The Chris Voss Show - The Chris Voss Show Podcast – The Empire of Depression: A New History by Jonathan Sadowsky

Episode Date: July 29, 2021

The Empire of Depression: A New History by Jonathan Sadowsky Depression has colonized the world. Today, more than 300 million of us have been diagnosed as depressed. But 150 years ago, “depression” referred to a mood, not a sickness. Does that mean people weren’t sick before, only sad? Of course not. Mental illness is a complex thing, part biological, part social, its definition dependent on time and place. But in the mid-twentieth century, even as European empires were crumbling, new Western clinical models and treatments for mental health spread across the world. In so doing, “depression” began to displace older ideas like “melancholia,” the Japanese “utsushō,” or the Punjabi “sinking heart” syndrome. Award-winning historian Jonathan Sadowsky tells this global story, chronicling the path-breaking work of psychiatrists and pharmacists, and the intimate sufferings of patients. Revealing the continuity of human distress across time and place, he shows us how different cultures have experienced intense mental anguish, and how they have tried to alleviate it. He reaches an unflinching conclusion: the devastating effects of depression are real. A number of treatments do reduce suffering, but a permanent cure remains elusive. Throughout the history of depression, there have been overzealous promoters of particular approaches, but history shows us that there is no single way to get better that works for everyone. Like successful psychotherapy, history can liberate us from the negative patterns of the past.

You wanted the best. You've got the best podcast, the hottest podcast in the world. The Chris Voss Show, the preeminent podcast with guests so smart you may experience serious brain bleed. Get ready, get ready, strap yourself in. Keep your hands, arms and legs inside the vehicle at all times. Because you're about to go on a monster education roller coaster with your brain. Now, here's your host, Chris Voss. Hi, folks. This is Voss here from thechrisvossshow.com, thechrisvossshow.com. Hey, we're coming here with another great podcast.

We certainly appreciate you guys tuning in. Thanks for being here. Those of you who are watching us live on LinkedIn, YouTube Live, Facebook Live, and all those different places, we're live. Be sure to send us up some questions. Tell us what you think. And if you've got some really good questions, they might appear on the show. Also, go to YouTube.com forward slash Chris Voss.

Hit the bell notification button over there. Go to Goodreads.com forward slash Chris Voss. See everything we're reading and reviewing over there. Also, go to all the groups we have on Facebook, LinkedIn, Twitter, Instagram, TikTok, all those different places. Just search for Chris Voss, The Chris Voss Show. You can find us over there. Today we have an amazing author on the show.

He is the author of the newest book that just came out, The Empire of Depression, A New History. His name is Jonathan Sadowski, and he's going to be joining us today to tell us about his book and some of the insights and stuff he's learned from his research. His book writing is animated by the questions, what do madness and its treatment tell us for the rest of the culture and society? And he is the Theodore D. Castell, I think, a professor of the history of medicine at Case Western University, Reserve

University, and holds a degree in African and European history. He's the author of the Imperial Bedlam, Institutions of Madness and Colonialism in Southwest Nigeria, and Electroconvulsive Therapy in America, and co-editor of the forthcoming six volumes. Holy crap, I'm still trying to write my first book. Cultural History of Madness from Bloomsbury. And it's rumored that I might be the number one character in that book. I don't know. Who knows? I'm just kidding. Anyway, welcome to the show, Jonathan. How are you? I'm doing great, and it's great to be here.

I'm always eager for a chance to talk about my book, and I really want people to go read it. Yes, definitely. Definitely. Give us your plugs for people to find you on the interwebs and to read more about you. Okay. I am a historian of medicine at Case Western Reserve University, and I'm really interested in madness and sanity. And one thing that's been an interest of mine throughout my career is the very complicated processes by which societies determine one from another. That is,

how do various societies decide where sanity begins and madness ends and so forth? And this is actually a major theme of my new book on depression. One of the things that makes depression interesting as a subject is that it refers in English both to a mood that is as close to a human universal as you can find. Everyone in every society, so far as we know, experiences depressed mood. However, in many societies, possibly most, and one including our own, American society, it also indicates an illness, and that's different from the mood, and that the mood can be a symptom of the illness, but the two are not identical. Now, the border between these is a very complex, knotty problem. For example, most of us, I think many of us at

least would agree that if a person is plagued by daily suicidal ideation that goes on for a long time, maybe that person should get medical help. If the person is so lethargic to the point nearly of catatonia or at catatonia, where they can't get out of bed, it's not simply that they don't feel motivated to, but they really can't get out of bed. In extreme cases like that, most of us are comfortable saying, that's a medical problem. That's not just a bad mood. And duration matters too. You can, if you go a couple of days feeling that way, okay, maybe something bad happened. You got dumped or you lost your job. But if it goes on for years, then we start to think maybe there's a bigger problem here that might need medical attention. But there's no real objective way to decide how

long is long enough. According to the current diagnostic manual, two weeks of symptoms is enough to get you a diagnosis. I'm not saying that's right or wrong. I'm just saying it's a little arbitrary. I think any psychiatrist would agree it's a little arbitrary. How long it has to be, how severe it has to be, these are very complicated problems. But, and here's the point, one point I really want to stress. The continuity between ordinary depressed mood and the illness depression, the fact that these things exist on a spectrum does not mean that depression is not a legitimate illness category. I reject the view that we are simply medicating unhappiness. Is that happening in some cases?

Yes. Many authors about depression have claimed this. I think it's more often claimed than it's shown. That is, I think people look at the numbers, how many people are getting diagnosed with depression, how many people are taking antidepressants and they say, whoa, we are over-diagnosing here. We are taking what used to be called ordinary sadness, the normal pain of living, and medicating it. Maybe. That's hard to show. But I do think that the very fact that people, normal people, go through the blues sometimes and have bad reactions to problems in their lives doesn't mean that there isn't a legitimate illness category.

And I don't want to, I mean, you may want to jump in with another question soon, but I want to say that one way of illustrating this point is to make the analogy with other illnesses that we don't really debate whether they're illnesses. We don't debate whether tuberculosis or AIDS or COVID-19 is an illness. And those things are caused by normal life events too, in some ways, right? Or traumatic life events, exposures to certain things in tuberculosis, certain working environments, poverty, all three of these infectious diseases I've just named thrive on poverty. And yes, of course, we need to treat the poverty and we need to address issues of inequality. But we don't say to those people, oh, no, you're just having a normal problem in living caused by your poverty.

We acknowledge that they need medical help. And the same is true for the depressed. Interesting. Interesting. I've suffered depression all my life. You talk in your book about how basically depression has colonized the world. 300 million of people have been diagnosed as depressed, but 150 years ago, according to the book, depression referred to as a mood, not a sickness. Are there more people getting depressed? Is this becoming like an epidemic sort of thing? Or do we always live with this as a human? There's three possible ways of answering that question. And I don't think this is an easy question to answer. One of the things that I really try to emphasize in my book is that when I think we know something definitively, I'll say so. But when I think there's

some mystery, I don't try to resolve issues that are not really possible to completely resolve, even if I have opinions about them. All right, long preface there. But here's my point. There's three ways of possible ways of understanding this large number of diagnosis, how many more people are getting this diagnosis now than did one or two centuries or three centuries ago. One way is to say we're living through very hard times, and there's all kinds of problems in the world. The problem, and people will say, look at various things, like they'll say, we live in this very alienated society because we're always on the internet, or we don't have communal activities anymore, or they'll point to great wealth inequality, which is a real problem. Climate change. Look, there's lots of real problems now.

I'm skeptical about that explanation because it's very hard to show, really, that life was much less distressing 100 years ago. If you look through the sociology of 100 years ago, it's all about how alienating modern life is. And you read people like Durkheim or whatever, they're all talking about how city life, the stresses of modern life, this has been going on, the stresses of modern life theory has been going on for at least 200 years now. And if you look at the first half of the 20th century, before depression diagnoses were on the rise, look, you've got global colonialism, you've got Jim Crow in the United States, you've two world wars, a massive depression. And then you look at the philosophy of the period, existentialism, basically telling us that there was no real objective purpose to life. So I'm really skeptical that we live in more depressing times now. Is it possible? Maybe. So the second possibility in, so that would be that there's a rise in the true prevalence of the illness, the what epidemiologists call true prevalence. Second possibility is that we're actually, the depression's always been there and we're

learning to detect it more. So, and there's something to that because if you look at the psychiatry of the 1950s, 1940s, there were prominent voices who were saying, we are really under-diagnosing depression now. And they thought if we went out into the community and really looked and brought people into the treatment, we'd find a lot more depression. That was what they thought. And so that's one possibility. And an analogy here would be autism. Autism rates are up. There's an entire wing of the anti-vax movement, which claims it's due to vaccines. And one of their arguments, fallacious arguments, is that if it's not that, what new exposure is there? And one answer to that is that we understand autism better now. We detect it better now. So of course, diagnoses are on the rise. Those people

would have been not understood as autistic before. And there's a third possibility. And the third possibility, which is very popular among my academic colleagues, the historians and anthropologists who study depression and mental illness, the third possibility is called diagnostic drift. And that basically means that we're renaming either states that were not considered illnesses before and calling them depression or taking things that had different names as illness before and calling them depression. So we used to talk about nerves or nervous breakdown. And that kind of language has dropped out to a large extent. My own opinion, having set forth these three possible things, my own opinion is that these things are not mutually exclusive.

And I think that some combination of real better detection and renaming or diagnostic drift, I think some combination of those two things is going on. I am not, one of the first things I said in Empire of Depression is that this book is not a long lament about overdiagnosis. You can find lots of books like that. A lot of them have valuable things to say, and I don't minimize the risk of overdiagnosis. But I thought it was important at this juncture to bring some attention to at least the possibility that by doing this diagnosis and getting people into treatment, we're reducing suffering, which is the most unarguable goal I think you can think of, right? Whatever goal people might have for society, for their personal life, reducing suffering, that's pretty good. So let's look at this on

the global scale for a moment, right? So a lot of languages don't have depression in their medical lexicon. And some have argued that means they didn't really have it if they don't name it as an illness state. But maybe they named it something else. And it's being called depression. Now, to a certain extent, that means that they are accepting or being forced to accept in some ways of thinking about it, Western psychiatric diagnostic name. I thought it was important to at least consider that there might be an upside to that, that there might be losses involved. There certainly are losses of local nuances and ways of understanding illness in the body if you simply stamp a Western label on another culture. On the other hand, I do happen to believe that antidepressants can help many people. We'd like

to have better, more powerful ones with more robust statistical effects, but I do think they're an important part of our repertoire, and if you can get that to people who really need it, that can be helpful. I want to add quickly now, too, before I get cast as a shill for big pharma here, I actually am a big advocate of psychotherapy and other ways of treating depression. I do not think, I think probably we've become over-reliant on pills. I do defend them against some of their most severe critics, but I do think that one of the unfortunate effects of what you could call Prozac hype, which started in the 1990s, has been to an over-reliance on medications where psychotherapy and other kinds of interventions

can work. And it's not just hype that's at fault here for the over-reliance on drugs. The whole structure of our medical system favors short office visits, insurance companies like this. Insurance companies don't want to have to pay for long, difficult psychotherapies. Yeah. In fact, my mom just had her second knee operation, another knee, and where normally they gave her two weeks of rehab and different things, they just kicked her out the next day. And she's really having a hard time with it right now. And I was really surprised. She has really good insurance.

But we really need to do something about health care in this country. Yes. Go ahead. good insurance, but this is, we really need to do something about healthcare in this country. So what sort of resolutions did you find in your book as to what people need to do to, I don't know, identify their depression? Is that, is this a good, what sort of the people who are, should be buying your book or reading your book? What sort of target audience do you have for those? I really have a broad target here. I certainly hope clinicians would read it. People who are treating depression, whether as psychiatrists, social workers, primary care workers, I certainly hope clinicians would read it, people who are treating depression, whether as psychiatrists, social workers, primary care workers, I certainly hope clinicians would read it. And I can tell you specifically what I hope clinicians would get from it. But I also

hope the general public would read it. And not just people with depression. Most of us know somebody with a depression diagnosis. We can argue about whether we're diagnosing too many people, but the fact is most of us know somebody who has this diagnosis. And I think that given that, it's really important that we come to a good understanding of the condition. And I think that given that, it's really important that we come to a good understanding of the condition. And I think history has certain specific things to offer to that. And I can talk about that in a moment too. But I just want to say, I've gotten some positive feedback about the book.

I'm very happy to say. And a number of people who've suffered from depression, some of them for years, have written to me. People have reached out on Twitter or by email. And sometimes they've had questions. If they've had clinical questions, I tell them I'm not a clinician, go see a clinician about that. But some of them have wanted to understand the social and historical background a little better. One of them, and this was actually probably for me, the most touching one, one person wrote to me and said that my book was the one book that they would give to their parents to help their parents understand what it means for them

to have depression. That I was, of course, very flattered by that. But I do think that it shows why we all need to have some understanding of this illness because it's touching all of our lives in some way or another. Yeah, I never really understood depression. I was suffering when I started my second company. I really started suffering from, I'd had ADD all my life. And I was 16. I remember locking the door like 12 to 16 times a night going, I'd go to back to bed and I'd be like, did I check the front door? And so I've suffered it through most of my young years. I didn't understand what it was. I just, I don't know. You just, you're just in it. So you do it. I know my brother suffered ADD and he'd wash his hands until they bleed, that sort of thing. And then when I started my second company, I started having daily panic attacks, like really badly, to where I'd shut down and have to take a nap just to have a heart attack and blow up my heart.

And then I remember I just had enough one day, and my brain was hurting. I was having headaches from it. And I went in one day, and the gal goes, yeah, you suffered from anxiety. I said, yeah, I suffer from fear and anger and misery and everything else too. So what the hell? And she's like, no, anxiety is a depressive condition. And that's when I found out about depression and some of these different things. And, and I think nowadays people are a little bit more aware of it because everyone seems to be on Prozac and it's interesting how more people know about it. But I think some people, I don't know, is it overdiagnosed in a lot of cases, do you think? I think probably. I do think that I did push back a little bit against some of my peers who've been really pushing the idea of we're just medicating sadness now. I thought that point had maybe been overemphasized.

That said, I do think, yes, there probably is some overdiagnosis going on. But I do want to say that I think that the fact that somebody has had genuine difficulties, traumas, abuse, neglect, isolation, loss of income, grieving. I don't think those things necessarily mean, if you've had those experiences, I don't think that necessarily means that you don't have an illness and you're just having a problem in living. The data mostly show that people who experience even extreme adversity, like being in a refugee camp, for example, even people, most people who experience extreme adversity will not develop clinical depression. And at the same time, we find that many people who experience only what they subjectively themselves acknowledge to be only mild adversity in life, you get clinical depression.

Why? I would say we don't completely know. I think there are enigmas that still surround this illness, the causes of it. I think that the hunt for a single cause of depression is misguided. That's one of the things I think that we learn from the history. I think that when you look at the past, you look at past clinicians and their theories and their etc. Looking for a single cause is not the way here. Now, this means a couple of things. It means that we do need to understand all three. It's probably more, but I'm thinking of three, all three dimensions of the person involved. We need to understand the person's social context, we need to understand the person's life history, and we need to understand to the extent we can the person's biology. One of the things that I find very interesting is that although we

supposedly live in this very biological age and we've become very reliant on medicines, chemical substances that we put in our bodies to treat these problems. Even though we're in this very biological age, ironically, I think we know more about the social and psychological causes of depression than we do about the biological causes. I don't think we know nothing about the biology. We do know some things about the biology. For example, there appears to be some heritability. It runs in families. This can't be entirely explained by the family environment, right? Because one objection might be, well, being a Democrat or a Republican tends to run in families. It's just you pick up things from your parents.

No, that doesn't actually work here because we're talking about twin studies that show greater degree of heritability, depending on the degree of genetic similarity, even independent of the environment. Okay, so we know there's some heritability. And probably there are certain changes in the brain that go on that can be somewhat helped by antidepressant drugs. But a lot of the biology remains very mysterious. I happen to think it's just a theory. I can't prove this. I happen to think that there are many kinds of depression and that probably different things are happening in the brain for different depressions. And this is why, probably, why psychiatrists find so frequently that a patient will respond to one medication and not to another medication and that it's a little bit hit or miss here. But in terms of what we know that a history of childhood abuse or neglect, for example, is a strong predictor of depression. That does not mean

that every single person who experienced childhood neglect or abuse gets depression, nor does it mean that having a well-protected childhood with nurturing, loving parents means you're not going to get depression. But diseases don't work that way. Look at lung cancer. We know if you smoke, you're at greater risk for lung cancer. It doesn't mean that people who don't smoke are never going to get lung cancer, nor does it mean that everybody who smokes is going to not for others. So this is known in psychiatry as the tailoring effect. And psychiatry is not at a point now where it can easily predict what drug will work for which person. There are some educated guesses you can make. Some drugs tend to increase anxiety. So if the person's depression is presenting with a lot

of anxiety, that might not be the best option and so forth. But there are a number of different neurotransmitters that seem to be involved. And so we're a little bit in the dark still about the depression, about the biology. Some have argued that these drugs are simply placebos. It's just the expectation that you're going to get better that creates, and the placebo effect is real. It's been shown all throughout medicine for both mental and physical illnesses. No question, placebo effect is a real thing. But the placebo effect doesn't account for the tailoring effect. That is why, if it's really just the expectation that you're going to get better, why does drug A work, drug B not work, drug C work for a particular individual? I think it's more plausible to look at that and say,

this person has a particular biology that we don't completely understand that responds to certain classes of drugs and not others. So what are the things that we touched on in your book that would be important to tease out to readers so they go pick up the book? What are the things that they could pick up? What other things haven't we touched on that would entice readers to pick up the book? Okay. Well, one thing, and maybe I've been touching on this, but I would like to reemphasize for a moment, is that we don't have to choose between mind and body in understanding depression. We call it mental illness. People who are skeptical of its illness status draw attention to the second part of that phrase, mental illness, and say that it's a

problem. I actually draw attention to the first part of it, that we call it mental as the problem. I think that's not to deny that there is an emotional aspect to it. There's a psychology to it. But depression is always bodily. I know of no cases. I've been studying this field for many years. I've been teaching a course on it for many years. I've read dozens and dozens of accounts of depression. It always seems to involve bodily sensation. So we don't have to choose between mind and body.

This also means that this has treatment implications because it means that we don't have to treat with only psychotherapy or only drugs. One or the other might work for some people and not for others. The data show that the two work best together. Just this morning, I was reading a really interesting article and I don't remember the author now, but I just found it on Twitter this morning at breakfast. There was a really interesting article that showed that psychotherapy and antidepressants both change the brain. This isn't surprising.

Why shouldn't they? But they change different parts of the brain, according to this study. That is, the antidepressants work on the amygdala, which is very involved in emotive reactions. And antidepressants maybe seem to work more on frontal cortex, the more cerebral aspects of it. And maybe that's why they work best together, is because they're targeting different parts of the brain. Why is this important and what does history have to do with it? History matters here. I, like many historians, lament the fact that many people come out of high school

thinking history is really boring and it's a bunch of names and dates from the past and why would you want to read that? But history is exciting precisely because it's a way of understanding the present, just like any other way of studying society. In this case, I can show, and I have shown historically, that people who have tried to reduce depression, either to psychology or to biology, have led us to dead ends. And that the most fruitful research has been the research and the most fruitful therapy has been that which takes all into account. I give the, there's a famous example that I use in the book, a man named Raphael Osheroff. He was, he was had a very severe depression, went to a hospital. The hospital that he went to was very dogmatically committed to Freudian psychoanalytic views of depression.

Now, the Freudian psychoanalysts have always, for the most part, in the mainstream, been aware that there's a bodily dimension to depression. Actually, the minority of them deny any biology. But this happened to be a hospital that wanted to focus exclusively on psychological interventions. This was in the 1970s. After he was there for a while, and he didn't get better, Ashraf, with the help of his mother, he sued them saying, I wasn't getting the standard of care because they didn't offer me antidepressants. That was an example of a dead end. I don't think that the hospital in question was wrong to want to explore Ashurov's inner conflicts, the psychological dimension of him. But it was wrong to deny that there could be any kind of biological aspect that could be treated. And in fact, most psychoanalysts historically have welcomed biological interventions because they made the patients well enough to be able to do productive therapy. Now, on the other side, when the Prozac hype came about in the 90s, and this had been building a little bit prior to the 90s, in some ways Prozac hit at a time that was primed because other things that I could go into were leading towards a more biological view of the illness. So what is the result of that? As I've been stressing, I do think

antidepressants help people. I think some of the other antidepressants that aren't in the same classes, Prozac, maybe need more use than they're getting now. But my reading of the literature, and as from the book, one thing I did to research the book was look at a number of memoirs. My understanding, my reading of patient experience is that even patients who welcome getting a medicine that can make them feel better, don't want to be reduced to a biological condition and a label. They want the totality of their life experience to be explored. And there's no reason you can't do both. So that's, so in the book, just to wrap up this theme about, about you don't have to choose between mind and body.

In the book, I use the analogy of a married couple that's been arguing for decades about the same things and they're trapped in a loop. That's the way I see what you could call team psychosocial on the one hand and team biological on the other hand. We have been having this argument for at least 120 years now. Is it mind versus body? It's time we learned from the history that it's both and moved on. And many voices are saying that now. Okay. Now, do you want me to go on with some of my key takeaways or do you have some? No, let's wrap those. Let's wrap those and tease out anything else you want to tease out on the book. Okay. I guess there's two other main points that I would like to make sure get hit. And the

next one I would call under the label, don't believe the hype. And what I mean by this, and this is another way in which a specifically historical approach helps us. There's been a cycle that you can observe over the last 120 years or so where a new treatment comes along and people get very excited about it. And the psychiatric profession gets very excited about it. And it's hailed as an advance over previous treatments to the extent that people want to abandon the earlier treatments. And what happens is that the limitations of the treatment slowly become visible. And once those limitations become visible, people start casting about for the next big thing.

And then the new shiny object comes along. So let me make this more concrete. In the early decades of the 20th century, probably the most important of these new treatments was Freudian psychoanalysis. I happen to believe it helped a lot of people. I think it still helps a lot of people. I believe that those who say that it's all been proven wrong and that it's a dead field, I think they're misinformed. However, as I showed with the case of Oshirov, it does have limitations by itself. And full-blown psychoanalysis, five days a week on the couch, that's really expensive. It's a big time commitment. It does have the virtue that you really can get into issues in a very deep and detailed way. Although I would say that psychodynamic therapy, which is Freudian therapy on a smaller scale,

maybe once or twice a week, you can get a lot done with that through insight. But basically, what the two share is that insight matters. But insight has limits. and that was the case with asharov all right so then another major treatment came around mid-century and that was the subject of my previous book electroconvulsive therapy commonly known as shock therapy and when it came out although many doctors and patients were skeptical of it it spread through American mental hospitals like wildfire. And some of its more zealous proponents came to the conclusion, oh, psychology doesn't matter. Really? The person's life history doesn't matter. We just need to give them this jolt of electricity. Now, electroconvulsive therapy is extremely effective.

It's a very controversial treatment, and people who don't like it are going to get mad at me. I'm used to that. I've been living with that for years. I don't care. I usually don't like it when people get mad at me, but on this issue, I'm just used to it. It's very effective, but it has adverse effects. I'm really convinced of this. How common they are is really hard to know from

the literature. I studied the literature, the scientific literature on memory loss greatly in depth. Hundreds of articles have been written about this. I don't really think they prove either way, whether it's common or rare, but it certainly is possible. So you don't necessarily want to rely on electroconvulsive therapy. It's a really good treatment for people, especially in very severe depressions where nothing else has worked. But something that's going to chip away at your memory is not something you really want to go. If you've got a more mild case or you have something that can respond to other treatments, in my opinion, by the way, if you doubt that people were saying when electroconvulsive therapy came around, if you doubt that people were saying, oh, we don't really need to understand psychology anymore. It's actually there's a whole dialogue about this in that fantastic book by Ralph Ellison, The Invisible Man, rather. So in Ralph Ellison's book, there is a depiction

of an electroconvulsive therapy treatment. It's not named, but it's really clear anyone who knows the treatment can see what's going on here. And one of the doctors' presence says, what about his psychological issues? Don't we have to explore them? And the other doctor is saying, and this is written right around the time ECT was new. The other doctor says, nah, we don't need to know any of that. We don't need to know any of that. We just need to jolt him. He'll be better.

All right. So ECT had problems. And then in the late 60s, early 70s, people started getting a little bit disenchanted with both psychoanalysis and electroconvulsive therapy. And so new psychotherapies came about. Probably the most hyped one was cognitive behavioral therapy, CBT. And like psychoanalysis and like electroconvulsive therapy, I have no doubt that cognitive behavioral therapy has helped some people, but it also has limitations and it was also overhyped. There's a, I think it was Tracy Thompson was the author on depression who wrote about this

very eloquently. She said that, you know, if you're basically, as you may know, cognitive therapy mainly works by trying to correct fallacious ideas that the patient has. Student fails the test. She thinks I'm a failure, goes into the therapist's office and says I'm a failure. Therapist says, well, no, you failed a test. You can't really conclude from that that you're a test. You can't really conclude from that, that you're a failure. That can be really effective to be shown these fallacious arguments, but there's a problem. Some people in deep depressions are very resistant and anyone who's worked with a deeply depressed person or known a deeply depressed person knows this logic isn't going to work. If a person is really, really deeply committed for

whatever reason to the view that they're a failure or that their life is pointless, just talking them out of it logically is not always going to work. And that's, Freud said this, actually. Freud said he was talking specifically about the guilty ruminations many depressed people go through. Oh, I stole some office supplies. I'm such a bad person. Freud said there's no point in trying to talk the person out of it because they're dealing with an unconscious conflict here. So I believe the unconscious continueshyped, and antidepressants. So in the 90s, Prozac was this huge rage, and very exciting. And there was even talk of people then of people making people better than what if we gave Prozac to people who aren't sick. And actually, Prozac doesn't seem to do much for people who aren't

sick. But beyond that, Prozac, like electroconvulsive therapy, has adverse effects. Personally, I think most people find the sexual side effects of Prozac, which are pretty common, to be pretty bad, maybe not as bad as losing whole chunks of your memory, but really not ideal way of living. So people got disenchanted to the point now where you have critics of antidepressants saying that they're completely worthless. So let's look at these four treatments for a moment. Are any of them worthy of being hyped to the point where we discard all other treatments? No. Are any of them worthless? No. They all have something to contribute to the treatment repertoire. So this cycle of hype and disappointment, a good psychotherapy is often described as allowing a patient to see that his, her life could have a different

narrative. They don't have to tell the same story over and over again about themselves as, say, a victim or a loser or a failure, and that they can rewrite the narrative. I'm arguing for a similar role for history, for as a society. We do not have to have this kind of compulsive repetition of hype and disappointment. And how can we avoid it? We can avoid it by understanding the history, seeing how this has happened in the past. Then when a new treatment comes along, and there will be new treatments coming along, they're already in the pipeline, and we will hear, I guarantee it, we will hear when they become common that they are the answer to depression, that they do not have all the bad effects of these other treatments,

or they're more convenient, or they have less side effects. And then we'll start, then there's the danger. We'll start overusing them. And when we start overusing them, we will get disappointed because they will not live up to the hype. But what if we interrupted that cycle? What if we said, okay, transcranial magnetic stimulation or psychedelics, two of the things that are being explored now, both very promising. What if we said, okay, this should be added to our repertoire, but we can keep the old things and we can recognize that these new things are probably not going to be perfect. All right. So that's don't believe the hype. And my last point that I want to make sure to hit

before we wrap up is listen to patients. And this has been one of the guiding factors or beliefs of my career. And it runs through all my writing that I've been doing since I've got into this field in the late 1980s. And I've studied colonial psychiatry in Nigeria, and then I went to a very different context. I looked at electroconvulsive therapy in America, I've been trying to include the voices of patients. It shouldn't be just the history of psychiatry itself. It should be the history of the people who have been helped or harmed by it. Now, there are two specific reasons that I'm going to give you why I think it's important to include the patient's voice. One has to do with adverse effects. Let's take the example of electroconvulsive therapy for a moment.

Patients have been complaining about memory loss since the treatment was introduced. It was introduced in the late 1930s, became common in the 40s and 50s. Patients complain about memory loss. The psychiatric profession has been slow to recognize that this might be a legitimate complaint. Something similar happened in schizophrenia treatment with tardive dyskinesia, which is a movement disorder which can result from taking certain antipsychotic drugs, the profession was very slow to acknowledge that this was a problem. So when patients talk about adverse effects, listen to them and take them seriously. The memoir literature on depression includes many examples of patients who went into their doctor and said,

this drug is making me feel X, Y, Z, or bad, only to have that complaint dismissed by the doctor who said, oh, it's not in the physician's desk reference. That's not in the literature. We have no science to prove that, effectively saying it's all in your head. Now, I do want to say it is possible that in some cases the patient is wrong. Maybe they're having the stomach ache or whatever other adverse effect they're having for another reason, and it's not caused by the drug. The patient isn't necessarily always, but I am saying that the patient's complaints about adverse effects always need to be taken seriously, even if it's not yet recognized in the scientific literature. I would agree. I also want to say, though, make a kind of counterpoint to this.

And this is another reason why I'm saying it's important to listen to patients, but it's a slightly different one. And here I'm addressing many of my colleagues in the field of history of psychiatry, because in the field of history of psychiatry, patient voices are extremely valued, but they're generally only valued as criticisms of psychiatry. And this leaves out a lot, because a lot of people feel themselves to be helped by their therapists or their psychiatrists. And so one of the things I stress is that listening to patients doesn't mean just listening to patient complaints. It means taking patient complaints seriously, but also taking patient relief, patient gratitude, patient. And this is really important to me also because I felt that I do believe that there are effective treatments for depression.

And I would have been horrified if anyone came away from my book and said, oh, psychiatry is an evil menace, which Tom Cruise went on TV some years ago and said that to Matt Lauer. Because that kind of talk, that kind of discourse can, and I have anecdotal evidence that this is actually true, it can lead people to not seek treatment. They think psychiatry is purely evil. Psychiatry has lots of documented abuses. I could go into them overzealous treatments, wrongful imprisonment, confinements. It's not hard to find examples of abuse and wrongdoing by the whole story. And I wanted to tell a story that acknowledged problems, but also showed people that there's hope. One last point about listening to patients. And that is, I've been talking a lot today about the importance of understanding depression from many angles, from the biological, the psychological, and the social. You don't have to take my word for it, though. This is what patients say.

If you look at what patients are saying, that's what they want. And I don't deny that there might be patients who are fully committed to simply just doing talk therapy. You don't want to touch their touch meds. That's fine. There may be others who are very happy to have their medications and don't really want to explore their problems in a talk therapy environment. My sense of it is that the majority of patients do want to be understood as a totality, and they do not themselves, patients themselves don't think we have to choose between, oh, it's caused by trauma. Oh, it's caused by genes.

Oh, it's caused by chemical imbalance, which is a phrase that's gotten a lot of scorn in recent years. They don't want to have to choose. They also don't want to have to choose exclusively among treatments. It's interesting. And there's a lot of insight that you have in your book. I'm sure it's going to be wonderful for people. So I appreciate you taking the time and giving us some teasers on what's inside the book and what people can look forward to. Thank you for spending the time with us today. Oh, it's been a pleasure talking with you, Chris, and really grateful for

the opportunity. Thank you, Jonathan. Jonathan, give us your plugs for people and find you on the interwebs and find out more about you in order to be a refined book. Okay. You can find my webpage by going to the history department at Case Western Reserve University. Click on the faculty link. It lists all the faculty. And then you can find my name. When you find my name, you can click on me.

And when you click on me, you'll see all three of my books have pictures there. You can also link to my resume, just my CV, and it will list all of my publications. So if you're interested in reading any of them in article form, you can do that. I actually recommend going to the books. Also, Empire of Depression, a new history. It's available on Amazon and other sellers. You can look it up. It's not expensive. There is no paperback at this time, but there is a Kindle edition. But even the paperback, it's not that expensive. It's even come down a little bit since December. So if you looked in December and it was in the 30s, it's in the 20s now. I also, if I may, although I am an academic historian, I really made an effort in this book to write in such a way that the general educated reader could pick it up. And I'm hopeful that those of you who are curious and want to read more, don't think, oh, I don't want to read a dry history book. I tried not to make it dry. I tried to make it come to life. I've been teaching a course on depression for many years, and I've always been struck by one of the ironies about this course is that the discussion is very lively. It's very animating. There's a lot of

interesting issues here. So it may not be a happy subject, but it is in some ways an exciting subject anyway. Yeah, it may not be a happy subject. It's is in some ways an exciting subject anyway. Yeah, it may not be a happy subject. It's the subject of depression. So very good. Jonathan, it's been wonderful to have you on the show. People go pick up the book where fine books are sold. Thanks to my audience for tuning in. Go to youtube.com, Fortuna's Chris Voss. Hit the bell notification, goodreads.com, Fortuna's Chris Voss. You can find us anywhere on the webs under Chris Voss or the Chris Voss Show. I certainly appreciate all my audience tuning in. Thank you. Be good to each other and we'll see you guys next time.