Enlightenment Now: The Case for Reason, Science, Humanism, and Progress

Consider one oft-cited study, which implausibly claimed that every cohort from the GI Generation through the Baby Boomers was more depressed than the one before.⁶³ The investigators reached that conclusion by asking people of different ages to recall times when they had been depressed. But that made the study a hostage to memory: the longer ago an episode took place, the less likely it is that a person will recall it, especially (as we saw in chapter 4) if the episode was unpleasant. That creates an illusion that recent periods and younger cohorts are more vulnerable to depression. Such a study is also hostage to mortality. As the decades pass, depressed people are more likely to die of suicide and other causes, so the old people who remain in a sample are the mentally healthier ones, making it seem as if everyone who was born long ago is mentally healthier.

Another distorter of history is a change in attitudes. Recent decades have seen outreach programs and media campaigns designed to increase awareness and decrease the stigma of depression. Drug companies have advertised a pharmacopoeia of antidepressants directly to consumers. Bureaucracies demand that people be diagnosed with some disorder before they can receive entitlements such as therapy, government services, and a right against discrimination. All these inducements could make people more likely to report that they are depressed.

At the same time, the mental health professions, and perhaps the culture at large, has been lowering the bar for what counts as a mental illness. The list of disorders in the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association tripled between 1952 and 1994, when it included almost three hundred disorders, including Avoidant Personality Disorder (which applies to many people who formerly were called shy), Caffeine Intoxication, and Female Sexual Dysfunction. The number of symptoms needed to justify a diagnosis has fallen, and the number of stressors that may be credited with triggering one has increased. As the psychologist Richard McNally has noted, “Civilians who underwent the terror of World War II, especially Nazi death factories . . . , would surely be puzzled to learn that having a wisdom tooth extracted, encountering obnoxious jokes at work, or giving birth to a healthy baby after an uncomplicated delivery can cause Post-Traumatic Stress Disorder.”⁶⁴ By the same shift, the label “depression” today may be applied to conditions that in the past were called grief, sorrow, or sadness.

Psychologists and psychiatrists have begun to sound the alarm against this “disease mongering,” “concept creep,” “selling sickness,” and “expanding empire of psychopathology.”⁶⁵ In her 2013 article “Abnormal Is the New Normal,” the psychologist Robin Rosenberg noted that the latest version of the DSM could diagnose half the American population with a mental disorder over the course of their lives.⁶⁶

The expanding empire of psychopathology is a first-world problem, and in many ways is a sign of moral progress.⁶⁷ Recognizing a person’s suffering, even with a diagnostic label, is a form of compassion, particularly when the suffering can be alleviated. One of psychology’s best-kept secrets is that cognitive behavior therapy is demonstrably effective (often more effective than drugs) in treating many forms of distress, including depression, anxiety, panic attacks, PTSD, insomnia, and the symptoms of schizophrenia.⁶⁸ With mental disorders making up more than 7 percent of the global burden of disability (major depression alone making up 2.5 percent), that’s a lot of reducible suffering.⁶⁹ The editors of the journal Public Library of Science: Medicine recently called attention to “the paradox of mental health”: over-medicalization and over-treatment in the wealthy West, and under-recognition and under-treatment in the rest of the world.⁷⁰

With the widening net of diagnosis, the only way to tell whether more people are depressed these days is to administer a standardized test of depressive symptoms to nationally representative samples of people of different ages over many decades. No study has met this gold standard, but several have applied a constant yardstick to more circumscribed populations.⁷¹ Two intensive, long-term studies in rural counties (one in Sweden, one in Canada) signed up people born between the 1870s and the 1990s and tracked them from the middle to the late 20th century, embracing staggered lives that spanned more than a century. Neither found signs of a long-term rise in depression.⁷²