[Paleopsych] NYT: There's Nothing Deep About Depression
checker at panix.com
Sun Apr 17 15:42:55 UTC 2005
Magazine > There's Nothing Deep About Depression
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
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
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
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
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
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
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
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
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
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
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
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
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
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.
More information about the paleopsych