[Paleopsych] NYT: There's Nothing Deep About Depression

[Premise Checker]

Magazine > There's Nothing Deep About Depression
http://www.nytimes.com/2005/04/17/magazine/17DEPRESSION.html
April 17, 2005

There's Nothing Deep About Depression

    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 Yorker 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 challenge 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, but disease simply and
    altogether.

    A udiences 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
    disease.'' 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 existentialism. 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, remains 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 disease 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.

    Depression 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 horror is 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,
    the 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.