How Everyone Became Depressed (26 page)

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He threw this off as a casual observation.
Just as a kind of post-holing in the great prairie of informal discussion in psychiatry over the decades: It is 1997 and Joseph Autry at the National Institute of Mental Health is being interviewed by Leo Hollister, a leading United States psychopharmacologist.

Autry: “In talking to my internist friends, they say that probably 40–50% of the patients that they see have some significant component of depression or anxiety disorder.”

Hollister: “It is interesting that you have mentioned the two together, because for many years John Overall and I were doing studies in depression, and we found that anxiety was just as frequent and just as severe in depressed patients as depression.”

Autry: “I think that’s absolutely correct. I think you also are seeing that many of the antidepressants that have been developed have in turn been used to treat anxiety disorders over the past several years.”
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Here is one more example, from across the Atlantic, not just for the sake of accumulating examples but to show that most clinicians, in their heart of hearts, thought anxiety and depression were really the same illness: It was only the DSM drafters who wanted to keep them apart. At a conference in the United Kingdom in 1991, the subject was panic disorder. John Francis William (“Bill”) Deakin, professor of psychiatry at Manchester University, said that “There is evidence that panic disorder is different from other forms of anxiety, although it does seem to emerge in the course of depressive illness. I don’t think that other symptoms of anxiety are distinct from depressive symptoms. They are all symptoms of minor affective disturbance. Very few people have generalized anxiety without symptoms of depression, either at the same time or emerging during the course of their lifetime disturbance.”
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Yes, indeed. Anxiety and depression are part of the same package, and it helps take the emphasis off mood and put it on the body as a whole if we refer to this package not as mixed anxiety-depression but with another term. I have proposed nerves, but am not entrenched on this, and a national discussion would be timely.

It has not escaped many observers that today we are drenched in anxiety. As Francis P. Rhoades, a 64-year-old Detroit family doctor, said at an FDA hearing in 1966: “We live in a society that is characterized by anxiety. Practically everybody is anxious about something all the time.”
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Musing about the age of anxiety has become a talk show staple. Where did this come from?

It is not just depression that was extracted from nerves and made into a disorder of mood. The same fate happened to anxiety.
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The disappearance of anxiety from the nervous diagnosis and its conversion into a mood disorder began in 1948 at the Boston Psychopathic Hospital with advocacy of methamphetamine for use in the treatment of tension (the “Pervitin interview”).
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(In 1947 methamphetamine was already being promoted for weight loss.
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) Thus, a pharmacological torch was carving out tension. Then in the same year, 1948, T. M. Ling and Lloyd Davies at the new Roffey Park Rehabilitation Centre for “industrial neuroses” in Horsham, Sussex, administered methamphetamine to 140 patients with “chronic anxiety” and “acute posttraumatic anxieties.” The drug was said to help the patients “relive their painful traumatic experiences with dramatic relief of tension, and a feeling of relaxation. In the cases that abreacted, the drug was of therapeutic value. In others, the use of the drug uncovered material available to the patient’s consciousness for integration and assimilation.”
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So here we have anxiety hived off from everything else and made pharmacologically into a separate illness.

In 1955 the pharmaceutical industry moved into anxiety in a big way with the launch of meprobamate, promoted by Wallace Laboratories as Miltown and by Wyeth Laboratories as Equanil. Meprobamate was flogged not as a sedative (which would have made it appropriate for nervous conditions) but as a tranquilizer, a new term. Meprobamate was thought to share with chlorpromazine (which was later an antipsychotic) and reserpine (an antihypertensive drug that enjoyed a brief sojourn in the psychiatric tent) the quality of making anxious patients tranquil. Because there were no tranquilizers for the other components of the nervous syndrome—depression, fatigue, and somatic symptoms—labeling a drug a tranquilizer and indicating it for anxiety silenced the discussion of anxiety as a nervous symptom. Wyeth’s ads stressed heavily that Equanil was an “antianxiety” drug and reduced muscular tension as well.
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Nothing was said about sedation or nerves. Similarly, Wallace Laboratories, which had originated the drug, billed Miltown as “an entirely new type of tranquilizer,” indicating it for “anxiety, tension and mental stress.”
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All this reinforced the idea of anxiety as an independent illness.

Chlorpromazine, the first antipsychotic, reached French markets in 1953 as Largactil, billed by its original manufacturer Rh ô ne-Poulenc as a “sedative,” among other uses. But the term was soon downplayed for “anxious states, psychasthenias, and neurovegetative dystonias,” a diagnosis popular in Europe for somatic anxiety that did not reach the trans-Atlantic world.
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Smith Kline & French Laboratories brought out chlorpromazine in the United States in 1954 as Thorazine, indicating it as an antiemetic. Yet the company had bigger fish to fry than the vomiting of cancer chemotherapy, and from 1955 on they were selling it for pain, psychosis, and anxiety (chlorpromazine is in fact effective for all three).
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An ad for Thorazine in “a child with a behavior disorder” in 1956 had every appearance of making the drug look like a sedative: “calming effect in seriously disturbed youngsters . . . reduces hyperactivity and aggressiveness.”
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As for “anxiety, tension, and agitated depression” in the “menopausal patient,” hey come on! Chlorpromazine is the drug of choice.
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Throughout this barrage of mood indications Smith Kline did not use the term sedative, and insisted that chlorpromazine was a tranquilizer.

Thus, around 1955 two powerful new drugs were launched—meprobamate and chlorpromazine—that claimed to treat anxiety independently of other conditions. They were not thought of as sedatives, and the “n” word for nervous was never, ever used in promoting them to the profession. Pharmaceutical marketing thus completed the process psychoanalysis had begun of cutting loose anxiety from nerves and casting it adrift as an independent disease.

The anxiety picture came even more sharply into focus with the discovery, or the claim, that the new benzodiazepine drug class, introduced with Librium in 1960, treated anxiety specifically rather than just generally sedating. There was a certain logic to calling this drug class, effective in many disorders, antianxiety agents. As Chicago neurophysiologist Ralph Gerard, an early American leader in neuroscience, explained in 1957, 3 years before the launch of Librium, “If a given drug is called a tranquilizer, it is likely to be prescribed for disturbed psychotics, to be compared with chlorpromazine . . . and to be regarded in the patient’s milieu as a stigma on the taker; if it is called a hypnotic, it is likely to be used on a ten- or twentyfold larger scale, to be compared with barbiturates, and to be accepted as neutrally as is aspirin.”
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Roche was wise. They chose a name that would win a large and anxious public, without inviting invidious comparisons with other popular agents such as Miltown. The benzodiazepines were to be antianxiety drugs.

And the benzodiazepines did seem to have a specific antianxiety effect. In 1974 Malcolm Lader and colleagues at the Maudsley Hospital in a double blind trial put a barbiturate head to head against three benzodiazepines and a placebo in 20 outpatients with chronic anxiety. The three benzodiazepines beat the barbiturate and the placebo hands down.
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The implication was clearly that anxiety was a disease of its own, miles away from whatever it was that the hoary old barbiturates had claimed to treat.

This new clinical focus on anxiety may have been responsible for some of the increase in anxiety—either as a subjective state or as a diagnosis—that seems to have occurred in the twentieth century. Fear has always existed, but anxiety does seem to be up. As journalist Patricia Pearson reminds us, “In these times we speak a great deal about fear, the politics of fear, the culture of fear . . . But fear and anxiety are vitally different experiences, and it is actually anxiety that characterizes our age. Fear is involved by an immediate threat, and galvanizes a response . . . The signature vexation of anxiety is that it is objectless. It washes over one in formless waves, pulls one under until the pressure and constriction are tangible and panic rears. ‘I’m in deep. I’m going down.’”
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In an analysis of 5450 patient charts at seven different clinics, an outpatient service, and a private practice in the Netherlands for the years 1900 to 1985, Giel Hutschemaekers found “a clear overall increase in anxiety complaints.” Before 1910, 41% of patients reported anxiety; in the early 1980s 72% did so. The incidence of anxiety had thus almost doubled, whether because of greater patient subjective complaints or increased physician sensitivity to anxiety, now that treatments for it were available
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(but treatments had been available, notably the barbiturates, in the previous period as well).

Within the grab-bag of anxiety disorders that DSM created in 1980, one stands closest to the nervous breakdown, panic disorder. And it is the epidemic of panic that strides in the shadow of the epidemic of depression.

The symptoms of panic disorder are like a snapshot in time of a more general breakdown: the desperate feeling of being unable to catch one’s breath, the pounding heart, the overwhelming anxiety about coping with this flood of symptoms cascading over the body. Within the panoply of anxiety symptoms, panic is not the most frequent: “Unspecified” anxiety disorders are by far the most common in office visits in the United States. Yet among the “specified” kinds of anxiety—phobia, obsessive-compulsive, posttraumatic—panic is in the lead, and has been sharply increasing in frequency.
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Panic disorder first surfaced late in the nineteenth century (see Chapter 5), then the paroxystic forms of anxiety languished in obscurity because patients with them had such an organic feeling that the psychoanalysts were not interested. The revival of interest in panic disorder began with the brilliant Harvard psychiatrist Mandel Cohen, arguably the founder of biological thinking in American psychiatry, in 1940, with his work on inducing panic chemically in patients who had an underlying anxiety disorder by having them rebreathe carbon dioxide (if you put a paper bag over your head and take and expel deep breaths for about 10 minutes you will do approximately the same experiment that Cohen did). His subjects began “clutching at throat, writhing and wringing hands,” and “experienced feelings and sensations resembling or identical with their anxiety attacks.”
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He revisited the subject again in 1951 with Harvard cardiologist Paul Dudley White, who was President Eisenhower’s physician after his heart attack in 1955—under the label “neurocirculatory asthenia”: “The patients may have chief complaints of choking and smothering spells, rapid heart beat, pain in the chest, nervousness, ‘get tired easily’ . . . or ‘I believe I have heart trouble.’” Neurocirculatory asthenia resembled the nervous syndrome in that 95% of the patients with it “tired easily.” Eighty-eight percent reported “nervousness,” and 50% reported “unhappiness,” the contemporary equivalent of what we would call depression. The disorder had a chronic form and an acute form, which latter probably corresponds to a panic attack: “Choking and smothering feelings are prominent, especially in crowds; patients complain ‘I have to open the windows’ or ‘leave the crowded bus.’” At the onset of symptoms, the patients dread having an “anxiety attack” and “may avoid church or the cinema, or if attending the latter, sit near the rear . . . in order to insure hasty egress, if necessary.”
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The term neurocirculatory asthenia, however, did not catch on.

In 1967 Ferris Pitts in the Department of Psychiatry at Washington University in St. Louis, prompted by the observation that anxious individuals tended to produce excess amounts of blood lactic acid during exercise, in a double-blind study undertook to administer infusions of lactate to patients with histories of anxiety and to controls. The anxiety patients responded to the lactate by developing anxiety attacks, but the controls on the whole did not. The investigators, who presumably did not know about Cohen’s one-page article in 1940, said, “This is the first reported demonstration that anxiety attacks and anxiety symptoms can be produced predictably by a specific stimulus . . . ”
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The paper put the organicity of anxiety attacks back on the table for discussion: Did these patients have a separate chemistry, comparable perhaps to the imputed neurochemistry of depression (“serotonin deficiency”)?

Meanwhile, events were on the move elsewhere. The terms “panic” and “anxiety attack” had been used sporadically in psychiatry for decades. Of 100 Boston patients with manic-depressive disease in 1957, 33% also had “anxiety attacks,” as opposed to 4% of medically sick controls.
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At the Second International Congress of Psychiatry in Zurich in 1957, Douglas Goldman, a Cincinnati psychiatrist and one of the pioneers of psychopharmacology, said offhandedly, “We see many cases of acute panic reactions that are schizophrenic in form,” as though the audience were perfectly familiar with the term.
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In 1959, Martin Roth, a pioneering student of illness classification then at Newcastle upon Tyne, anticipated panic disorder with his diagnosis “the phobic anxiety-depersonalization syndrome”: “There was a fearful aversion to leaving familiar surroundings, to walking in the streets and to entering shops, travelling in vehicles or visiting cinemas or theatres. Waiting or sitting still in such settings was prone to evoke a sense of impeding disaster, acute agitation and flight in panic.”
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Again, the diagnosis, perhaps because of its very clunkiness, did not catch on, but the term panic was certainly abroad.