “It’s mild, but it’s not minor. Nope. Definitely major depressive disorder, atypical features, chronic.” Which means, he seems pleased to tell me, that I meet the criteria for at least four other studies that Mass General is running. I can take Celexa or Mirapex or Lexapro or something called s-adenosyl-l-methionine. I can climb into an MRI, get hooked up to an EEG, take home a device to monitor my pulse and breathing. I can get paid as much as $360 for my trouble. I can go back to the waiting area, read over the consent forms that spell out in great detail — down to the final disposition of the two tablespoons of blood that they will take — what will happen to me, what is expected of me, what my rights are, how I can bail out if I want to, and then I can make my decision.

I’m a quick shopper, and when Papakostas returns, I have already signed the papers for research study 1-RO1-MH74085-01A1, agreeing to return to Mass General next week and then every other week for the next two months, so that they can evaluate the alleged antidepressant properties of omega-3 fatty acids — in other words, fish oil.[2]

[2] According to the World Health Organization, the countries with the highest consumption of fish have the lowest rates of depression. And it happens that omega-3s make cell membranes, such as the receptors in your brain that absorb serotonin and other neurotransmitters, more permeable. To a psychiatrist already convinced that depression is the result of deficiencies in serotonin transmission, the significance of this correlation outweighs any of the other possible explanations for why someone in fish-deprived France might be more prone to depression than someone in Korea or Japan.

Which is why Julie and Caitlin — tall and attractive and polished bright, like all the research assistants here — are soon hovering over me in a tiny exam room that contains a metal table and a scale and a phlebotomist’s chair, tweezing tentatively through the thatch on my chest and worrying out loud that they are hurting me. They finally clear the spots for the EKG electrodes and run the scan. They take my pulse and blood pressure, weigh and measure me, and draw my blood into a vial. Fair-skinned Caitlin is blushing a little as she hands me the brown paper bag with a cup for my urine specimen. I can see how cowed these young women are by this forced intimacy, and I try to tell them they needn’t be so shy. But they know I have just been declared mentally ill, and I wonder if reassurance from the likes of me just makes things worse.

But I haven’t come here to minister to them or, for that matter, to maintain my dignity. In this nondescript office building beside the towers and pavilions of Massachusetts General Hospital in Boston, these dedicated people do the research that determines whether drugs work — which is to say, whether drugs will come to market as government-sanctioned cures. In the process, they turn complaint into symptom, symptom into illness, and illness into diagnosis, the secret knowledge of what really ails us, what we must do to cure it, and who we will be when we get better. This is the heart of the magic factory, the place where medicine is infused with the miracles of science, and I’ve come to see how it’s done.

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