American Melancholy: Constructions of Depression in the Twentieth Century

Introduction

Introduction 1 If you read about depression anywhere today—medical journal, popular magazine, National Institute of Mental Health (NIMH) pamphlet, or pharmaceutical company drug promotional literature—you will find three main pieces of information either explicitly stated or strongly implied: depression is a disease (like any other physical disease), it is extraordinarily prevalent in the world, and it occurs about twice as frequently in women as in men. The usual evidence marshaled to support these assertions includes clinical trials of patients responding to medications, World Health Organization statistics on the global burden of depression, and epidemiological data on the sex ratios in depression. All of this information sounds very compelling and scientific. Perusers of popular magazines a century ago would not have been able to find depression mentioned as a disease, or even as a state of mind. The concept of depression in the popular realm referred to an economic, not an emotional, condition. Yet now depression is everywhere. Magazine readers will find frequent mention of depression in their favorite periodicals, from Newsweek to Ladies’ Home Journal to Sports Illustrated to Parents Magazine. Popular accounts typically include the specific symptoms of depression, some explanation about treatment, and often patient stories of their experiences with depression. Commentators from public policy experts to physicians to journalists to patients discuss the tremendous extent of depression and its cost to society in time, resources, and human suffering. All of these accounts include the basic scientifically sounding facts of depression’s status as a disease, its prevalence, and its predominance in women. 2 American Melancholy It would be tempting to see the emergence and proliferation of information about depression over the last century as evidence of scientific progress and discovery. Yet on closer inspection there is clearly more to the story, particularly around the issue of depression and gender. When I was in medical school and heard about depression the first time, I was immediately struck by the assertion that it was twice as common in women as in men. I started to look into this and ask around, but I was deeply unsatisfied by the answers I received from both my senior supervisors and the literature I consulted. In essence, the explanations given were: there is something in women’s brains (probably related to estrogen) that produces depression; women’s response to stress is to make them depressed; and, most commonly, depression has occurred more in women throughout recorded history. I have to confess that I was suspicious of the claim that depression had always been more prevalent in women. (I had learned enough by that point in my training to know that the claim to eternal tradition was usually attached to a deeply ideologically driven practice.) As to the other two possibilities, I wondered about the men who were diagnosed with depression (what was wrong with their brains—too much estrogen?) or who were experiencing the same stress as women but were not apparently getting depressed. What about the other major lopsided mental illness statistic—that men suffered from substance abuse disorders at least twice as often as women? Was there a connection? The supposed sex difference in depression was also troubling because the diagnosis seemed somewhat arbitrarily defined (five out of a possible nine diagnostic criteria) and strongly suggested gender and power differences rather than simple biological sex differences. As I looked into the history of depression, I discovered that it was not well established that women had always suffered from depression more than men. In fact, there was no specific disease of depression prior to the 1980 edition of the American Psychiatric Association’s Diagnostic and Statistical ManualIII (DSM-III)—although there were disease categories of manic-depressive psychosis and involutional melancholia that shared a few of the same features as the current diagnosis of depression. Further, I discovered that the vast majority of clinical trials of medication for depression from the 1950s through the 1990s were done on predominantly female populations of patients, even before patients were selected for trials based on diagnosis or symptoms. As I pursued my inquiry about gender and depression, I was more and more struck by how much depression has become almost exclusively perceived as a woman’s disease in both medical and popular settings. In 1995, a Time magazine cover story on depression showed a picture of a solitary woman 3 Introduction looking down at...