Razer on Mark Latham's Harden Up prescription for the depressed chattering class

This past weekend, Mark Latham gave his fortnightly column in the Australian Financial Review to critique of the movie Birdman. As a connoisseur of the contemporary lens, the former politician falls just a little short and would perhaps be better simply smashing cameras than waiting around for them to disappoint him. It is difficult to agree with his brutal assessment of a work that has been hailed as a career-defining Hamlet for its director and trickier still to allow his view that this is a movie about “mental illness” as it is presently understood. It is not so much a contemporary and realist “mental illness” that we see unfolding in Michael Keaton’s Birdman but an old-fashioned and metaphoric madness. This is not a movie that explicitly urges understanding of the mentally ill but one that implicitly urges impatience with those delusions produced by fame and power.

Still. It’s difficult to come up with column ideas outside the general range of “Everything that Keating Did Was Marvellous” and so, Latham has seized upon this half-opportunity to revisit one of his observational standbys, “The Chattering Classes Are So Bored With Their Keating-Produced Prosperity, They Pretend They Are Mentally Ill”. Latham presaged this idea of mental disorder as a bourgeois indulgence when he claimed last November that the honest, hardworking women of western Sydney have no neuroses. Mood disorders and post-natal depression, he said, were an imagined accessory of an indolent middle-class. Who, presumably, should just honour a photograph of Paul Keating and Jack Lang framed in a valentine as a therapeutic measure instead of “popping pills”.

I imagine the ALP has already begged Latham to stop campaigning for Lindsay. Perhaps they should also remind him that there is a very clear and persistent national and international correlation between mental illness and poverty. The merest interrogation of statistics on mental health would upturn the link between income and social inequality with depressive illness and bury Latham’s queer entitlement to tell us all to Harden the Fuck Up. To be clear, it is those who suffer social and economic isolation who are at the greatest risk for mental illness.

Of course, Latham has been served this argument in recent days. Well, select non-economic parts of it, in any case. As this review of popular opinion indicates, the objection to Latham’s brutal dismissal of mental illness as a middle-class fantasy generally proceeds, “but it’s real and I feel it”.

Between this popular view that “mental illness doesn’t discriminate” and Latham’s unpopular view that it is a largely imaginary thing that is itself a sign of middle-class discrimination, there is, perhaps, another way to address what results in impatience on both sides. And that is by looking a little more arduously at the history of mental illness and its present function. And conceding that one or two of the things that Latham has to offer are, in fact, vaguely legitimate.

Mental illness does discriminate, but not in the way Latham says it does. It disproportionately afflicts Aboriginal Australians, prisoners, women, homeless, low-income earners and others who experience social and/or economic exclusion. This is not to say, of course, that some of the well-to-do beneficiaries of a Keating economic agenda do not suffer from what we call mental illness. It is, however, to urge that in the utilitarian context of policy discussion, services and solutions must be found for the social groups who need them most and can access them least.

It is here that we can entertain a partial understanding of Latham’s disgust for a mentally unwell middle-class that relentlessly examines its own disquiet by means of prevalent feelpinion. There is not a week in publishing that passes without some popular self-outing by a middle-class sufferer of mental illness who is extravagantly thanked for “starting the conversation” and “ending the stigma”.

The obvious problem with personal works on mental illness by the media class is that they contribute to the assumption that “mental illness does not discriminate” and so do little to urge for discriminating solutions delivered to the people and regions who most broadly need them. The less obvious problem is one of false enlightenment. With every middle-class confessional of mental illness — and this is not to say that some of them are not both very well-written and well-intentioned — we convince ourselves that here is a truth hitherto ignored. And, conversation about mental illness is not ignored. It’s just a little ignorant.

If Latham is annoyed by anything, it is perhaps the constant act of false revelation. I am absolutely sure that the frequent personal writing and broadcast on mental illness is produced by people who suffer. The personal disclosure is not false but what is false are the ideas that (a) no one talks about mental illness and (b) talking is a way out of mental illness.

It is absolutely true, of course, that the talking cure is one legitimate means of addressing mental illness. But the technique pioneered by Freud to unfold between therapist and patient was never intended to play out in a public context. As the methods of psychoanalysis have been largely abandoned by the medical profession and replaced by Latham’s “pill popping” — and in this case, he’s right. More than twelve million prescriptions for anti-depressant medications are written in Australia each year — it has been taken up by media.

The act of taking an intimate methodology into a public forum is not only one that is potentially dangerous — the act of continually baring oneself or comparing oneself to others is a terrible stand-in for truly unfettered conversation with an analyst. It allows the individual experience — in this case, the middle-class one that grates on Latham — to become a metaphor for all experience and it individualises the response to a widespread social program.

Organisations like beyondblue constantly chide us that the lack of individual understanding prevents people from accessing the care that they need. If only everybody truly understood mental illness, so the reprimand goes, it would be far less of a problem. People would go and seek care and doctors would dispense it more effectively.

While it is true that it is very unpleasant to feel misunderstood while in the grip of a mental illness, it is also potentially true that mental illness in the terms it is broadly and compassionately discussed is itself misunderstood.

Even if we find no scintilla of agreement with Latham that the middle-class commentators on mental illness are “faking it” and indulging in a fantasy of oppression in the absence of any other enemy, we can perhaps agree that mental illness is a troubling category. And one that has become very one-size-fits-most.

From the time of Hippocrates, there were two distinct definitions of “melancholia”, or what we would now call depressive illness. There was that which arose with cause and that which arose without. Some people had reason to be sad and some just had bad “humours” working within them.

This is a distinction that was all but erased in 1994 with the fourth revision of the Diagnostic and Statistical Manual for Mental Disorders (DSM). This blockbuster of the American Psychiatric Association, which influences mental health care in the west more than any other publication, took sadness from its social context. Whereas once one’s depression could be seen as “reactive” and the result of divorce, job loss or the physical diagnosis of a critical illness, it now became a category with none of the Hippocratic distinctions. In 1994, there was a single exception for the diagnosis of depression, now able to be “treated” with a new site of anti-depressant SSRI category drugs, and that was bereavement. In the fifth revision of the DSM published in 2013, grief was removed as an exception. Actually, bereavement itself was medicalised. And recommendations for its treatments with a new suite of anti-depressant SNRI category drugs was recommended.

We believe that our personal understanding of mental illness drives recovery when, in fact, it is a codified understanding of mental illness that is driving us. We live in an age where many human foibles become matters for medical discussion. If you eat and order a pizza once a week, you now have, according to the DSMV, Binge Eating Disorder. We live in an age where many logical responses to social and emotional hardship become loosened from their real world moorings and become depression or anxiety.

This is not to say, as Latham does, that sadness or worry once understood as ordinary should not be treated. Nor is it to champion his obscene claim that economic growth means that Australians should feel no sadness. The GDP is not a measure of the social inequality that afflicts many Australians and can result in the diagnosis of mental disorders. It is to say, however, that the fundamental Hippocratic division between moods that are the result of injury and moods that are the result of disease urgently needs to be restored.

This counsel for a more nuanced, and more legitimately scientific, understanding of mental disorders is not just some lay whining. It is the work of eminent theorists in the field, including the now repentant editor of the DSMIV, Allen Frances. Frances, along with respected American psychiatrists Horwitz and Wakefield and local child psychiatrist Professor Jon Jureidini are among those impatient for reform that understands both the social and biological influences in what we call mental disorders. In hopeful recent news, the US National Institute of Health has attempted a transformation of diagnosis by announcing its intention to study the neurochemical factors which may produce “bad humours” in its new research criteria.

Psychiatry is, at present, largely a case of very bad science. There are no blood markers or brain scans in psychiatry. There are just a lot of drugs. And these drugs are administered on the basis of self-reported symptoms and evolved with no regard for how they might affect a patient who has a reactive depression as opposed to one who has the yet-to-be-discovered neurochemical kind. And it is this economically motivated scientism that informs the “understanding” we urge in all the feelpinion pieces that Latham despises.

Latham despises these pieces for entirely the wrong reasons, of course. His disdain for middle-class women as vessels of prosperous indolence, and not Keating ideology as he would prefer, is plain old crusty Labor sexism where ladies are surplus to the production of the dutiful masses. Further, his insistence that this understanding is a “left wing” agenda when it is plainly conservative is a logical balls-up. There is nothing more right-wing than saying, as Jeff Kennett does, that mental illness is free from social influence.

But, this is what most people are saying. We have accepted the economically created fiction that mental illness is a democratic affliction. Because “anyone can get it”, the social specificity of certain experiences — say, being black and in prison with a limited life expectancy — is seen as indistinct from middle-class ones.  This ideology works to convince ourselves of the bullshit that We Are All One when we are not at all “one” in terms of social and economic equality. And it also has the very real impact of shackling research into mental illness. When we all become “one” scientifically and the criteria is only “do you feel bad?”, science is bound to draw false conclusions.

Latham, of course, draws false conclusions. But, so do many of the respondents to his revulsion for the current social and medical approaches to mental illness. We can all agree perhaps, that large numbers of people need help. The fact that this help is restricted scientifically and ideologically by the idea that “mental illness doesn’t discriminate” is perhaps the real tragedy in this debate.

28 responses to “Razer on Mark Latham's Harden Up prescription for the depressed chattering class

  1. Helen is correct in saying that societal acceptance on mental disorder as “not discriminating” and “anyone can get it”, together with providing mandatory Cognitive Based Therapy sessions for depression and anxiety in primary schools, provides a foundation where young Australians attribute all their problems, emotions and feelings to this black dog called Mental Health. I mean, what else could it be, when there is no mention on regular human emotions except in the context of a school “mental health” program forced onto kids. They come out of the education system self-diagnosing themselves with one mental illness or another, including those current categorisations related to Gender Identity, also taught in schools.

    If anyone wants to see how indoctrination can promote visits to GP’s claiming mental illness, further referrals to psychologists and ultimately psychiatrists, resulting in drug taking for a “disease” that is not really a disease, but a condition, all they have to do look at how schools, TV commercials and every public institution exposes our kids to this nonsense at a young age until they can not tell the difference between being a human with normal emotions or being sick with a mental illness that “anyone can get”. Its surely a sad society we’re living in and Mark Latham is just pointing it out to those that don’t see it. He is not downplaying the problems of those with real mental illness. Then again, there are no blood markers for real mental illness, maybe because the psychiatric profession has seen how Methyl-B12 has helped many people in depressive states recover from their sickness.

  2. Its not even that therapy/meds are expensive. Its that *poverty is depressing*. I’ve had two run ins with clinical depression. One after a messy and bitter end to a romantic relationship where I perhaps didn’t quite cope as well as I should have. Meds eventually got me right. And the second a decade and a half later during a stint of unemployment as my bills spiralled well beyond my capacity to pay them and my credit card started to flatline. Poverty is crushing and the walls of anxiety and fear that build up as the prospect of homelessness looms can be overbearing.

    God help me should I find myself unemployed in the current welfare torture regime. Wait, I am umemployed. FML

  3. Therapy is expensive. Medications are cheap. Until that changes, there will be no change in the focus of mental health treatment. It’s depressingly simple.

  4. As someone dealing with mental illness (I would self-diagnose myself as belong to the group of people that Latham says just need “get over it” , he joins a number of my family members there) I welcome Helen’s keen eye on the subject. This certainly provides some perspectives for me to work my way out of the black cloud. I count myself lucky that I am in a certain socio-economic situation (call it class if you will) that allows me ridiculously easy access to mental health resources (in fact, not accessing these resources should be sure signs you’ve got a mental illness). My ‘take away’ point is that there needs to be a more concerted effort to get these resources to those parts of the community who not only need them more keenly (brought on by poverty, social/cultural isolation, racial/sexual identity, etc) but face the greatest obstacles to accessing them (cost, distance, language, stigma, etc). Then people might accept my condition again.

  5. Following on from my last comment. Going back to Christmas, we in Cairns suffered the trauma of eight siblings losing their lives to what any lay person would deem a mental health issue. I remember the occasion as it occurred at the time of the Sydney siege. Not taking away from the loss of life there, Prime Minister Abbott was quick to embellish the incident to the level of terrorist attack & promptly funded what was deemed necessary while the need for determining what not to have the Cairns massacre happen again was quietly left to the annals of time.

  6. Don’t agree with HR on this one, depression is as discriminatory as the common cold.
    Politicizing a disease is a risky business. All forms need to be treated without triaging poor, rich, white, black, male, female into predetermined groups with varying rights to treatment.

    1. Excellent writing Helen. So much I wanted to go over the article twice so as to ensure my reply was warranted.
      So as you point out, by clinically diagnosing a mental illness which is a very American way of doing things allows for a prescription to solve or at least alleviate the symptoms. Mental illness is too broad to be analysed & diagnosed in any flippant analysis. Depression & anxiety as well as sadness are normal human emotions. It is determining when further help is warranted that is for someone else to call on. You raised some very concerning points where if it is possible to intervene in a way that allows for all people to feel inclusive of a society, being employed, having emotional support etc may go some way to perhaps not manifesting any mental illness.
      We all at times feel the negative effects of emotions. The tragedy is needing to turn to a book for clinical diagnosis & therefore treatment.

  7. I think Marks only reacting to the mind state of the nation— we’ve been sold sick and we’ve bought it, and our mental health system, –+ all the vested, have got their hands in the till of misery, including the sufferers— of course not all, but a very large percentage, but that’s only because our mental health treatment regime, here in Australia, is run at an 80% failure rate, so the ones that knock on the door who would have been cured within weeks, had they knocked on a door in Finland, or some third world countries where they actually cant afford the medication,– plus we are forcefully doing that, when we know that long term medication keeps you sick– that’s a fact– so really how can anyone expect to get better when we are actually keeping them sick by continuously poisoning them, and getting them to admit their sick, let alone, how do you think that is effecting society—one sad face makes another–no ones seeing it, because there either too busy selling it, or too busy buying it– so really mark is just seeing what the mental health industry is creating.

  8. Thank you for this very interesting article. It must have been difficult to put into plain language so much very technical language and some difficult ideas. I started to read the first response and was lost in the language, I simply could not understand it although I felt that what the writer is saying could be important. Making hard ideas comprehensible is a real skill, so thank you Helen Razer. On a side note, in recent years I have not much bothered with what Mark Latham says about anything. He clearly has too much time on his hands and a giant shoulder chip which he can’t reach with the axes he is grinding ~ all of which makes reading his columns far too dull and thick to wade through. But I’m glad an article of his spurred this interesting and thought provoking piece by Helen Razer!

  9. Yes Mark. Most cases of so called mental illness just require a belt behind the ears and a kick up the backside and told to get on with life.

  10. Lovely.

    As conservative friends of mine love to point out, the left loves to make docos and write articles listing and elaborating the sins of the rich. Then they like to spew forth the sins of the poor, which they say are never mentioned. These sins include the abuse of poverty relief, laziness, a hatred of discipline and a sense that they are entitled to what hard working types get. They get a bit confused when I have asked where are the docos and articles and thinky pieces listing and elaborating examples of these abuses. Frontline and Sundance feature none. The Wall Street Journal has not done an expose on cavalier plebs laughing as they go to the bank. These clever, weasely poors are invisible. But boy when we catch ’em I’m sreu

    Also, insanity among the poor is certainly prevalent. Capitalism creates poverty. It is the job of a society that chooses to be capitalist to address its deleterious effects. Capitalism isn’t a virtue, its a tool. Mr. Latham perhaps did not know the wealthy as I did. I can’t tell if they are crazy but they sure did a lot of expensive drugs in college… and after. And these were kids at Princeton. Not Mr. Latham’s lazy poors. Expensive mood elevators are the prerogative of privilege and they are taking advantage of that. Were they happy or sad? Couldn’t tell you. They couldn’t have either. But these people blamed their drug use on their class – at least in the USA



    The rich use more drugs than the poor because they can. Do they do it because they are happier? Probably not.

    1. and yes, the uber-rich fraud-addicted coke snorters in Wall Street all have their ‘GET OUT OF JAIL FREE’ cards too!

  11. I wish Mark ‘Loose Cannon’ Latham had been present at the memorial service I went to recently. A young middle-class man, privately educated, extremely intelligent, but a low income earner due to his dyslexia (and, who knows, possibly due also to mental illness), took his own life. He was greatly loved and admired by many, many people. He refused all offers of help. There is a history of mental illness in his middle-class family.

    He tried to ‘tough it out’. It is likely that anti-depressants, on their own, could have prevented his death. He needed that, at the very least. Probably medication and the more expensive ‘talking therapies’ would have altered his whole outlook on life, or at least extended his life-span and achievements significantly.

    He had so much support from parents and friends. He excelled in some specialised areas and worked successfully much of the time, but was unable to recognise his own value, even when his clients expressed their gratitude. The missing link was his inability to accept the need for treatment for his severe depression. He was at the stage where no solution seems remotely possible.

    Telling a seriously depressed person to ‘pull up your socks, man up, don’t be so self-indulgent’ is probably the most destructive advice that anyone can give to someone experiencing clinical depression. Anyone with half a brain knows that. He should try saying that to a person with a physical illness such as cancer. I have to say that my husband, in the final stages of a brain tumour, judged himself in the same manner. He believed that all his sleeping and ‘lounging around’ was sheer laziness. He also believed that he would recover very soon, such was the level of his insight, so he would have been hugely cheered by Mark Latham’s ‘get a grip’ mentality.

    It is extremely fortunate that these days nobody takes the slightest notice of Mark Latham.

    1. Screw the grammer and spelling Mr.Wild – the point is that you’ve squarely ‘hit the nail on the head’ so to speak. Respect!

  12. Latham is right. In my confused years on this earth all 65 of them I find people very badly afflicted but it is class based. Working people and youth are aflficted as are women and people aout the back of. Just think of being somewhere for years and years and it doesnt rain. What does that do to you. The wealthy or well off seem to be extremely fragaile (the ones I’ve come across) but are often delusional, paranoid but often just straight Pyschopathic arseholes that we have comes to see as “normal ” for capitalism.

  13. And on the other side of the coin, being depressive while suffering extreme poverty seems to me an entirely rational reaction to circumstance. Treating the symptoms is rather missing the point I would think. Bring them out of poverty rather than give them another pill.

    Sometimes insanity is the only sane response to an insane world.

  14. “Between this popular view that “mental illness doesn’t discriminate” and Latham’s unpopular view that it is a largely imaginary thing that is itself a sign of middle-class discrimination”

    Perhaps HR and Latham aren’t so far apart in their underlying views as may be thought on first reading. Both highly sceptical of current diagnoses and treatment.

    I suspect, as unpopular as this might be, that there may be some truth in Latham’s argument, and probably more truth in Helen’s, but not at odds with each other.

    I hope you don’t take that as a criticism Helen, it isn’t mean to be.

    As an analyst (of numbers) I wouldn’t give much weight to any statistics on depressive illnesses in society. The goal posts have shifted on this so many times that nothing can be made of it. Nor would I believe that there is a direct socio-economic link, other than at the extreme poverty end of the spectrum. I suspect the ‘doctors wives (or partners, let’s not be sexist here) group of depressives may have more avenues, and perhaps more reason, to hide their depressive illnesses and therapies.

  15. I agree that there may be no known blood markers for depression, and that diagnosis is often post hoc inductive reasoning e.g. if these pills for depression helped you feel better, then you had depression.

    However, that doesn’t mean it isn’t real. When a 100mg of Zoloft a day is the difference between regularly thinking about driving your car into an oncoming truck, and not, then I’ll take – and am taking – the 100mg of Zoloft (now thankfully sold as a generic brand).

  16. There can be more to a talking cure for mental illness than just telling one’s own personal story. We can encourage others to seek out a mental assessment and consider possibly taking medication and/or talking things through with a health care professional.

    I self-outed myself for the first time publicly as having a bipolar condition on 20 October 2014. This was the first day of my defamation trial against Andrew Bolt and the Herald Sun.

    I was self-represented throughout the proceeding which commenced way back on 30 April 2012 when I was still a law student. And I was admitted to the legal profession as an Australian Lawyer on 19 March 2013.

    Barrister Dr Matt Collins QC (whom yesterday began grilling Treasurer Joe Hockey in a Fed Court defamation trial), was lead Counsel for Bolt & HWT against me in my October 2014 trial.

    Documents that were added to the Court Book by the Defendants just before my Bolt defamation trial was heard by Justice Terry Forrest gave every indication that Dr Collins QC intended to out me as having a bipolar condition for whatever tactical reason. Perhaps he would argue this would be relevant to damages; or maybe Dr Collins would spring it on me to try and unsettle me if barristers might do that sort of thing.

    So on the first day of the trial, 20 October 2014, I got out the front of that and gave my personal evidence from the witness box about my long journey from when the bipolar illness first seized me at age 19 until I finally had the insight to present for a medical diagnosis in 2005 (age 35), and then after much reluctance I started taking medication in 2007. I then achieved and maintained mood stability from 2007. It’s quite a miracle. My personal evidence on all that is here:


    This was a “self-outing by a middle-class sufferer of mental illness” that Helen Razor writes of — however, against her thesis, it had plenty of potential to do good for me and those it might reach. My story is of a long-term sufferer who found a medication regime with no noticeable side-effects that removed the endemic disruption in my life. If you hear this story and feel the same way then I encourage you to seek a mental health assessment and if diagnosed consider your treatment options. I feel it can also contribute to diminishing stigma.

    Although, it is not so clear that I have enjoyed all that many middle-class advantages. I was a Melbourne High School student in 1987 who started an accounting cadetship with Deloittes in 1988. My life was then greatly disrupted with the onset of the bipolar illness from when I was 19 until I achieved mood stability in 2007. Those years of raging bipolar illness were marked with a disrupted career and relationships. I am to a significant degree quite poor as a consequence, although highly educated as the illness would fit in well with the peak moments of exams and assignments — just as it can sometimes fit in with the up-and-down life of creative artists with a bipolar illness, such as Stephen Fry, Catherine Zeta-Jones, Richard Dreyfuss, Carrie Fisher, Linda Hamilton, Jean-Claude Van Damme, Adam Ant, Sinead O’Connor and Russell Brand. However, it should be noted there are few celebrities in the millions of us around the world who are variously diagnosed, undiagnosed and coping or not coping so well.

    Since my 2014 Bolt defamation trial, I have applied for some jobs as an early career lawyer with Legal Aid.

    I publicly shared these job applications where I am quite aware that I am being very candid about my underlying mental illness (now well-managed) and also likely bankruptcy following from the Unsuccessful Bolt defamation trial (Appeal on foot).


    VIC and NSW Legal Aid are organisations where I feel that I have a better prospect for such disclosures given their genuine respect for diversity — but then this only goes so far given human nature and organisational-caution, in what is also an increasingly competitive job environment for early career lawyers to get a break.

    My objective of writing my job application in such a candid way is to hopefully catch the eye of a person in the HR decision-making process who embraces the diversity of a person who has found mood stability with bipolar medication. It may also be that it is to my credit that I stood up to the NewsCorp bullies.

    My perhaps more effective objective has also been to use the job application material to publicly reach out to a wider footprint of the 50,000 or so people who have a connection through my website and 9,000 twitter followers (https://twitter.com/BoltTrial2014).

    With all these connections, I hope to there might be a few people in a position to give me a go as a lawyer. I am very experienced in self-representation:


    +Kind tweet from Stephen Mayne:

    I would now like to ‘turn-pro’ to represent others as a lawyer under the supervision of a lawyer with a full practicing certificate. I am ready to start tomorrow in any legal firm or legal organisation in any part of Australia to work in any area of the law.

    In my personal evidence at the Bolt Trial, I also had this to say on well-managing my bipolar illness in all the years since 2007. It is a talking cure for mental illness which also reaches out beyond myself to encourage others to seek help:

    So all during this time I’ve had stability of mood, Your Honour. It’s really changed my life and I would recommend to people to get an assessment or a couple of assessments and consider medication. So I found the stability. To me, from 2007 it’s like sort of waking up from a coma saying, you know, you were 30 then and I’m 45 now. I don’t feel 45. I feel like I’m about 30 because I had so much disruption in those 15 or 20 years that it’s sort of like missing time.

    So I’ve had stability in all that time since 2007 up to now. That’s seven years I’ve been taking that medication every day. I mean sometimes I forget but not – I don’t ever choose not to take it. I have a pill box reminder and I actually have Lithium and I explored a different type of medication called Lamotrigine which is anticonvulsant and that actually gives you more of a base under the depression, whereas Lithium stops you more going up too high. So I use Lamotrigine for the base and a little bit of Lithium to help with the top and I feel like I’ve felt when I was 16 or 17 and have done all that time. It’s quite a miracle.

  17. Great read Helen!

    Just to say, to other sufferers of chronic depression; after hearing on ABC radio about the strength of evidence in taking anti-inflammatorys as a useful help in treatment, my doctor was willing to prescribe some and give it a try. It’s been 8 weeks now and I think – I think – I can say it may be helping. Early days yet – but worth doing some reading on.

  18. If there is only one thing worth taking away from this piece (and, of course, there isn’t), then the observation about a one-size-fits-all depression is it. Mark Latham’s article has, at least in this respect, played the very useful role of generating the opportunity which Helen Razer has very perceptively grasped. Her “take away” point merits much more publicity that it currently receives, and she should be applauded for raising it, especially in the face of the seemingly constant stream of “awareness” campaigns which invoke the emotionally-charged term “epidemic” and assert, in support, that (for instance) 80% of us will experience an episode of “depression” or “anxiety” in our lifetimes, that what “sufferers” need most to do is “reach out”, accept and declare their condition because “treatment” is essentially straightforward and effective. The one-size-fits-all conception is, I believe, having seriously negative consequences on public understanding of “mental” illness (or more properly neuro-psychiatric conditions), on diagnosis, and on treatment.

    The writer mentions “the now repentant [former editor of the DSM] Allen Frances” as a critic of the one-size-fits-all conception. But the most eminent, rigorous, and very persuasive critic of the orthodox DSM conception and advocate for the revivial of “melancholia” as a neuropsychiatric sub-type of severe depressive illness, is the polymath Professor Gordon Parker of UNSW. It was disappointing not to read any mention of his name in this article, in particular given that his research team has recently discovered the first neurobiological “signature” for melancholic illness, a search that has for many decades proven elusive: http://archpsyc.jamanetwork.com/article.aspx?articleid=2119327.

    I want to make a few comments which may flesh-out, for interested readers, what I identified as the “take away” point that Raiser makes.

    First, because, according to the orthodox DSM model, diagnoses in the depressive area of psychiatric morbidity are syndromal rather than based on distinct disease entities, symptomatology is the touchstone of currently orthodox depressive nosology. The DSM, the institutional and clinical embodiment of this orthodoxy has, since around the early 1980s, viewed and continues to view “depression” as a unitary phenomenon whose relative sub-classifications depend primarily on identifying the degrees of *severity* and *chronicity* by which the mood disorder affects the patient. So, a patient may receive a diagnosis ranging from “depressed mood”, “minor depressive disorder”, “dysthymia”, to “major depressive disorder” (there is also a whole category of clinically sub-syndromal mood disorders that, particularly in primary practice, are not uncommonly pathologised by being redescribed as “depression”).

    When one thinks about it, this is a very peculiar method for classifying illnesses. The analogy is of course imperfect, but consider an oncologist: he or she does not primarily diagnose a tumour by reference to whether it is severe or only mild. Rather, severity is a potential property of some types of cancer, whose nature is classified by reference to traits biologically internal to, and often distinctive of, that type.

    As Razer in part observes, the current approach embodied in the DSM supplanted earlier ones which (I simplify drastically, of course) distinguished (to the extent possible in a discipline which must grapple with the overlap between the subjective/phenomenological and the biological dimensions of the illnesses it seeks to treat) endogenous from exogenous depressions, autonomous from reactive depressions, and melancholia from non-melancholic depressions. These distinctions did not always depend or focus on presumed differences in the *aetiology* of the distinct depressions they posited. Some depended on very close examination of the course of a patient’s illness, whatever the “cause” which precipitated the illness may have been. In this way, such a method presupposed no binary distinction between the biological and the environmental: negative environmental triggers could in some cases precipitate an autonomous neuro-psychiatric process which becomes biologically entrenched and thus unresponsive to subsequent positive environmental stimuli. The research which Maxwell Bennett has been doing on the effect of exposure to chronic stress on neurological networks is one area where this idea of “autonomous” versus “reactive” depressions may apply (though I do not think he invokes those terms since his prime focus is neurology not depressive nosology).

    Secondly, the reason I mention this bit of history, and the departure the extremely influential DSM initiated from it, is that the DMS’s unitary conception of “depression” may be one reason why statistics such as that which I cited above appear to indicate a pervasive epidemiological crisis when it comes to rates of “depression” in the populace and over the course of anyone’s life. Latham is most certainly correct in responding sceptically to the proposition that “depression” is at epidemic levels. In one sense, the publicity of statistics in this way (i.e., in a way which omits to disclose the weaknesses of the clinical framework according to which “depression” is currently diagnosed in the first place) is quite clearly well-intentioned: it seeks to destigmatise an illness which can ruin people’s lives, thereby encouraging them to seek treatment for it.

    But, thirdly, I don’t think good intentions are always conducive to good outcomes, especially if they are based on misconceptions. I should explain this a bit more.

    (a) An extremely lively current debate in psychiatry examines what is often referred to as the “paradox” of over-diagnosis and undertreatment of “depression”. It is a paradox generated by the DSM “cookbook”, as one eminent psychopharmacologist colloquially refers to it. Though the determinants are multiple and complex, involving not only the prescriptions of the clinical framework but also the time and resource-pressures under which many primary care physicians struggle and the influence of pharmaceutical companies, over-diagnosis is partly driven by the DSM’s unitary conception of depression and its variable and often subjectively applied sliding scale of severity and chronicity. Over-diagnosis may not present as anything medically harmful if the medications prescribed to treat “depression” were uniformly negligible in their side-effects. But any patient will tell you this is not the case. Nor is it the case that newer medications are less prone to less serious side-effects than older agents, though it is the newer agents which are routinely prescribed. In contrast, the side-effects of older agents (whose profitability to pharmeceutical companies is negligible when compared to newer medications), such as the very effective MAOIs, are vastly exaggerated. Nor should it be inferred that newer agents represent a scientific advance on older ones. Quite frequently, new agents (SSRIs, SNRIs) are “tweaks” of immediately preceding ones in the same or similiar “classes”, formulated because of the imminent expiry of patent protection.

    (b) Undertreatment may be thought of as the more serious, and sometimes tragic, aspect of the paradox. It, too, is partly driven by the deficiencies of the current clinical framework. If “depression” is in substance a unitary entity, this often supports an inference that treatment should be too. If we restrict our attention exclusively to pharmaceutical interventions, the conventional “algorithm” prescribes starting with the least effective (narrow-spectrum) agents and progressing to the more robust and broad-spectrum ones, with adjunctive therapy between each stage. Now, this algorithm presumes that all depressions are responsive to, or capable of response to, each of the agents the algorithm includes, no matter what their psychopharmaceutical mechanisms and effects relative to the nature of the depression being treated, and no matter whether they target a single neurotransmitter or each of the catecholamines and 5-HT. The result is that a patient who is suffering terribly from a melancholic, autonomous, or endogenous depression is forced to proceed through a raft of ineffective treatments (assuming he or she is not directed into psychotherapy first!) before he or she is even given the opportunity of trialling a medication which has a greater chance of being successful (i.e., a TCA, an MAOI). To prolong suffering for the sake of an algorithm that assumes depression is a unitary phenomenon is gratuitous and futile. In my view, this is not medicine.

    (c) As for social outcomes, the increase in the rate of diagnosis since the unitary view of depression was introduced (which to some extent must be conceded to be attributable to the hugely beneficial removal of stigma and awareness campaigns which encourage sufferers to seek treatment), can have the counter-productive effect of bringing out what is most cynical and dismissive in those people, often people exercising administrative or other power, who have little empathetic imagination and even less personal experience of mental health adversity. If I may take the liberty of speaking of an episode in my own undergraduate life, I have been affected for years by severe melancholia, with psychomotor retardation as the key disabling symptom. I have – as a result of the orthodox “algorithm” – been forced to trial many, many medications (trials which take weeks, sometimes three or four months). They were not effective. The only effective medication for psychomotor retardation that I have ever taken is my current one, an MAOI, started in February this year after (finally!) finding a specialist willing to prescribe it. It belongs to a class of medication which most psychiatrists have never prescribed and about which they have deplorably inadequate and outdated knowledge. Yet it is among the most effective in existence. It is also the first of the antidepressant medications to have been discovered, in the early 1950s.

    In spite of my academic skills and competency at university, I was in substance excluded from my Faculty not because of my efforts at treatment, but because their ineffectiveness was something entirely beyond my control. I was forced to “show cause” multiple times, in spite of my disclosing in advance the medical difficulties I faced. After I was excluded, the Dean went into print, exhibiting in all her ignorance the kind of attitude to “depression” of which Latham, owing to the inadequacy and partiality of his analysis, might also be accused, and referred cynically to the number of students who had registered with disability services; and went on to say that those students who listed a psychiatric disability (i.e., “depression”) did so ex post facto because they were just too indolent to drag themselves out of bed in the morning and sit an exam for which they were assumed not to be prepared. The Pro-Dean, again a la Latham, subsequently publically announced that the goal of the Faculty is to produce “tough” students. Suck it up; stuff happens; grow a pair; toughen-up, princess: such are the Bogan injunctions which come very easily to people who are otherwise rightly sceptical of the claims of a “depression epidemic”.

    What both announcements embody is a legitimate scepticism about the legitimacy of “depression” as now understood, a specticism founded in the increase in the rate of students seeking consideration on the ground of “depression”, an increase which is itself partly driven by the DSM-facilitated “over-diagnosis” to which I referred above. The cruel twist is that such legitimate scepticism is very easily extended to embrace the inference that *anyone* with “depression” is just a pussy. Because “depression” is over-diagnosed, the inference follows that all diagnoses are likely to exemplify this state of over-diagnosis. The unitary conception allows administrators to paint everyone with “depression” with the same broad brush, and those who have suffered from an autonomous depression for years and persevered in spite of this are assimilated to those whose moods have been negatively affected by life challenges which (it is hoped) will prove to be transient and responsive to counselling or a more conducive environment.

    I would strongly recommend that anyone interested in these debates about depressive nosology consult the work of Professor Gordon Parker.

    1. Glad to hear a balanced view. Over the years, I have had many interactions with people diagnosed with mental illness. In my experience, many of these people fall into one of two categories. The first are those who may be going through a depressive period, often triggered by situational or environmental factors. Often, these people will be the first to “reveal their suffering” and beg for understanding. They revel in therapy and the chance to talk about their issues. They will frequently use their “illness” as an excuse not to do an assignment, to get up on time etc. If told to just get on with things, they will cry discrimination and heartlessness.
      Then there are the second category, of people experiencing a chemical imbalance that leads to chronic depression, bipolar and other conditions. For these people, no amount of therapy or talking about it will fix things completely. They will find the positive speak of many “mental health professionals” patronising and disheartening, because they know that they will have these feelings regardless of how perfect life might be. As one of these people, I actually hope that none of my friends and family ever “understand” because I would never want anyone I love to understand what it’s like to be in the dark places my mind makes. People in this category are more likely to successfully commit suicide.
      What we need is more research, to find a test that can assess the levels of key chemicals in the brain and determine if the depression and anxiety are due to emotional or chemical causes. Treatment can then be developed accordingly. But for Latham to brand all people on anti depressant medication as weak is just another example of why I have lost people I know and love to suicide, because they didn’t think they deserved help.

    2. This largely concerns the MAOI issue. I too have recently had to endure years of a severe “treatment-resistant” major depression where I could not get an MAOI prescribed. This is despite a previous history of successful treatment with the MAOI tranylcypromine and despite specifically asking to be prescribed the drug.

      I first experienced severe treatment-resistant major depression many years ago and ultimately responded to an MAOI. My life pretty much returned to normal after years of derailment. In 2010 I lapsed into a severe depression, after many years where only medium doses of more “conventional” anti-depressants were needed to keep me going on the few occasions when I experienced depressions of a relatively moderate kind.

      From late 2010, it was only after three-and-a-half years of going through what felt like every other anti-depressant drug in the book before a psychiatrist would finally prescribe me an MAOI. A month after starting on the MAOIs, my suicidal ideation ceased for good. None of the other drugs had stopped suicidal thoughts.

      The only notable potential practical side-effect for me that is somewhat unique to MAOIs is needing to avoid aged cheeses and a couple of other foods I like. This is no more than a minor irritation. But, what a relief not to put up with the sexual anhedonia I experienced on SSRIs and SNRIs! Many psychiatrists apparently consider sexual anhedonia a minor side-effect. Maybe Markk Latham does too. I don’t.

      However, the worst side effects I ever experienced during decades of psychiatric treatment came during withdrawal from the SNRI enlafaxine (Effexor), preparatory to commencing the MAOI tranylcypromine (Parnate). It would be hard to exaggerate the mental and physical torture of the last couple of weeks of this process. Effexor is commonly prescribed. It was described to me before I agree to take as the “gold standard” for treatment of depression. I was never warned that it is notorious for the severity of the withdrawal process. Nor was I warned when starting the withdrawal process of just how severe this could be. I apparently had a worse than normal withdrawal, but what I experienced is certainly documented in the literature. This does not seem to give psychiatrists or even GPs pause in deciding to prescribe it.

      I suspect the psychiatric profession is being lazy and faddish. And far too cautious.There has been almost no research into MAOIs for decades, despite it being known that there are patients who will respond to MAOIs, but not SSRIs and SNRIs or the old tricyclics although of course most psychiatrists have never seen such a patient, because they won’t prescribe the drug. .Easier to make the assumption that it is on a par with leeches.

      Meanwhile, research into ECT continues apace.The general public doesn’t seem to know that ECT is still a standard treatment for severe depression. It’s all pop a Prozac and bob’s your uncle for the serried ranks of the middle class worried well, apparently. People agreeing to be zapped just doesn’t fit Lathamite-type narratives. Latham’s intellectual rigour is about as hard as one of those nice middle class cheeses you can’t eat if you take MAOIs.

      Something else which bothers me is that it seems to be becoming de rigeur to prescribe a mood stabiliser to augment the anti-depressant, and possibly another depressant as well (although the latter is not really an option with MAOIs). Mood stabilisers are sedating, and the last thing that I need is to feel sedated. I’ve heard mutterings over the years about augmenting my treatment with amphetamines, but I am not holding out any hope for that – it sounds too much as if it is probably worth a go. I am inclined to wonder if what we are looking at is actually an overtreatment/undertreatment paradox. Unseemly zeal in prescribing the drug or drug combo du jour, on the one hand, and withholding those more left field possibilities with a proven track record but a rakish reputation, on the other.

      Australian psychiatry at large getting on board with lobbying for ketamine and psychedelics for treatment-resistant depression – I’ll believe it when I see it. On top of this, today’s average shrink seems incapable of delivering any talking therapy, beyond a bit of CBT which is of very limited use to someone with melancholic depression. It is now necessary for me to see a psychologist as well, when I’m up to it. It was not always so.


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