Nice article....
The New York Times
April 17, 2005
There's Nothing Deep About Depression
By PETER D. KRAMER
Shortly after the publication of my book ''Listening to Prozac,''
12 years ago, I became immersed in depression. Not my own. I was
contented enough in the
slog through midlife. But mood disorder surrounded me, in my
contacts with patients and readers. To my mind, my book was never
really about depression.
Taking the new antidepressants, some of my patients said they found
themselves more confident and decisive. I used these claims as a
jumping-off point
for speculation: what if future medications had the potential to
modify personality traits in people who had never experienced mood
disorder? If doctors
were given access to such drugs, how should they prescribe them?
The inquiry moved from medical ethics to social criticism: what
does our culture demand
of us, in the way of assertiveness?
It was the medications' extra effects -- on personality, not on the
symptoms of depression -- that provoked this line of thought. For
centuries, doctors
have treated depressed patients, using medication and psychological
strategies. Those efforts seemed uncontroversial. But authors do
not determine the
fate of their work. ''Listening to Prozac'' became a ''best-selling
book about depression.'' I found myself speaking -- sometimes about
ethics, more often
about mood disorders -- with many audiences, in bookstores, at
gatherings of the mentally ill and their families and at
professional meetings. Invariably,
as soon as I had finished my remarks, a hand would shoot up. A
hearty, jovial man would rise and ask -- always the same question
-- ''What if Prozac had
been available in van Gogh's time?''
I understood what was intended, a joke about a pill that makes
people blandly chipper. The New Y! orker had run cartoons along these
lines -- Edgar Allan
Poe, on Prozac, making nice to a raven. Below the surface humor
were issues I had raised in my own writing. Might a widened use of
medication deprive us
of insight about our condition? But with repetition, the van Gogh
question came to sound strange. Facing a man in great pain, headed
for self-mutilation
and death, who would withhold a potentially helpful treatment?
It may be that my response was grounded less in the intent of the
question than in my own experience. For 20 years, I'd spent my
afternoons working with
psychiatric outpatients in Providence, R.I. As I wrote more, I let
my clinical hours dwindle. One result was that more of my time was
filled with especially
challenging cases, with patients who were not yet better. The
popularity of ''Listening to Prozac'' meant that the most insistent
new inquiries were from
families with depressed members who had ! done poorly elsewhere. In
my life as a doctor, unremitting depression became an intimate. It
is poor company. Depression
destroys families. It ruins careers. It ages patients prematurely.
Recent research has made the fight against depression especially
compelling. Depression is associated with brain disorganization and
nerve-cell atrophy.
Depression appears to be progressive -- the longer the episode, the
greater the anatomical disorder. To work with depression is to
combat a disease that
harms patients' nerve pathways day by day.
Nor is the damage merely to mind and brain. Depression has been
linked with harm to the heart, to endocrine glands, to bones.
Depressives die young -- not
only of suicide, but also of heart attacks and strokes. Depression
is a multisystem disease, one we would consider dangerous to health
even if we lacked
the concept ''mental illness.''
As a clinician, I found the what if chal! lenge ever less amusing.
And so I began to ask audience members what they had in mind. Most
understood van Gogh
to have suffered severe depression. His illness, they thought,
conferred special vision. In a short story, Poe likens ''an utter
depression of soul'' to
''the hideous dropping off of the veil.'' The questioners
maintained this 19th-century belief, that depression reveals
essence to those brave enough to
face it. By this account, depression is more than a disease -- it
has a sacred aspect.
Other questioners set aside that van Gogh was actually ill. They
took mood disorder to be a heavy dose of the artistic temperament,
so that any application
of antidepressants is finally cosmetic, remolding personality into
a more socially acceptable form. For them, depression was less than
a disease.
These attributions stood in contrast to my own belief, that
depression is neither more nor less than a disease, bu! t disease
simply and altogether.
Audiences seemed to be aware of the medical perspective, even to
endorse it -- but not to have adopted it as a habit of mind. To
underscore this inconsistency,
I began to pose a test question: We say that depression is a
disease. Does that mean that we want to eradicate it as we have
eradicated smallpox, so that
no human being need ever suffer depression again? I made it clear
that mere sadness was not at issue. Take major depression, however
you define it. Are
you content to be rid of that condition?
Always, the response was hedged: aren't we meant to be depressed?
Are we talking about changing human nature?
I took those protective worries as expressions of what depression
is to us. Asked whether we are content to eradicate arthritis, no
one says, ''Well, the
end-stage deformation, yes, but let's hang on to tennis elbow,
housemaid's knee and the early stages of rheumatoid di! sease.''
Multiple sclerosis, acne,
schizophrenia, psoriasis, bulimia, malaria -- there is no other
disease we consider preserving. But eradicating depression calls
out the caveats.
To this way of thinking, to oppose depression too completely is to
be coarse and reductionist -- to miss the inherent tragedy of the
human condition. To
be depressed, even gravely, is to be in touch with what matters
most in life, its finitude and brevity, its absurdity and
arbitrariness. To be depressed
is to occupy the role of rebel and social critic. Depression, in
our culture, is what tuberculosis was 100 years ago: illness that
signifies refinement.
Having raised the thought experiment, I should emphasize that in
reality, the possibility of eradicating depression is not at hand.
If clinicians are better
at ameliorating depression than we were 10 years ago -- and I think
we may be -- that is because we are more persistent in our! efforts,
combining treatments
and (when they succeed) sticking with them until they have a marked
effect. But in terms of the tools available, progress in the
campaign against depression
has been plodding.
Still, it is possible to envisage general medical progress that
lowers the rate of depression substantially -- and then to think of
a society that enjoys
that result. What is lost, what gained? Which is also to ask: What
stands in the way of our embracing the notion that depression is
disease, nothing more?
This question has any number of answers. We idealize depression,
associating it with perceptiveness, interpersonal sensitivity and
other virtues. Like tuberculosis
in its day, depression is a form of vulnerability that even
contains a measure of erotic appeal. But the aspect of the
romanticization of depression that
seems to me to call for special attention is the notion that
depression spawns creativity.
Objective evidence for that effect is weak. Older inquiries, the
first attempts to examine the overlap of madness and genius, made
positive claims for schizophrenia.
Recent research has looked at mood disorders. These studies suggest
that bipolar disorder may be overrepresented in the arts.
(Bipolarity, or manic-depression,
is another diagnosis proposed for van Gogh.) But then mania and its
lesser cousin hypomania may drive productivity in many fields. One
classic study hints
at a link between alcoholism and literary work. But the benefits of
major depression, taken as a single disease, have been hard to
demonstrate. If anything,
traits eroded by depression -- like energy and mental flexibility
-- show up in contemporary studies of creativity.
How, then, did this link between creativity and depression arise?
The belief that mental illness is a form of inspiration extends
back beyond written history.
Hippocrates was answering some such claim, when, around 400 B.C.,
he tried to define melancholy -- an excess of ''black bile'' -- as
a disease. To Hippocrates,
melancholy was a disorder of the humors that caused epileptic
seizures when it affected the body and caused dejection when it
affected the mind. Melancholy
was blamed for hemorrhoids, ulcers, dysentery, skin rashes and
diseases of the lungs.
The most influential _expression of the contrasting position -- that
melancholy confers special virtues -- appears in the ''Problemata
Physica,'' or ''Problems,''
a discussion, in question-and-answer form, of scientific
conundrums. It was long attributed to Aristotle, but the surviving
version, from the second century
B.C., is now believed to have been written by his followers. In the
30th book of the ''Problems,'' the author asks why it is that
outstanding men -- philosophers,
statesmen, poets, artists, educators and heroes -- are so often
melancholic. Among the ancients, the strongmen Herakles and Ajax
were melancholic; more
contemporaneous examples cited in the ''Problems'' include
Socrates, Plato and the Spartan general Lysander. The answer given
is that too much black bile
leads to insanity, while a moderate amount creates men ''superior
to the rest of the world in many ways. ''
The Greeks, and the cultures that succeeded them, faced depression
poorly armed. Treatment has always been difficult. Depression is
common and spans the
life cycle. When you add in (as the Greeks did) mania,
schizophrenia and epilepsy, not to mention hemorrhoids, you
encompass a good deal of what humankind
suffers altogether. Such an impasse calls for the elaboration of
myth. Over time, ''melancholy '' became a universal metaphor,
standing in for sin and
innocent suffering, self-indulgence and sacrifice, inferiority and
perspicacity.
The great flowering of melancholy occurred during the Renaissance,
as humanists rediscovered the ''Problems.'' In the late 15th
century, a cult of melancholy
flourished in Florence and then was taken back to England by
foppish aristocratic travelers who styled themselves artists and
scholars and affected the
melancholic attitude and dress. Most fashionable of all were
''melancholic malcontents,'' irritable depressives given to
political intrigue. One historian,
Lawrence Babb, describes them as ''black-suited and disheveled . .
. morosely meditative, taciturn yet prone to occasional railing.''
In dozens of stage dramas from the period, the principal character
is a discontented melancholic. ''Hamlet'' is the great example. As
soon as Hamlet takes
the stage, an Elizabethan audience would understand that it is
watching a tragedy whose hero's characteristic flaw will be a
melancholic trait, in this
case, paralysis of action. By the same token, the audience would
quickly accept Hamlet's spiritual superiority, his suicidal
impulses, his hostility to
the established order, his protracted grief, solitary wanderings,
erudition, impaired reason, murderousness, role-playing, passivity,
rashness, antic disposition,
''dejected haviour of the visage'' and truck with graveyards and
visions.
''Hamlet'' is arguably the seminal text of our culture, one that
cements our admiration for doubt, paralysis and alienation. But
seeing ''Hamlet'' in its
social setting, in an era rife with melancholy as an affected
posture, might make us wonder how much of the historical
association between melancholy and
its attractive attributes is artistic conceit.
In literature, the cultural effects of depression may be
particularly marked. Writing, more than most callings, can coexist
with a relapsing and recurring
illness. Composition does not require fixed hours; poems or essays
can be set aside and returned to on better days. And depression is
an attractive subject.
Superficially, mental pain resembles passion, strong emotion that
stands in opposition to the corrupt world. Depression can have a
picaresque quality --
think of the journey through the Slough of Despond in John Bunyan's
''Pilgrim's Progress.'' Over the centuries, narrative structures
were built around
the descent into depression and the recovery from it. Lyric poetry,
religious memoir, the novel of youthful self-development --
depression is an affliction
that inspires not just art but art forms. And art colors values.
Where the unacknowledged legislators of mankind are depressives,
dark views of the human
condition will be accorded special worth.
Through the ''anxiety of influence,'' heroic melancholy cast its
shadow far forward, onto romanticism and existentiali! sm. At a
certain point, the transformation
begun in the Renaissance reaches completion. It is no longer that
melancholy leads to heroism. Melancholy is heroism. The challenge
is not battle but inner
strife. The rumination of the depressive, however solipsistic, is
deemed admirable. Repeatedly, melancholy returns to fashion.
As I spoke with audiences about mood disorders, I came to believe
that part of what stood between depression and its full status as
disease was the tradition
of heroic melancholy. Surely, I would be asked when I spoke with
college students, surely I saw the value in alienation. One medical
philosopher asked
what it would mean to prescribe Prozac to Sisyphus, condemned to
roll his boulder up the hill.
That variant of the what if question sent me to Albert Camus's
essay on Sisyphus, where I confirmed what I thought I had
remembered -- that in Camus's reading,
Sisyphus, the existential hero, re! mains upbeat despite the futility
of his task. The gods intend for Sisyphus to suffer. His rebellion,
his fidelity to
self, rests on the refusal to be worn down. Sisyphus exemplifies
resilience, in the face of full knowledge of his predicament. Camus
says that joy opens
our eyes to the absurd -- and to our freedom. It is not only in the
downhill steps that Sisyphus triumphs over his punishment: ''The
struggle itself toward
the heights is enough to fill a man's heart. One must imagine
Sisyphus happy.''
I came to suspect that it was the automatic pairing of depth and
depression that made the medical philosopher propose Sisyphus as a
candidate for mood enhancement.
We forget that alienation can be paired with elation, that optimism
is a form of awareness. I wanted to reclaim Sisyphus, to set his
image on the poster
for the campaign against depression.
Once we take seriously the notion that depression is a disea! se like
any other, we will want to begin our discussion of alienation by
asking diagnostic questions.
Perhaps this sense of dislocation signals an apt response to
circumstance, but that one points to an episode of an illness.
Aware of the extent and effects
of mood disorder, we may still value alienation -- and ambivalence
and anomie and the other uncomfortable traits that sometimes
express perspective and
sometimes attach to mental illness. But we are likely to assess
them warily, concerned that they may be precursors or residual
symptoms of major depression.
How far does our jaundiced view reach? Surely the label ''disease''
does not apply to the melancholic or depressive temperament? And of
course, it does
not. People can be pessimistic and lethargic, brooding and
cautious, without ever falling ill in any way. But still, it seemed
to me in my years of immersion
that depression casts a long shadow. Though I had! never viewed it
as pathology, even Woody Allen-style neurosis had now been stripped
of some of its charm
-- of any implicit claim, say, of superiority. The cachet attaching
to tuberculosis diminished as science clarified the cause of the
illness, and as treatment
became first possible and then routine. Depression may follow the
same path. As it does, we may find that heroic melancholy is no more.
In time, I came to think of the van Gogh question in a different
light, merging it with the eradication question. What sort of art
would be meaningful or
moving in a society free of depression? Boldness and humor -- broad
or sly -- might gain in status. Or not. A society that could
guarantee the resilience of mind and brain might favor operatic art and literature. Freedom from depression would make the world safe for high neurotics, virtuosi of empathy, emotional
bungee-jumpers. It would make the world safe for van Gogh.
Depre! ssion is not a perspective. It is a disease. Resisting that
claim, we may ask: Seeing cruelty, suffering and death -- shouldn't
a person be depressed?
There are circumstances, like the Holocaust, in which depression
might seem justified for every victim or observer. Awareness of the
ubiquity of horroris the modern condition, our condition.
But then, depression is not universal, even in terrible times.
Though prone to mood disorder, the great Italian writer Primo Levi
was not depressed in his months at Auschwitz. I have treated a handful of patients who survived horrors arising from war or political repression. They came to depression years
after enduring extreme privation. Typically, such a person will
say: ''I don't understand it. I went through -- '' and here he will
name one of the shameful events of our time. ''I lived through that, and in all those months, I never felt this.'' This refers to the relentless bleakness of depression, th! e self as hollow shell. To see the worst things a person can see is one experience; to suffer mood disorder is another. It is depression -- and not resistance
to it or recovery from it -- that diminishes the self.
Beset by great evil, a person can be wise, observant and
disillusioned and yet not depressed. Resilience confers its own
measure of insight. We should have no trouble admiring what we do admire -- depth, complexity, aesthetic brilliance -- and standing foursquare against depression.
Peter D. Kramer is a clinical professor of psychiatry at Brown
University and the author of ''Listening to Prozac.'' This essay is
adapted from his book
''Against Depression,'' which Viking will publish next month.
Copyright 2005
The New York Times Company
