Reinventing Depression: A History of the Treatment of Depression in Primary Care, 1940-2004 (review)

This book is the result of a collaboration between Christopher Callahan, an American academic physician, and German Berrios, the erudite British historian of psychiatry who is the editor of the journal History of Psychiatry and the author of the much-admired History of Mental Symptoms.¹ Together, the authors attempt to analyze changes in the delivery of mental-health services in the United Kingdom and the United States over the last sixty-odd years. They focus on the diagnosis and treatment of depression in primary-care settings, the place where most depressed patients are seen. This book is timely and welcome, given the fact that contemporary policymakers are still actively debating the merits of different strategies to enhance the treatment of depression.

The authors first set out to debunk a few myths, and they do so with ease and great effect. What kind of care could one have expected from a primary-care physician in 1950? Most hark back to some Marcus Welby dispensing kindness and wisdom by the bedside, tending to the needs of both body and soul. Unfortunately, historical records tell of a different old-time generalist, one very familiar to those enrolled in managed-care plans today. In 1953, American primary-care doctors saw an average of thirty patients a day, which all told meant about fifteen minutes a pop. Physical examinations were cursory and highly limited, medical records were nonexistent, and the beleaguered doctor wrote a prescription for all but about 5 percent of his visitors, according to one study (pp. 16–24). In 1952, the most common remedies prescribed were hypnotic sedatives: barbiturates and bromides, in that order. That is to say, the psychopharmacologic treatment of stress and emotional distress was a significant part of the bread and butter of everyday practice.

For the authors, the debunking of these idealized notions of primary care at mid-century allows for a clearer appreciation of the dramatic changes that have taken place in the delivery of mental-health services in general medical settings more recently. To understand those changes, the authors turn to the history of psychiatry after World War II. They take a surefooted run through public health strategies fostered by penicillin and the war on germs, and the adoption of such models in psychiatry based on hoped-for antidepressant "silver bullets" like lithium and the monoamine oxidase inhibitors. But these drugs were not ones that primary-care doctors embraced: they were difficult to use, required close follow-up, could be dangerous, and were controversial. Furthermore, depression itself was not an easy entity to pin down, given the varied definitions that floated through the psychiatric community.

Instead, primary-care doctors—urged on by public demand and advertising—embraced Miltown by the late 1950s, and then made Valium the most commonly prescribed drug in the world by the late 1960s. The authors suggest that these medications became popular because of their "safety" (relative to barbiturates), "efficacy," and "marketing" (p. 109). Generalists focused not on controversial psychiatric diagnostic categories, but rather on vague notions of emotional distress, which offered no rational constraints on prescribing these medications promiscuously. The harried doctor who in fifteen minutes needed to do something with his stressed-out or unhappy patient would, it seems, write a prescription for a sedative. Between 1955 and 1980, academic psychiatry offered little other guidance to primary-care doctors, who returned the favor by showing no great interest in psychiatry.

Callahan and Berrios contend that all this changed around 1980. The "reinventing of depression" began when psychiatry developed a stable diagnostic nomenclature (the DSM III), valid measures of psychiatric severity (such as the Hamilton scale), a clear biomedical model for affective disorders, and outreach programs to educate the public and the generalists as to the high prevalence of depression. They argue that this created a "new paradigm" that could be sold to...