Spontaneous Happiness [NOOK Book]

Spontaneous Happiness

Little, Brown and Company

PART ONE

THEORY

1

What Is Emotional Well-Being?

I do not claim to have attained optimum emotional well-being. Actually, I think that may be a lifetime goal. For me it’s an ongoing process that requires awareness, knowledge, and practice. I do know what good emotional health feels like, and that motivates me to keep at the practice. I’d like to share some of my experiences with you.

On occasion, both when things are going well and when they aren’t, I have a profound sense that everything is just as it should be, that my opinions about my situation are irrelevant. That realization is freeing. It helps me to stay comfortably in the vicinity of emotional sea level, the zone of contentment and serenity that I mentioned in the introduction.

Let me tell you about two such occasions.

In June 1959, for several weeks before and after my graduation from my public high school in Philadelphia, I was spontaneously happy, not in the usual sense of that word but more from a deep knowing that I was all right, on the right track, doing what I had been put here for. Things were going very well for me that spring. I had great friends, was enjoying good relations with my parents, had the affection and support of excellent teachers, felt ready and excited to leave home, and saw many opportunities opening up before me for travel, adventure, learning, and discovery. I liked myself. I had much to be happy about in the usual sense, much good fortune, but the deeper feeling came from knowing that I was the person I was supposed to be, uniquely equipped to navigate the world and meet any challenges I might confront. I thought I would be able to maintain that feeling always. It did stay with me for many days and it does return. Whenever it comes back, I am grateful.

Forty-seven years later, at the end of July 2006, I was awakened by an unusually early phone call at my summer retreat in British Columbia. My medical associate Dr. Brian Becker told me that a flash flood had devastated my property in the desert outside Tucson. My first question was “Is anyone hurt?” I was much relieved to hear that the two people staying there had escaped unharmed when a fourteen-foot wall of water came through the property in the middle of the night. My office building had taken the worst hit. Over the next few hours and days, I learned that all of my files, most of my personal papers, and many of my books were lost. The flood carried away photographs and memorabilia going back to grade school, furniture and personal effects of my recently deceased mother, and many of my favorite plants. Although these losses made me sad for a time, oddly, I felt at peace with all of it. To the bewilderment of my partner, who said she couldn’t imagine being calm in the face of such news, I declined to return to Arizona, feeling no need to oversee the cleanup and assessment of damage. I was able to let go of attachment to my possessions, and once again, this time in circumstances that I might have expected to make me quite unhappy, I was spontaneously embraced by the feeling that all was as it should be, that my opinions didn’t matter, and that I was emotionally free.

Experiences like these give me a sense of emotional well-being, especially in its core elements of resilience and balance. I have already mentioned these factors as defining characteristics of health that allow organisms to interact with potentially harmful influences and not suffer injury or harm. In the emotional realm, resilience enables you to bounce back from losses and reversals and not get stuck in moods that you don’t want to be stuck in. Think of an elastic band that can be twisted and stretched but always goes back to its more or less original shape. If you cultivate emotional resilience, you don’t have to resist feeling appropriate sadness; you learn that your moods are dynamic and flexible and that they soon return to the neutral balance point, the zone of contentment, comfort, and serenity.

When I ask people to give me images of contentment, they usually come up with ones like these:

• a child licking an ice-cream cone

• a person lying on a couch after a fabulous holiday dinner in the company of family and friends

• a dairy cow munching lush grass in a postcard-perfect meadow

• a dog lying in front of a fire, being stroked by its human companion

I would call these images of satisfaction rather than of contentment, just a temporary response to fulfilling needs or gratifying desires. Contentment, I think, has more to do with being at peace and feeling good about who you are and what you have without regard to satisfying your desires and needs. Contentment is enduring. You carry it with you. The sixth-century BCE Chinese philosopher Lao-tzu got it right (as usual) in few words: “One who contains content, remains content.” A striking aspect of this state of mind is that it does not foster passivity (which Westerners often criticize Eastern philosophies for doing). In both 1959 and 2006 and whenever it has returned, my sense that all is right with the world has actually spurred me on to effective action and improved my efficiency.

I suggest that the ability to feel contentment is a key component of emotional well-being. It is also a goal of many religions and philosophies that recognize that the source of human unhappiness is our habit of comparing our experiences to those of others and finding our reality to be wanting. The choice is ours: we can keep on craving what we don’t have, and so perpetuate our unhappiness, or we can adjust our attitude toward what we do have so that our expectations conform to our experience. There is much discourse by philosophers and teachers on this theme, because we all eventually learn that we can’t always get what we want. How many of us work at appreciating what we have?

If you are not sure what I mean by work at appreciating what we have, you will be interested to know that techniques exist for just this kind of practice. They include ancient forms of meditation and new forms of psychotherapy, and I will explain them in chapter 6, where I discuss ways of changing destructive mental habits in order to improve emotional wellness.

What about comfort? The word comes from a Latin root meaning “strength” and denotes a state of ease and freedom from pain and anxiety. To be comfortable is to enjoy contentment and security and presumably be stronger as a result. I would argue that, like contentment, comfort is something you can carry with you, a feeling you should be able to access in a great variety of circumstances.

Because I grew up as a city boy and did not live outside an urban environment until my late twenties, I was uncomfortable in nature, unable to enjoy camping or being in the wilderness for more than a few hours. I had to learn how to be at ease in nature, but once I set my mind on doing so, the process was not difficult. It changed me, made me healthier in body and mind, and opened worlds of new experience that have greatly enriched my life. One welcome aspect of the change was that I lost my anxiety around insects, especially bees and wasps, which had made it impossible for me to relax out of doors. I don’t know just how this happened, but as it did, I came to understand the behavior of these creatures, appreciate their beauty, and coexist peacefully with them. I’ve now lived in or near wilderness for most of my adult life and have no problems with insects.

It’s good to be comfortable in nature, but it’s even more important to be comfortable in your own skin. Whatever your external circumstances, you will not know ease if you are not at ease with yourself. The more comfortable I am with myself, the more effective I am in communicating, teaching, and working with patients, many of whom tell me I am a comforting presence, making it easier for them to talk about their concerns and problems and give me the kind of information I need in order to make accurate diagnoses and determine the best treatment plans.

Serenity is another quality I associate with emotional sea level. We might picture the peaceful calm of still air and an unclouded sky or a placid body of water, but the word serenity also refers to the absence of mental stress and anxiety. Again, this emotional state can be cultivated, and maintained, even in the midst of external agitation. A Sufi fable tells of a ship of pilgrims engulfed by a great storm at sea. The passengers are gripped by fear. They wail and moan, sure that death is imminent. Only when the storm subsides do they notice that one of their number, a dervish, has sat through all the tumult in calm meditation. They crowd around him in wonder, and several ask him, “Don’t you know that at any moment we could have perished?” He replies, “I know that I might perish at any moment always and have learned to be at peace with that knowledge.”

Serenity can be a gift of aging if you are open to it. Many older people tell me they have much greater emotional equilibrium than they did when they were young, that they are better able to adjust to life’s ups and downs. Serenity also comes naturally from acceptance, especially of “the things I cannot change,” in the words of the much-quoted Serenity Prayer. But attaining serenity is also a process and a practice. My own efforts to cultivate it through meditation and the practice of nonattachment have had the practical benefit of enabling me to be very cool in emergencies, to respond swiftly and efficiently and not panic, just as I did when my property was flooded.

If you are in good emotional health, you should be able to respond appropriately to whatever situations you encounter: to feel appropriately happy about good fortune and appropriately sad about bad, to be able to feel appropriately angry or frustrated about the state of the world and the annoying behavior of others and to let go of those feelings once you’ve acknowledged them. It’s important to remember that our moods are supposed to vary through both the positive and negative regions of the emotional spectrum.

Just as we have both cloudy and sunny days, we are all sad at some times and happy at others; such changes are part of dynamic balance. Emotions out of balance are most obvious in individuals with bipolar disorder, marked by the abnormal cycling of mania (elevated mood, energy, and excitement) and depression. Bipolar disorder can cause a great deal of suffering, for both the affected individuals and those around them. Many people with creative talents carry this diagnosis, and some are high achievers, especially in their manic phases, but without treatment, individuals have little chance of maintaining stable relationships or productivity, and the risk of suicide is high. Research on the causes of bipolar disorder suggests that both genetic and environmental factors are involved, and it pinpoints disturbed function in specific brain areas. Management of the disorder relies on psychiatric drugs as well as psychotherapy.

Over the years, a number of bipolar patients have sought my help. Dissatisfied with standard care, especially the side effects of their medications, they have hoped to find ways of being more in control of their erratic moods. In the detailed histories I recorded of them, I noted that the emotional imbalance in these patients always goes along with imbalances in other areas of their lives. Their sleep patterns are erratic, as are their eating, their physical activity, and their ability to maintain order in their living spaces. The essential problem that I perceive in them all is life out of balance. The mood disturbances that plague them strike me as exaggerations of normal emotional variability, quantitatively, not qualitatively, different from the changeable moods most of us experience. I would never advise patients with bipolar disorder to discontinue their medication, but I do strongly advise them to cultivate greater balance in their lives wherever they can, by eating at regular times, adhering to a fixed schedule of sleeping and waking, creating order in their physical environments, getting regular exercise, learning yoga or tai chi, and trying some form of meditation. By doing so, they can indirectly improve their emotional health and spend less time at the extremities of the mood spectrum and more toward the midpoint. I follow this advice myself and have incorporated it into the action plan I’ll give you in chapter 8.

The mood swings of bipolar disorder exemplify one kind of emotional problem. Just as the variability of the beating of a healthy heart is subtle, so should the variability of human emotions be moderate. It is perfectly normal to experience “the blues,” just as it is perfectly normal to experience joy and bliss, but optimizing emotional well-being means gaining greater control of the variability of moods, damping down the oscillations, and enjoying the rewards of the midpoint. It also means not shutting down that dynamic variability, not getting emotionally stuck. Imagine yourself on a seesaw. The goal is to have pleasant excursions around the balance point, not to endure violent swings or to stop moving. And you certainly don’t want to get stuck on the ground.

It is near the balance point that you will find resilience, contentment, comfort, and serenity. This is your emotional safe harbor, which you can leave but to which you should be able to return easily and naturally. I advise you to beware of the countless books, websites, television shows, seminars, religions, and drugs (especially drugs) promising ceaseless bliss. The notion that a human being should be constantly happy is a uniquely modern, uniquely American, uniquely destructive idea.

A German friend recently told me that the American greeting ritual—person #1 says, “How are you?” and person #2 must summon a smile and respond, “Great! Great!”—strikes her as bizarre, artificial, and exhausting beyond measure. I agree. I am asked how I am all the time, and as I recite the obligatory “Great!” I can’t help wondering what I’m doing. The question feels intrusive, the answer disingenuous, the whole exchange false.

Yet enforced, almost bullying cheerfulness dominates our culture. In her book Bright-Sided: How the Relentless Promotion of Positive Thinking Has Undermined America, Barbara Ehrenreich writes that when she was diagnosed with breast cancer in 2000, she found the wildly optimistic pink-ribbon culture surrounding the condition nearly as daunting as the disease itself. It did not allow her to express fear, anger, worry—all perfectly normal responses to a potentially life-threatening diagnosis. Instead she was told over and over that cancer was her chance to grow spiritually, to embrace life, to find God. The message forced on her was “What does not destroy you, [to paraphrase Nietzsche] makes you a spunkier, more evolved sort of person.” So put on a happy face.

Ehrenreich goes on to deconstruct the career of George W. Bush, a high school cheerleader (cheerleading, Ehrenreich notes, is an American invention) who maintained that role throughout his presidency, remaining doggedly, destructively optimistic about everything from Wall Street’s inability to police itself to America’s counterterrorism efforts. “The president almost demanded optimism,” noted Bush’s secretary of state Condoleezza Rice. “He didn’t like pessimism, hand-wringing or doubt.” His detractors called this “toxic optimism.”

Are we more or less happy than people in other parts of the world? That is not an easy question to answer, in part because different cultures define happiness in different ways, and translations of the word might not convey the same meaning. A number of scholarly articles on this subject have appeared in the Journal of Happiness Studies. One, from 2004, notes that in Europe and North America, where independence of the self is a cultural norm, happiness is often construed as a positive attribute of the self, to be pursued through personal striving and achievement. In East Asia, on the other hand, happiness is dependent on positive social relationships of which the self is a part; in those cultures, pursuing personal happiness often damages social relationships by creating envy in others, and there is less desire for it. Other scholarly articles report significant differences from country to country in rates of reported happiness, with North Americans at the top, but it is far from clear whether we are actually happier than Germans or Greeks or whether we are just more likely to say we are. (One interesting note is that while the meaning of happiness in English has not changed, the adjective happy has weakened, so that many people now use it interchangeably with okay or all right, as in statements like “I’m happy with the new schedule.”)

Our cultural insistence on being happy is most obviously counterproductive during the annual holiday season. Throughout most of recorded history, people in the Northern Hemisphere regarded the days around the winter solstice as a time of danger, with the source of light and warmth at its lowest, weakest point in the sky, the months of harshest weather about to come, and a time of short days and long nights, when only the wise could discern the return of the light. The natural cultural response was to gather indoors and huddle in front of fires, feasting together, telling stories, and drawing strength from social bonds. Our culture today, in contrast, tells us that the holiday season is the most wonderful time of the year, when we should all be constantly happy. Bombarded with this message, over and over, at top volume, on all channels so that we cannot escape it, we have developed impossible expectations. The discordance between our expectations of happiness and the emotional realities of the holidays is a major reason for the high incidence of depression at this time of year.

Let me introduce a word that describes a more realistic emotional goal. Lagom is a Swedish term that does not have an exact English equivalent; it means something like “just right” or “exactly enough.” It has been called the most Swedish of Swedish words, and it permeates the entire culture: architecture, politics, economics, and every aspect of daily life.

Contentment, serenity, comfort, balance, and resilience together constitute a lagom version of positive emotionality and, I think, a sane alternative to the perpetual happiness expected and demanded in our society. It should be more than enough to sustain us, and it will not burn us out or condemn us to alternating cycles of bliss and despair. This is what I felt in 1959 and 2006 and at other times in a long and eventful life. I believe it can be cultivated until it becomes our default emotional state. That is what I try to do in my life. It is what this book will help you do in yours.

2

An Epidemic of Depression

Everyone I know is depressed, including me,” says a friend in New York. She adds, “I think the whole country is depressed.”

These are exaggerations, of course, but statistics indicate that something has gone seriously awry with our emotions. The World Health Organization predicts that by 2030 more people worldwide will be affected by depression than by any other health condition. The number of Americans taking antidepressant drugs doubled in the decade from 1996 to 2005, from 13.3 million to 27 million. Today an astonishing one in ten people in the United States, including millions of children, is on one or more of these medications.

Depression has always been with us, though never so much of it. Ancient Greeks called it melancholia, literally meaning “black bile.” They believed that a balance of four humors (bodily fluids) affected one’s health, with an excess of black bile resulting in sadness. A word of Latin origin for “sad” is lugubrious, with a root meaning of “mournful,” significant in that depression has long been accepted as a natural response to the loss of a loved one, pathological only when it persists beyond the normal limits of mourning. Lions, some birds, and a few other animals may respond this way to the death of a mate; some lose interest in eating and in caring for themselves and can even die as a result. Some dogs exhibit such behavior when they lose a closely bonded companion, either canine or human.

The sadness of mourning is an example of situational depression, a reaction to a terrible loss or other catastrophe, and it makes sense to us, especially if it lifts after an appropriate course of time. But when depression comes for no apparent reason and, worse, refuses to depart, it confounds us. Antonio in Shakespeare’s The Merchant of Venice complains of causeless sadness—a reflection, some biographers believe, of the playwright’s own melancholia:

In sooth, I know not why I am so sad:

It wearies me; you say it wearies you;

But how I caught it, found it, or came by it,

What stuff ’tis made of, whereof it is born,

I am to learn….

Throughout history, people have struggled to account for such endogenous (coming from within) depression. The distinction between endogenous depression and situational depression still seems useful to me, although the Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, now breaks depression into a great many types and subtypes. The most serious of these is major depressive disorder.

The current edition of the DSM gives specific criteria for the diagnosis of this most severe form of depression. To fall into this category, a patient must have experienced at least one major depressive episode, defined as:

[A] period of at least 2 weeks during which there is either depressed mood or the loss of interest or pleasure in nearly all activities. In children and adolescents, the mood may be irritable rather than sad. The individual must also experience at least four additional symptoms drawn from a list that includes changes in appetite or weight, sleep, and psychomotor activity; decreased energy; feelings of worthlessness or guilt; difficulty thinking, concentrating, or making decisions; or recurrent thoughts of death or suicidal ideation, plans or attempts. To count toward a Major Depressive Episode, a symptom must either be newly present or must have clearly worsened compared with the person’s pre-episode status. The symptoms must persist for most of the day, nearly every day, for at least 2 consecutive weeks. The episode must be accompanied by clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Major depressive disorder is a serious illness with a high risk of suicide. It always requires competent management by mental health professionals. The recommendations in this book may be very useful as adjunctive treatments for major depressive disorder, but they should never be used in place of medication or other standard therapy.

The clinical language of the DSM hardly conveys the suffering of people with severe depression. The novelist William Styron, author of Sophie’s Choice, provides an eloquent and heartrending interior view of it in his 1990 book, Darkness Visible: A Memoir of Madness:

The pain of severe depression is quite unimaginable to those who have not suffered it…. What I had begun to discover is that, mysteriously and in ways that are totally remote from normal experience, the grey drizzle of horror induced by depression takes on the quality of physical pain. But it is not an immediately identifiable pain, like that of a broken limb. It may be more accurate to say that despair, owing to some evil trick played upon the sick brain by the inhabiting psyche, comes to resemble the diabolical discomfort of being imprisoned in a fiercely overheated room. And because no breeze stirs this cauldron, because there is no escape from the smothering confinement, it is natural that the victim begins to think ceaselessly of oblivion.

I have never felt such lasting emotional pain, nor had a major depressive episode. At various points in my life, however, I have experienced a depressed mood for most of the day more days than not over weeks and even months. During those periods, I also had low energy, feelings of hopelessness, and little desire for social interaction. Sometimes I became anxious and agitated as well. Because my sleep was not refreshing, I found it hard to drag myself out of bed in the morning to face another bleak day of gloomy ruminations about disappointments in life and my own shortcomings. From that emotional vantage point I could see nothing to make me feel cheerful, find nothing to enjoy, no reason to laugh. Luckily, I did not try to boost my mood with alcohol or other substances. (I was aware of the strong association between depression and substance abuse and dependence.) I did turn to food for comfort, often overeating or eating things I normally would not eat, like ice cream and chips.

Some of my most painful memories are of depressions that overcame me when I was living in especially beautiful places. In 1972, for example, I spent a month in a cottage on the shore of Lake Atitlán in the highlands of Guatemala, on my way to South America. The English writer Aldous Huxley wrote of it, “Lake Como [in Italy], it seems to me, touches on the limit of permissibly picturesque, but Atitlán is Como with the additional embellishments of several immense volcanoes. It really is too much of a good thing.” In any direction I looked I saw beauty: the deep blue mirrorlike surface of the lake, snowcapped volcanic cones, colorfully dressed Maya Indians on primitive roads that connected their lakeside villages. And I was miserable, unable to shake my dark mood. The contrast between my mood and my surroundings made me feel somehow contaminated and unworthy of the place. Not only did that add to my despair, but it made me even more averse to venturing out and seeking social contact. I told myself that I shouldn’t subject others to my negative emotions or risk “infecting” anyone with them.

Over the years I tried various forms of psychotherapy and counseling but got little benefit from them. Once, in my early forties, I filled a prescription for an antidepressant (Zoloft) but gave it up after a few days because I could not tolerate its side effects. It numbed my body and dulled my mind. Although I knew these immediate effects were supposed to pass and I would have had to wait up to several weeks for an improvement in mood, I was unwilling to put up with them.

Eventually I came to accept my depressive episodes as existential in nature—part of my being—to be endured and not inflicted on others. That way of thinking increased my tendency to be antisocial and isolated, traits not uncommon in writers. I even suspected that the introspection associated with these episodes might be a source of creativity and inspiration. (In retrospect, I think social isolation was a major factor in deepening and prolonging my depressions.) This pattern in my emotional life was frequent in my twenties, thirties, and forties, and then it began to wane, and it has steadily diminished and now rarely recurs. When it does, it seldom lasts more than a day or two, even when I encounter tough situations. Possibly, the improvement is a natural reward of aging; more likely, it is the cumulative result of changes I’ve made in my life. According to the DSM’s classification, I would have been diagnosed with dysthymic disorder, the commonest form of mild to moderate depression. This diagnosis accounts for much of the epidemic of depression occurring today and is the kind most responsive to the interventions suggested in this book.

Dysthymic disorder is distinct from depression associated with psychosis, manic episodes, direct effects of psychoactive drugs or medications, or general medical conditions (like hypothyroidism). The diagnostic criteria for it include a depressed mood for most of the day for more days than not for at least two years, and the presence, while depressed, of two (or more) of the following:

• poor appetite or overeating

• insomnia or hypersomnia (excessive sleep)

• low energy or fatigue

• low self-esteem

• poor concentration or difficulty making decisions

• feelings of hopelessness

Furthermore, during the two-year period, depressed mood and other symptoms are not absent for more than two months at a time, and they cause clinically significant distress or significant impairment in social, occupational, or other areas of functioning.

I am somewhat wary of trying to classify our emotional states in neat categories as the DSM does, with numerical codes, no less. The DSM puts anxiety disorders in a different section from forms of depression, with different numerical codes, but, as in my case, anxiety often accompanies depression. (A prominent health website notes that in one group surveyed, 85 percent of those with major depressive disorder were also diagnosed with generalized anxiety disorder.) I’m afraid that, despite psychiatry’s earnest efforts to emulate the greater precision of other medical specialties, depression cannot easily be packed into diagnostic pigeonholes. It is as protean as the human condition itself. If you suffer from depression, my advice is not to dwell on the DSM’s technical descriptions of its various forms, except to make sure that you do not have one that requires professional management and medication, such as major depressive disorder or bipolar disorder. Focus instead on the ways that you can get unstuck emotionally and move the set point of your moods away from depression.

Now to the question I raised at the beginning of this chapter: Why is there an epidemic of depression today? Why are so many people unhappy? What can have changed in our society in the past few decades to account for the unprecedented escalation of depression diagnoses? I say “our society” because, although depression occurs everywhere, nowhere does it affect as many people as in the developed, affluent, technologically advanced countries.

A genetic predisposition has been implicated in depression, but our genes have not changed significantly in the past twenty years.

We know that hormones play a role. Women are twice as likely as men to experience depression; as many as one in four women may suffer a major depressive episode over the course of a lifetime. Before puberty, rates of depression are equal in boys and girls, suggesting that hormonal influences may account for much of the disparity in the adult population. These facts are interesting but do not explain the new trend.

We know also that depression commonly coexists with physical illness: it affects 25 percent of patients with cancer, diabetes, or stroke; 33 percent of heart attack survivors; and 50 percent of those with Parkinson’s disease. Many of these chronic conditions are more prevalent today but not prevalent enough to account for so much depression.

Might the epidemic have something to do with the graying of our population in such large numbers, a recent and dramatic change? Older people are more likely to experience bereavement, illness, loss of independence, and other life stresses that can undermine emotional well-being, especially in the absence of strong social support. Nevertheless, experts on aging agree that depression is not a normal consequence of growing older. And one of the age groups most affected lies toward the opposite end of the age spectrum.

The National Institute of Mental Health reports that in any given year, 4 percent of adolescents in our society suffer severe depression. Depression is also being diagnosed much more frequently in preteens than ever before. Along with attention deficit hyperactivity disorder (ADHD) and the autistic disorders, depression accounts for the unprecedented, widespread use of prescribed psychiatric drugs by our young people.

The state of our world is certainly cause for anxiety and gloom, but that is nothing new. In the first half of the twentieth century, a great many people lived through the most horrific wars of all time as well as the worst economic depression, yet they were better off emotionally than many people today. Recall the famous opening lines of Dickens’s A Tale of Two Cities: “It was the best of times, it was the worst of times, it was… the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us…” Such is the state of the world—past, present, and, most likely, future. It is our choice to pay greater attention to its beauty or its ugliness.

Two explanations strike me as most compelling for the present epidemic, and they are by no means mutually exclusive. The first is that a significant portion of the epidemic has been manufactured by the medical-industrial complex. The second is that dramatic changes in living conditions have altered human brain function, dampening emotional variability and displacing its set point toward depression.

Let’s examine these one at a time.

To question the legitimacy of the rising incidence of depression diagnoses is provocative and polarizing. But it is undeniable that tremendous profits are being made from the current epidemic—by pharmaceutical companies, big insurers, and corporate health care providers; they all have a huge incentive to keep the epidemic going and growing. Today, direct-to-consumer (DTC) advertising of antidepressant drugs relentlessly pushes the idea that all unhappiness equals depression and is treatable with medication. In 1996, the pharmaceutical industry spent $32 million on DTC antidepressant ads; by 2005, that had nearly quadrupled, to $122 million.

The strategy has certainly worked. More than 164 million antidepressant prescriptions were written in 2008, totaling $9.6 billion in US sales. That’s why today, television commercials like this one are ubiquitous:

A morose-looking person stares out of a darkened room through a rain-streaked window. Quick cut to a cheery logo of an SSRI (selective serotonin reuptake inhibitor, the most common type of antidepressant pharmaceutical). Cross-fade to the same person, medicated and smiling, emerging into sunlight to pick flowers, ride a bicycle, or serve birthday cake to laughing children. A voiceover gently suggests, “Ask your doctor if [name of drug] is right for you.”

The clear messages are: sadness of any duration is depression; depression is a chemical imbalance in the brain; and a pill will make you happy—so ask your doctor to prescribe it for you.

Having created a vast American market for antidepressants, drugmakers are now vigorously exporting these dubious messages worldwide. Crazy Like Us: The Globalization of the American Psyche by journalist Ethan Watters is a disturbing account of how American psychiatric concepts are displacing traditional cultural views of mental health and illness—especially those surrounding sadness. Mood disorders affect people of all cultures, but their forms of expression vary. A Nigerian man, Watters writes, “might experience a culturally distinct form of depression by describing a peppery feeling in his head. A rural Chinese farmer might speak only of shoulder or stomachaches. A man in India might talk of semen loss or a sinking heart or feeling hot. A Korean might tell you of a ‘fire illness’ which is experienced as a burning in the gut. Someone from Iran might talk of tightness in the chest, and an American Indian might describe the experience of depression as something akin to loneliness.”

Until very recently, the psychiatric term for depression in Japan was utsubyô, designating “a mental illness as chronic and devastating as schizophrenia” that makes it impossible to hold a job or have anything like a normal life and requires long-term hospitalization. Utsubyô was an uncommon disorder and one surrounded by serious social stigma. It did not offer pharmaceutical companies much opportunity for profit.

Over the past decade, however, a massive marketing campaign launched in Japan by GlaxoSmithKline, makers of Paxil and related SSRI antidepressant drugs, has changed all that. Informed by academic Western psychiatrists about how Japanese concepts of depression differ from those in the United States—and, more to the point, about how those concepts might be transformed—GlaxoSmithKline promoted the idea that depression should be renamed kokoro no kaze, meaning something like “a cold of the heart-mind.” This new name accomplished three things:

• It implied that depression was not a severe condition and so should not carry a social stigma.

• It suggested that treating depression should be as simple as taking medication for a cold.

• It indicated that, just as everyone got colds from time to time, so did everyone get depressed now and then.

The fact that DTC advertising is illegal in Japan was little impediment; the company pushed this notion in thinly veiled public service announcements on television, as well as in magazine articles, books, and other ostensibly objective media. The result: in 2000, its first year on the Japanese market, Paxil brought in $100 million. By 2008, annual sales in Japan exceeded $1 billion. Asked how he felt about helping drug companies open this market, one American psychiatry professor laughed and remarked, “We were very cheap prostitutes.”

Medical doctors, whether in the United States, Japan, or any other country in the pharmaceutical industry’s crosshairs, should be a last line of defense against the endless barrage of drug ads and editorial propaganda. After all, none of it would work if physicians refused to prescribe the products.

But physicians do prescribe them. Why?

The reality is that the pharmaceutical industry’s aggressive marketing meets little resistance from overworked professionals who staff health care systems in much of the developed world. Especially in the United States, physicians often label patients depressed without taking detailed, comprehensive medical histories, and using this diagnosis has become a common and lazy way of handling those with vague or confounding symptoms. Similarly, medicating children frequently takes the place of addressing the complex causes of behavior, learning, and mood disorders—or even unexplained aches and pains. Teens who are grumpy, hostile, or unruly may be judged depressed and put on psychiatric drugs even though they are not sad.

In my view, prescribing antidepressant drugs is too often a quick and easy substitute for developing treatment plans that address the totality of health concerns and lifestyle factors that have an impact on wellness, including emotional wellness. With abbreviated office visits in the current era of managed care and profit-driven medicine, these trends have worsened.

So, then, how much of the depression epidemic is real and how much is spurious? A study published in the April 2007 issue of the Archives of General Psychiatry based on a survey of more than eight thousand Americans concluded that estimates of the number who suffer from depression at least once during their lifetimes are about 25 percent too high. The authors noted that the questions clinicians use to determine if patients are depressed don’t account for the possibility that they may be reacting normally and temporarily to upheavals such as loss of a job or divorce. (Only bereavement due to death is accounted for in the standard clinical assessment.)

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Excerpted from Spontaneous Happiness by Andrew Weil Copyright © 2011 by Andrew Weil. Excerpted by permission.
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