Christopher M Callahan and German E Berrios, Reinventing depression: a history of the treatment of depression in primary care, 1940–2004, Oxford University Press, 2005, pp. xvii, 214, £30.50 (hardback 0-19-516523-3).

Abstract

Over the last ten years, according to the WHO, depression has emerged as the leading cause of disability amongst young adults in developed countries. It is estimated that 3 per cent of the global population now suffer from the disease and over twenty million take Prozac. The apparent growth of this illness and the appearance of new treatments (especially the SSRIs) has attracted widespread critical comment. Sceptical psychiatrists, such as David Healey and Elliot Valenstein, have traced the role of the major pharmaceutical companies in the identification and marketing of psychiatric conditions and pharmaceutical solutions; bioethicists and therapists, such as Carl Elliott and Peter Kramer, have argued that we are entering an era of cosmetic pharmacology as new pharmaceutical treatments make possible new conceptions of identity and agency. Yet despite the considerable critical and philosophical comment that the rise of the new anti-depressant treatments has attracted, few have engaged in any serious examination of the actual coalface of depression treatment—the frontline prescribing work of general practitioners and family doctors in Britain and the USA. Reinventing depression does just this. It provides a welcome and necessary intervention in both the debate over anti-depressant use and the historiography of late-twentieth-century psychiatry. Callahan and Berrios argue that the persistence of depression in industrialized countries can be attributed to the ongoing attempt to treat mental illness as a clinical rather than a public health problem. The appearance of new pharmaceutical treatments has moved in tandem with the development of materialist models of the disease. This faith in neurobiological aetiologies has led, the authors argue, to our under-estimation of the social and psychological factors that contribute to the illness and to the under-recognition of the burden of depression in the wider community. The failure of our current approach to depression does not arise from any particular inadequacy in the newer forms of drug treatments or clinical investigation, rather it is an artefact of wider political changes in the status and organization of general practice and primary care psychiatry. In their exploration of the connections between our changing conceptions of depressive illness and the changing practice of primary care, Callahan and Berrios have produced an exemplary and deeply nuanced piece of medical history. They begin their case contesting the myths of the “old time doctor” and the idea (advanced by Edward Shorter) of a traditional empathic doctor–patient relationship. Instead they draw on early post-war surveys of primary care by J S Collings and Stephen Taylor to argue for a long tradition of overworked and under-funded local practitioners prescribing non-specific sedatives and hypnotics to patients presenting for psychological distress. They claim that levels of psychiatric morbidity in the community have remained fairly constant although they recognise that the clinical profiles of certain mental diseases are mutable and reflect wider social and environmental transformations. Callahan and Berrios make perceptive connections between the changing clinical profile of depression, new developments in pharmacology and epidemiology and the political organization of general practice. They demonstrate the limited impact of the new anti-depressants of the 1950s (chlorpromazine, imipramine and the monoamine oxidase inhibitors) outside asylum psychiatry, arguing that it was market driven promotion of the non-specific minor tranquillizers that established the treatment regime for emotional disorders in primary care. Likewise the development of new gradualist models of morbidity in cardiology (notably Pickering's work on hypertension) led to new measurements of the severity of depression, which in turn supported new epidemiological investigations into the under-reporting of emotional distress in the wider community. My only minor cavil with this sophisticated reading is that it tends to under-estimate the role of general practitioners themselves in the development of new psychiatric treatment regimes. Certainly many of the authors' arguments for the unique opportunities afforded to the general practitioner for longitudinal studies of the history and context of emotional disorder were made by visionary general practitioners like C A H Watts back in the early 1950s. Similarly the role of the Royal College of General Practitioners in fostering primary care research into psychiatric epidemiology is not acknowledged, which is surprising given that this contributed in part to the new assessment of psychiatric morbidity described in the volume. These are, however, very minor quibbles in what is an extremely thoughtful and impressive piece of work.