Anti-depressant scandal

The helpful delusion: Evidence is growing that mental illness is more than dysfunction, with enormous implications for treatment

Justin Garson

In later work, Nesse argued that depression is sometimes the brain’s evolved signal that something in a person’s life needs to change, such as a harmful relationship, an unrealistic career plan or a goal that needs to be re-evaluated. What that means in practice is that it’s not always best to bombard depression with medication. Sometimes, it’s better to figure out what depression is trying to say. The theory that depression is an evolved signal doesn’t ignore the fact that depression often has a tragic outcome. Nesse and Williams’s core point was that we can no longer take the dysfunction paradigm as the silent default when treating depression.

I wondered if anyone else grasped how subversive this book was to contemporary psychiatry’s disease mentality. I also wondered if anyone else in history had advocated a similar point of view. Of course, before Charles Darwin, doctors wouldn’t have had the language and concepts of evolutionary biology to express their ideas. Instead of saying that depression is an evolved adaptation, they might have expressed themselves in other ways.

I kept digging through the annals of psychiatry, rifling through old books and articles to find others who’d had a similar insight. Take Philippe Pinel, the head of the Bicêtre and Salpêtrière mental asylums in Paris during the French Revolution. Historians remember Pinel as someone who helped introduce the ‘moral treatment of the insane’ to France, but they often overlook his other radical ideas, such as that some intense episodes of manic psychosis, which he called accès de Manie, had a healing power – after such episodes, he observed, chronic patients were often ready to be discharged.

As I did this research, a vision began to unfold before me. What if you could tell the story of psychiatry, from the ancient Greek doctors to today’s geneticists and neuroscientists, in terms of a profound schism? This schism isn’t the one we often read about, between proponents of a more psychoanalytic ‘mind’ versus more biological ‘brain’ point of view. It’s a clash between those who see purpose in madness – I call it ‘madness-as-strategy’ – and others who see only pathology and disease, or ‘madness-as-dysfunction’. And what if this historic battle is coming to a head today?