How Everyone Became Depressed (21 page)

At the beginning, in the Task Force’s first draft of proposed diseases in August 1975, under “mood disorders,” the basic classification that Spitzer, Endicott, and Robins had been hewing away at in the RDC, the Task Force had “major mood disorders” versus “minor mood disorders,” and each had its major depression or minor depression.
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So far, so good.

But the Task Force was constantly stung by the reproach that the insurance companies would never pay for anything “minor,” so minor depression had to go—and therewith the doctrine of two distinct depressions, which we have been calling melancholia and nonmelancholia, went as well. In their next draft, in March 1976, the Task force forgot about major and minor and distinguished between episodic (meaning acute) and intermittent (meaning chronic) mood disorders, adding, probably at Don Klein’s insistence, demoralization disorder, in which Klein was a big believer.
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The two depressions had become not major and minor as before, but acute and chronic (“intermittent”). This acute–chronic distinction, together with a severity scale, was maintained for the next several drafts.

Meanwhile in the real world, news was starting to trickle out that the Task Force had big changes in mind for the profession. The first public airing of the new scheme took place at a meeting in St. Louis in 1976, and here the analysts began to scream. At a meeting of the Assembly, the American Psychiatric Association’s House of Delegates, in May 1976, these voices became loud, and Howard Berk, an analyst in Forest Hills, New York, became chair of an oversight body the Assembly created to ride herd on Spitzer and his crowd. In April 1977 Berk wrote the district organizations that, in essence, Spitzer was out of control and that the APA Assembly would definitely need to review the draft DSM before it was forwarded to the World Health Organization as “the official nomenclature of the United States.”
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So, there were big stakes.

The analysts’ fierce opposition created an unexpected political problem for Spitzer: acute versus intermittent depression corresponded to none of their categories. And Berk was whipping up the Assembly in the direction of rejecting the entire draft. In November 1978 Washington, DC analyst Paul Chodoff, tongue in cheek, called Spitzer “the chief assassin and gravedigger of the concept of neurosis.”
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Within mainline psychiatry Spitzer was simultaneously being pulled in opposite directions. Impressed by research that showed the number of stress factors in endogenous depression was the same as that in reactive depression,
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some psychiatrists started to argue that there was no difference between endogenous and reactive, and that endogenous depression should be abolished. Lyman Wynne, a Task Force member from the University of Rochester, told Spitzer in February 1978 that endogenous should be dropped from the vocabulary: “ . . . I would wager that ‘endogenous’ means lack of precipitating factors to most psychiatrists. On the other hand, when life events are carefully assessed, the alleged lack [of such events] for the ‘endogenous’ cases has repeatedly evaporated.”
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And Paula Clayton added in February 1979, “I wholeheartedly concur with Lyman’s suggestions.” Many patients with the diagnosis endogenous depression had very low Hamilton depression scores, she said: “Clearly severity does not necessarily correlate with ‘endogenicity.’ I am very much in favor of the term endogenous being dropped from DSM-III.”
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By contrast, Don Klein was pulling hard in the other direction, of shoring up endogenous in such a way as to differentiate it truly from nonendogenous depression. Klein had in mind the symptom of “autonomy,” meaning that the patient does not get better on good news. In April 1978 Klein told Spitzer that the crucial question was not whether the depression came out of the blue, but whether “Once the episode is underway, it is autonomous, that is unresponsive to changes in the initiating circumstances. If the patient with a depressive episode regains his job the illness continues.”
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(Mood autonomy became the basis of Klein’s doctrine of endogenomorphic depression that he floated in 1974; later, he emphasized “non-precipitation” rather than autonomy. Endogenomorphic depressions could be either endogenous or nonendogenous, but had a special responsiveness to medication.
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Thus Spitzer was torn between the advocates of one depression versus two, and for the duration of the drafting was buffeted by the two camps.
In January 1978 the term “major depression” returned to the draft classification. But what did this mean, given that “chronic affective disorders” was also in the roster? In March, Spitzer made a crucial decision: How to classify a woman featured in a training exercise who had episodic depression? Is she “major” or is she “chronic”? He decided that she was “major.” “The Cross sectional symptomatic picture of Major (full syndrome) takes precedence over the course.” Yet the analysts would not agree. “Most analytic types would regard this patient as a good example of a Chronic Depressive Personality, despite the fact that one can with perseverance count up four or five associated symptoms.”
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(The Task Force was now listing symptoms, and saying that a patient would have to score a given number to qualify for the diagnosis.) Herewith Spitzer was saying that whatever the patient’s past history of illness, it was the current picture that counted, and if a patient had over three symptoms on the list, the diagnosis would automatically be major depression. “I now have a picture of Kraepelin and Bleuler staring at me hauntingly in my room,” Spitzer added.
In April 1978 this decision was solidified: all “episodic affective disorders” would be called “major affective disorders” and all recurrent major affective disorders lasting more than 6 months would be called “chronic.” So any acute episode clearly not part of a recent history of depression would be major depression.
We are witnessing here, under the pressure of politics, the slow evolution of the sophisticated depression scheme of the Research Diagnostic Criteria into a single diagnosis: major depression. But we are not quite there yet because the classification still contained “chronic affective disorders,” and Spitzer wanted to characterize them as “minor,” despite the yowls of the insurance companies, to indicate that “the full depressive syndrome is not present.”
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(This puts to rest the charge, often heard later, that Spitzer abolished minor depression at the insistence of the insurance companies.)
Was there trouble ahead? In May 1978 Spitzer told the Task Force that “Part of our problem is that there is some feeling that it my be too easy to get into Major Depressive Disorder in DSM-III.” RDC requires 2 weeks; our current draft requires only 1.
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In fact the published version in 1980 would require 2 weeks, but at this point Spitzer only vaguely sensed “the plague of affective disorders,” as Don Klein put it, that was about to descend on psychiatry. It was, in fact, far too easy to get into Major Depression. And there was nothing else.
The final piece of architecture fell into place in July 1978 when Spitzer suggested rechristening Chronic Minor Depressive Disorder (CMDD) “dysthymia.” “CMDD” was “doomed to fail,” he said, “and rightly so . . . It is clumsy, and a four-word diagnostic term is hardly very appealing. Of more importance, there are not only insurance problems with the use of the term ‘Minor’ but there are also conceptual problems. This diagnostic entity can be devastating, and the term ‘Minor’ certainly does not suggest this.”
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(Unknown to Spitzer, who found the word dysthymia in Leland Hinsie and Jacob Shatzky’s Psychiatric Dictionary, dysthymia had a long history in medicine and “distimia” was in current use in Italy as a synonym for mood disorders.
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Now this sounds very much as though the concept of two depressions had been somehow preserved, doesn’t it? We have a major depression, which you can “get into,” as the phrase went, with four of the eight listed symptoms, and we have a chronic depression called dysthymia that, Spitzer insisted, could be devastating. Yet in the events that followed, dysthymia was downgraded to being a new name for neurotic depression, a kind of depressive personality that, although it kept the term depression current, previously had not even been considered a mood disorder but rather a neurosis. (Tom Ban, veteran psychopharmacologist at Vanderbilt University, later said of dysthymia patients, “They don’t have a depressive disease in which the mood transforms their experiences.”
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The analysts had been simmering with discontent for the previous 2 years. In March 1979 this discontent came to a boil as analyst Roger Peele, assistant superintendent of Saint Elizabeths Hospital, a government psychiatric facility in Washington, DC, proposed to Spitzer the revival of “neurotic disorders,” which would cover many of the proposed DSM-III diagnoses as a kind of umbrella. Peele’s note had a collegial tone, yet there were teeth in it: “Preservation of ‘neurotic disorders’ provides us with a greater unanimity within the profession, avoids a major clash within the Assembly and a possible Assembly-Board struggle. It would also head off, I would submit, a referendum that would ill serve DSM-III even if DSM-III won.”
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Spitzer panicked at this head shot. Without consulting with other Task Force members, 2 weeks later he wrote the committee of the American Psychoanalytic Association that liaised with the Assembly of the American Psychiatric Association a humble letter requesting a “neurotic peace treaty.” The DSM-IIIdraft would insert “neurosis” at various strategic points.
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Would this be enough to satisfy them?
Spitzer’s letter of concession certainly was not enough to satisfy members of the Task Force, who were furious at this authoritarian end run. Don Klein wrote Spitzer 3 days after receiving Spitzer’s memo confessing what he had done: “I must admit that I was flabbergasted by this memo. . . . I was particularly concerned about the seemingly autocratic procedure . . . The Task Force already has taken a clear stand upon the utility of the term ‘neurosis.’ Your current stand is, as far as I can see, entirely your own creation and was taken without their consultation with the Task Force or its agreement.” Terrible time pressure, sure, said Klein, but not even a telephone call! “I am left with the nagging feeling that this was an attempt to create a fait accompli, so that the Task Force has its hands tied.”
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The point here is that yet another fateful decision in the DSM process was entirely Spitzer’s alone, and not that of a group of psychiatrist Wise Persons.
The psychoanalysts held out for something more than a bunch of vague references to neurosis strewn throughout the text. They evidently wanted dysthymia to be renamed neurotic depression, and Spitzer conceded.
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The revised draft of April 25, 1979 said that “chronic depressive disorder” had been renamed “Dysthymic disorder (Neurotic depression).”
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So neurotic depression, the blues of bored suburban housewives in the 1950s, had survived as the second depression. Everything else was major depression. This was actually quite a stunning achievement. Spitzer had collapsed the two depressions of melancholia and nonmelancholia, in use in psychiatry for over two centuries, into a single depression, called major depression, and ensured that it was the only diagnosis you could get into unless you were seeing a psychoanalyst and could qualify for neurotic depression. Major depression, often simply called “depression,” went on to become the diagnosis of one-tenth of the United States population—one out of every 10 on that subway car was depressed—and it all happened at the Psychiatric Institute.

In DSM-III major depression had various subtypes. One of them was melancholia. This was a result of the buffeting Spitzer received from the different camps. In February 1979, he got an impassioned letter from Bernard Carroll at the University of Michigan. Carroll, an Australian “double doctor” (endocrinology and medicine) by origin and then 39 years old, had proposed the dexamethasone suppression test in 1968 and was in the vanguard, together with Edward Sachar, Don Klein, and Max Fink, of biological thinking in psychiatry. “My emphatic view is that it is a serious mistake to have only one basic depressive typology or category . . . I believe that there should be two categories of depression. These should be endogenomorphic [Klein’s 1974 idea] and non-endogenomorphic depression.” Carroll explained that each category might have its own severity scale. “I am sincerely suggesting these changes to you with the greatest possible sense of urgency. I honestly believe that you will be buying yourself (and the rest of us) a lot of grief if you allow the unitary category of major depressive disorder to remain.”
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At this late stage in the drafting, such a missive was as welcome to Spitzer as rat poison, and he replied dismissively.
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But it made him aware that he would have a problem if he ignored melancholia.

Around the same time, in early February 1978, Carroll and colleagues at the Mental Health Research Institute of the University of Michigan published a letter critiquing the concept of “endogenous depression,” as articulated in the Research Diagnostic Criteria, which, of course, Spitzer had edited.
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He may have got the wind up over this as well.

Two weeks after replying to Carroll, Spitzer resolved to act. He wrote to the “Affective Mavens,” as he called the inner circle, “We are in big trouble!” Our severity typology misses the point of whether the cases of major depression are endogenous or not. “There needs to be some way of subtyping Major Depressive Disorder that would enable this distinction to be made.” Spitzer went over the factors that, he believed, constituted endogenous depression, such as loss of pleasure in activities, nonreactivity, inappropriate guilt, and psychomotor slowing.

“What to call this syndrome?” he asked the committee, taking for granted that they would agree to include it. Here, again, he went over the obvious candidates—endogenomorphic (con: “implies the absence of a precipitating event”); vital depression (con: “Does this mean a lively depression?”); and anhedonic syndrome (con: “the syndrome includes features that are not symptomatic of anhedonia”).