





[The following transcript is from debatesdebates, a nationally-broadcast public television show produced and directed by the late Warren Steibel at HBO studios in New York City. This show, entitled "Is An Egalitarian Healthcare Workable?," was taped on August 19, 1997. Show #210. Please contact debatesdebates in New York for permission to reproduce this transcript. http://www.debatesdebates.com] "Is Depression A Disease?" Debatesdebates

Produced by Warren Steibel

Taped: March 31, 1998, New York

Show #235, Aired the week of May 13, 1998

NO YES Thomas S. Szasz, M.D. Donald F. Klein, M.D. Professor Psychiatry Emeritus Director SUNY Health Science Center Department of Therapeutics Syracuse, New York N.Y. State Psychiatric Institute Jeffrey A. Schaler, Ph.D. Frederick K. Goodwin, M.D. Adjunct Professor Former Director, NIMH School of Public Affairs Center for Neuroscience, American University Medical Progress & Society Washington, D.C. George Washington Univ. Medical Center Wash., D.C. Ron Leifer, M.D. Peter Kramer, M.D. Psychiatrist & Author Professor & Author The Happiness Project Listening to Prozac Ithaca, N.Y. Brown University Dept. of Psychiatry & Human Behavior MODERATOR: Welcome to this week's television debate, "Is Depression a Disease?". I'm Martin Nix, I'm the time keeper and part time referee. Let's get ready to start our introductions. Dr. Donald Klein. KLEIN: My name is Dr. Donald Klein. I am Professor of Psychiatry at Columbia University and Director of Research at the New York State Psychiatric Institute. My work with depression started about forty years ago, when we were studying the first anti-depressant, Tofranil. We found that patients who could have no joy in life, no pleasure, profound insomnia, anorexia, lost weight, were often suicidal, when given Tofranil, nothing much happened for a couple of weeks, and then after two and a half, three weeks, remarkable changes occurred. They would say things like the veil has lifted, I am suddenly able to live again, I can be a person. Now, what was astounding about this, is that that drug, when given to ordinary human beings, did not make them happier. It had practically no effect upon ordinary people. Therefore, depression, clinical depression, is not unhappiness, it is an illness that is open to medication and can be medicated well. It is that elementary fact, that the antidepressants do little to normals, and are tremendously effective in the clinically depressed person, that shows us that this is an illness. MODERATOR: Thank you, Dr. Thomas Szasz. SZASZ: I am Thomas Szasz, and I am here and my colleagues are here to discuss whether depression is a disease. We will argue that it is not a disease. And I can show some of the basic elements as follows. A disease scientifically is defined as a biological abnormality that affects living tissues. Trees can be diseased, plants, animals, and humans. A real disease is typhoid fever, we call it a literal disease. Spring fever sounds like a disease but it is not a disease. The whale is a real animal, but it is not a fish, it is a metaphorical fish. So when we say depression is not a disease, we do not minimize the human phenomenon suffering. It exists like the whale exists but it is not a disease. Point number two: treatment has got nothing to do with disease. None of us object to psychiatry between consenting adults, when psychiatrists talk about this treatment and disease, they mean locking up people in prisons that they call hospitals, and forcing on to them chemicals that they call treatment. We have no objection to voluntary treatments, like for diabetes. And thirdly, suicide is not a medical problem. It is a moral problem, it is a legal problem, it is an existential problem. Killing oneself is as old as mankind, it is exactly like killing others, or killing animals. It's not a medical problem. MODERATOR: Thank you, Dr. Donald Klein, would you introduce your first teammate? KLEIN: Yes, Fred Goodwin is Professor of Psychiatry at George Washington University, and formerly Director at the National Institute of Mental Health, he has been an eminent researcher in the area of depression for over thirty years. GOODWIN: I'd like to be philosophical as Dr. Szasz was. The concept of disease in medicine really means a cluster of symptoms that people can agree about, and in the case of depression we agree 80% of the time. It is a cluster of symptoms that predicts something, it predicts a natural course, an outcome, it predicts the way in which treatments work or don't work. Now, one thing we don't realize very much is that in the case of the reliability of a diagnosis, that is, how much do people agree, actually depression ranks up there pretty high with the rest of medicine. I don't think many people realize that doctors looking at a mammogram to tell a woman whether she has breast cancer, agree 67% of the time, whereas doctors interviewing a depressed patient to see whether they have clinical depression, is 80% of the time. In fact, it's right up near the top. I think the issue is that in depression, in "big D" depression, we often confuse, it's a semantic issue, we confuse the state of being depressed with the disease of being depressed, which involves a lot more than feeling and thinking, it involves a whole bunch of physiological disregulations. And now, in terms of this issue of whether we know something about the pathology of the disease, I think brain imaging is making these arguments a little bit dated. Because in fact now we can look at brain images with PET scans and MRIs, and see that there are differences in depressed patients and people who are not depressed. MODERATOR: Thank you, Dr. Szasz, your first teammate. SZASZ: I am happy to introduce Dr. Jeffrey Schaler, my friend and Adjunct Professor at American University. SCHALER: Thank you, Tom. Well, right off the bat I see we disagree. And I see that our opponents are already confusing diseases with behaviors. Now, depression most certainly is not a disease, because depression is a word that we use to describe activity, and activities are behaviors based in values. They aren't physical, they are ways of moving in the world. Now, if by a disease you mean something physiological, if you have a particular way of deciding that a person's brain is not producing enough serotonin, for example, or uptaking enough, or there's a problem in uptake or transmission of serotonin, then perhaps what you've discovered and outlined would qualify as a bona fide disease. In that case, though, you don't rely primarily on activity or symptoms, I beg to differ, a diagnosis is not made on the basis of a cluster of symptoms, it is made on the basis of a cluster of signs. And when we talk about signs in medicine we are talking about physiological lesions, neurochemical imbalances, etc. Depression is not found in a corpse at autopsy, because depression does not refer to anything physiological, it refers to how a person conducts himself, or moves in the world. Thank you. MODERATOR: Thank you, Dr. Klein, your final teammate. KLEIN: Yes, our next discussant is Dr. Peter Kramer. Dr. Kramer is Professor of Psychiatry at Brown University. He is the author of the extremely well known and excellent book, Listening to Prozac. KRAMER: Thank you, Donald. I am very pleased to be on this side of the aisle because I have written a couple of books, Listening to Prozac, and Should you Leave?, that concern the minor chronic states of depression that verge into personality styles. And I think there, there's lots of room for debate, and lots of interesting reasons perhaps to say that culture may do better to call those something other than illnesses. But, the core element, the core disease depression I think is now indisputable, and I think we might as well end the debate right here and go on to the second issue of the extent of the disease. I think Dr. Schaler is willing to say that if we can find changes on autopsy that characterize someone who is severely depressed, he's going to come on over to our side, maybe Dr. Szasz would like to, as well. And it certainly is true that people who have died, males who have died violent suicides, have characteristic low levels of brain serotonin. This is something that has been researched around the world. And, so I think there is a core illness that is depression. And we have to go on to say, what is its extent? MODERATOR: Thank you, Dr. Szasz, your final teammate. SZASZ: I am happy to introduce my friend Dr. Ron Leifer, a practicing psychiatrist in Ithaca and author of The Happiness Project. LEIFER: Thank you, Dr. Szasz. And not so fast, Dr. Kramer. I don't think the discussion is over yet. Just the title of this program, "Is Depression a Disease?" I think reveals the weakness of your side. Wouldn't it be foolish if we were sitting here discussing, "Is Diabetes a Disease?," or "Is Pneumonia a Disease?" That, the fact that we are discussing this reveals that there is some question about it. Also, the question "Is Depression a Disease?" is not a factual question. We're not going to find disease anywhere in nature, it is a name, and the question is should we use that name with all its implications or not? In my view, your side is emphasizing the biochemical changes. In my view, I'm calling it a disease because presumably there are biochemical changes, and I'm willing to concede all the facts, all the facts that you fellows have found in laboratories, given that they are properly discussed, debated, and criticized, which I don't think is true. You guys are in the majority, you've got the forces of propaganda, you've got the psychiatric establishment, you've got the pharmaceutical industry, all saying that depression is a disease caused by a biochemical imbalance. We have been for thirty years trying to get to this point where we have an opportunity to debate you. Now that we have this opportunity I'd like to say that I have a different view of depression. In my view, and I'm a Buddhist, which is shown by my book, in my view, depression is a spiritual problem. The main symptoms of depression are hopelessness and helplessness. The main problem is that we're all living life with hopes and with some desire to control our lives. If our hopes are unrealistic, our hopes are going to be dashed. In my view, depression is dashed hope, and a feeling of being out of control of one's life. Depression is about the future, it's a sense of not having the possibility of being happy in the future. When we get into this kind of spiritual predicament, our body can bog down. I think that the spiritual problem causes changes in the body, so that all those changes are present. The question is, are they cause or effect. I think they are effect rather than cause, an effect of a spiritual problem. MODERATOR: Thank you. Well, you're opportunity has arrived. We're ready to start the debate. Thomas Szasz, you can stand up. First question from the other side. KLEIN: Thank you. Dr. Szasz, isn't it so that there have been many diseases that have been identified in medicine long before we had any idea of what the biological difficulty was? SZASZ: That's correct. KLEIN: Therefore, why do you take the stand that these illnesses we refer to as depression, cannot be a disease, it cannot simply be that we have not yet identified the biological changes that cause that disease? SZASZ: It cannot be identified for the reasons Dr. Leifer already mentioned, because its initial position from which it is identified is a purely subjective reaction, like pain from stimulus. So it is not a disease it is a perception. But also, my argument, as I stated it right off, is two-pronged. I am willing for the sake of the argument, and I personally resent the idea of wanting to come over to another side. I have had forty years of experience of coming over to the other so I don't need any invitations. The other side, in my opinion, uses the term disease to lock up people, deprive them of liberty and deprive them of responsibility. You can give people all the antidepressants you want, as far as I am concerned, I just don't want you to give them to people who don't want them. So the idea of depression is not the only issue that we are discussing here. KRAMER: I think you have come over to the other side if you say you can give all the antidepressants you want, under the rubric of medicine, only don't lock up people. Because then we're having a political debate, not a medical debate. I think that your work has been very important over the past forty years in asking psychiatry to distinguish between two models: one, the psychotherapeutic model, which I think you've attacked actually quite successfully, and the other medical model. And I think you have said, in your mind, the right standard for psychiatry is that disease has to be physiochemical and it has to have effects on organ systems. And I say that if you would like to declare victory and go home, you may, I think that psychiatry has risen to that challenge, has shown that depression has physiochemical causes and effects. And we can give medications that in a percentage of people will reliably produce the whole syndrome of depression. SZASZ: Excuse me, I don't want to interrupt, but you are never addressing the issue of involuntary treatment. KRAMER: No, I wanted to discuss "Is Depression a Disease?" GOODWIN: That's a separate debate, I think. It's an important debate but a separate one. SZASZ: It's not a separate debate because a word means its consequences. You don't get the meaning of words from a dictionary, floating around. If mental disease means, why do we have separate hospitals for mental diseases and medical diseases? Why can you plead insanity? I mean . . . GOODWIN: As you yourself said, we don't involuntarily treat people for medical diseases. I'd like to as you . . . do you think Alzheimer's is a disease? SZASZ: Of course it is a disease. GOODWIN: And it involves behavior? SZASZ: Of course it involves behavior. Doesn't having a cold involve behavior? GOODWIN: You said if it involves behavior it couldn't be a disease. SZASZ: No, you don't diagnose it, Alzheimer's, if I may remind you. Who discovered Alzheimer's? A pathologist, on the corpse. GOODWIN: Now they are close to diagnosing with brain imaging . . . SZASZ: Brain imaging is a great scientific discovery. GOODWIN: Now they do that with depression as well, you are aware of that? SZASZ: Of course I am aware of that. GOODWIN: So here you have two illnesses, one we call Alzheimer's which you say is a disease, it involves a whole range of behaviors, feelings, thinking, behaviors. There's another one that involves behavior, feelings, thinking, behaviors . . . SZASZ: But depression is a highly reversible phenomenon. GOODWIN: Is that your criterion for disease? What about pneumonia? SZASZ: No, but Alzheimer's is not. GOODWIN: Does that mean diseases are not reversible? SZASZ: Look, the criterion for disease is not made by you and me. As you know, depression is not listed in textbooks of pathology. Maybe when it's listed in textbooks of pathology I might be willing to concede, like Dr. Klein suggests, that it's like neuro-syphilis or epilepsy, the history of medicine, it's quite correct, you discover new diseases, like AIDS. GOODWIN: Periodic fever, is not listed either, because there's no pathology we know of, but it's a disease. SZASZ: That's a borderline case. Do you recognize the existence of metaphoric diseases? GOODWIN: I'm not sure what you mean. SZASZ: I just told you, a whale is a fish, it is a metaphoric fish. Now if you don't know what a metaphor means, then we can't discuss it, because our contention is that this is a metaphor that has gone amuck. GOODWIN: I think you are mixing together the symptoms of depression with the whole syndrome. SZASZ: No, we are making the distinction between literal and metaphorical diseases. Is spring fever a metaphorical disease or not? KRAMER: I think our contention is that depression is a literal disease. SZASZ: What about involuntary treatment? KRAMER: The problem with a debate against depression as a disease is its two-pronged, and I think your side tries to take the easier side of each prong. That is you say, on the one hand disease is socially constructed, but depression is constructed wrongly socially. On the other hand, disease must be physiological, which by the way, I disagree with, that diseases must be defined on the basis of known pathophysiology. MODERATOR: Do you have a quick answer to that? SZASZ: Well, I come down to the fact that words mean their consequences. I am not willing to disconnect the debate of "Is Depression a Disease" from involuntary treatment. Because you can call anything anything you want. MODERATOR; Thank you. Dr. Donald Klein, it's your turn. SCHALER: Dr. Klein, you cited the fact that when people take certain kinds of drugs they feel better as supporting the existence of depression. KLEIN: I think you misunderstood me. I said that when normal people take these drugs, they don't feel better, that's the essential difference. I said that when depressed people that can be clinically defined in terms of their syndrome, their anorexia, their insomnia, when they take their drugs, they don't feel better right away, and then several weeks later they feel better. SCHALER: And that's true across the board, so every one who feels better from taking Prozac, for example, was suffering from some abnormal level of serotonin, is that correct? KLEIN: That is an unnecessary corollary to what I'm saying. I'm saying, I can define a person's disease, and I can treat it. You're trying to say anything the drug does defines the disease. SCHALER: But how is it, can you take blood and diagnose a person for being depressed in terms of low serotonin levels? KLEIN: I would like to be able to, we're not at that point yet. SCHALER: You can't, so you diagnose primarily through symptoms. KLEIN: In medicine you move forward and you understand things better as you go along. SCHALER: So you cannot diagnose someone by taking a normal blood test and seeing whether they are depressed or not? KLEIN: Of course not. SCHALER: Is there such a thing as asymptomatic depression? KLEIN: That's an oxymoron. SCHALER: You have to have certain behaviors and activities in order to make the diagnosis? KLEIN: No, you have to have certain things such as an inability to respond to pleasure. SCHALER: But that is a behavior, though, that's an activity. KLEIN: I'm sorry, I don't consider that a behavior in the sense of doing something. SCHALER: You don't differentiate . . . KLEIN: It's a deficit state. Here's a steak, does it taste good to you? No it doesn't taste good to me. Is that a behavior or is that a statement that the person is unable to respond with pleasure to a definite stimulus. SCHALER: You are referring to a behavior and that is a strategic maneuver. SZASZ: But is having pleasure or not having pleasure a medical issue? KLEIN: Why shouldn't it be? What if you have hyperthyroidism and you can't have pleasure, either? SZASZ: What is the mother of Jesus called in Latin? Mater Dolorosa. You look to museums, what do you see? Depressed people . . . KLEIN: You are trying to confuse me . . . you're trying to confuse unhappiness with depression, not the same thing. SZASZ: No, you are trying to confuse it. KLEIN: No, I'm sorry, you did by bringing the Mater Dolorosa thing. Let me point out something else. . . LEIFER: How do you know it's not the same thing? You are just simply saying that. You are defining that they are not the same thing. KLEIN: Very simple, I have given antidepressants to normal people and they don't get happy. LEIFER: I had a patient last week who said, "Don't tell me I'm depressed, I want to talk about sadness, if I talk about depression, you're the expert. If I talk about sadness I'm the expert. This is arbitrary, we can call it whatever we want. To me, depression is sadness. KLEIN: I don't think patients should define the issues. The patient doesn't define the issues, it is a medical issue. The patient says, "I don't want to call it depression", you say "ok, that's not depression, that's terrific". LEIFER: But that's because you have the power to define it. How do you know that the physical changes are the cause or the result of the depression? In my view they are the result. KLEIN: All right, then, you have to explain the genetics of depression. LEIFER: You don't have to explain the genetics of depression because the genetics could refer to temperament. Research has not been done on the relationship between genetics and temperament. I would likely concede that there is a relationship between genetics and temperament. Every animal breeder knows it and everybody who has got more than two children, three children knows that temperament could be inherited. So the fact that you can find that people with some kind of a temperament are more prone to depression doesn't mean the genes caused the depression. It means that people have different physiological and genetic equipment to deal with life. KLEIN: You're saying that A doesn't lead to C, A goes through B to lead to C, so what? LEIFER: Let me give you an example, it's the last second in a basketball game, my team scores a goal, I get very happy and excited, the catacholamines in my blood go up. Am I excited because of my catacholamines or am I excited because my team won the game? I think the analogy is exact, people become depressed because life doesn't go their way. Their serotonin level goes down. KLEIN: A lot of people become depressed for no apparent reason whatsoever. LEIFER: For no apparent reason you see, I see it, you don't. KLEIN: You don't really see it. Of course you can see people the most. SZASZ: But it's very difficult to see something you don't want to see. LEIFER: Exactly. KLEIN: We spent a lot of time with patients in hospitals trying to find out what got them that way, and many times we just could not. MODERATOR: OK, moving on to a happy Jeffrey Schaler now. Please stand up, first question from the other side. GOODWIN: I'd like to ask, do you diagnose schizophrenia as a disease? SCHALER: No. GOODWIN: Ah…and have you talked to parents of schizophrenic children? SCHALER: I've talked to parents of children, but I have not talked to parents of schizophrenic children. GOODWIN: And do you diagnose manic-depressive illness as a disease? SCHALER: No, no. GOODWIN: And how do you understand manic-depressive illness, when people have regular recurrence like clockwork . . . SCHALER: I understand manic-depressive illness as a metaphorical illness, people get sad, people get angry, and a lot of times they have a lot of good reasons for being sad and angry. GOODWIN: How would you deal with . . . I treat a lot of these severe patients . . . you don't, you're not a physician, but, I understand that limitation, but when a severely depressed patient comes into my office, they can't stay asleep, their mind is so slow they talk about "it feels like molasses", they can't remember anything, they can't possibly experience, everything literally looks gray, their mind is as shutdown as the mind of the Alzheimer's patient, my mother has that, and I know what that feels like. Who can't literally think of one thing to the next or even tell where she is. Now this is a brain disease, are we, the mind . . . SCHALER: Now wait a minute, you're confusing again, you're confusing behavior with brain disease. GOODWIN: The mind is a disorder, the mind depends upon the brain, would you agree with that? SCHALER: We can't speak of minds as independent of brains, in the sense; of course, to speak of brain as independent of mind, we're talking about a dead person. GOODWIN: So if you have the mind as dependent upon the brain, and intertwined with the brain, then if you have a disease of the brain, it will be a disease of the mind. SCHALER: No, not necessarily. People have diseases of the brain and they don't have what you call mental illness. GOODWIN: That's true, but it depends on the area of the brain you are talking about. SCHALER: But I'm not sure what your question is. What do I do with people you might diagnose as clinically depressed? What do I say to those people? Well, again if they are coming to see me willfully I assume there's something they want to talk about, and what I look at is how the activity that you call depression is in fact a strategic maneuver that is used by these individuals to avoid coping with experience. KRAMER: Right, sometimes you are making the terrible mistake, there have been ethical mistakes on each side, the terrible ethical mistake of trying to make people morally responsible for things which very likely they have no moral responsibility for. SCHALER: Although I did anticipate this, you seem to work two sides of the street. On the one hand, you say, and I'm really curious as to how you reconcile this information. On the one hand you write the foreword to Louis Fierman's book, talking all about how these problems are existential problems. These are existential problems. And on the other hand you talk about how they are biological problems. KRAMER: My criteria for mental health is the ability to walk both sides of the street and I want to know whether you can walk the other side of the street. SCHALER: Well, according to psychiatric literature, some people call that psychosis. KRAMER: Let's start with pseudo-dementia. You asked whether people can be depressed who give no indication, don't indicate through their own words that they are depressed. There are people who are elderly, severely depressed, they are in the hospital, they are misdiagnosed as having dementia, if someone comes around and thinks to give them an antidepressant, they get better. They get fully better; they have an undiagnosed reversible disease. We don't always diagnose . . . SCHALER: Saying that over and over doesn't make it so. People smoke marijuana . . . . KRAMER: I'm sorry, what's not so? SCHALER: Saying that they have a brain disease doesn't make them have a brain disease. Now people take all kinds of drugs, legal and illegal, and they feel better as a result. Are you saying that people who use marijuana, snort cocaine, or shoot heroin all have brain diseases? And that's why they use these drugs? They feel better from them. When I drink a glass of wine in the evening, I feel better, does that mean I'm suffering from wine deficiency? KRAMER: Your question is whether depression sometimes in severe forms can be diagnosed without symptoms and solely on the basis of signs, and I said . . . SCHALER: And how do you make that diagnosis? KRAMER: When I say yes, I would like you to say that we have won the debate and can go home. SCHALER: Because you are still basing your diagnosis on behaviors. Are you taking blood? Are you taking an MRI and basing a diagnosis on signs? No, you avoid dealing with that, that's a fact. You are basing it on the behaviors and the conducts. If in fact . . . KRAMER: I'm trying to not bluff your criteria one by one. SCHALER: My criteria are the same as any pathologist's. If these criteria actually exist, they would be in a textbook on pathology. It's a fact! If what you say was true you would find depression in a textbook on pathology. End of story. GOODWIN: There are many diseases in medicine for which there is no specific pathology known.