Against Depression

"What if Prozac had been available in van Gogh's time?" That's the question Peter Kramer, a professor of psychiatry known for his bestselling book Listening to Prozac, hears whenever he makes a public appearance, and he's sick of it. The people who ask it, he observes, are all the same: "hearty men trying to win standing with the audience about them, as if we were all complicit in a good joke." In other words, it's a stupid question masquerading as a clever one, posed by the kind of person who is unshakably -- and mistakenly -- convinced of his own originality.

You can't blame Kramer for being so irritated by these dumb smart alecks that it took him a while to look behind the question. A good therapist, however, knows that a persistent preoccupation, however superficially banal, suggests a significant underlying problem. If it's society -- rather than an individual patient -- that keeps picking away at "the van Gogh question," then Kramer, who has a sideline in writing about the intersection of biology, psychology and culture, is the man to figure out why.

Are we really ready, Kramer asks in his new book, Against Depression, to accept that depression is a disease? Though most informed Westerners would probably agree that it is, we aren't as unambivalent about the matter as we might think. We'd have no compunction about enthusiastically endorsing a plan to wipe out diabetes, cancer or malaria, but when Kramer began asking people if they'd support the "eradication" of depression, "invariably, the response was hedged." They asked for precise definitions and expressed "protective worries" about utopian plans to change "human nature."

If you unpack the glibness of the van Gogh question, the implications are obvious. The painter suffered greatly from (probably) both depression and epilepsy, and his art strikes us as intimately concerned with those two, intertwined afflictions. Would the paintings be less revelatory if van Gogh himself were not so miserable? Would they even exist at all? Depression, in many people's minds, is integral to the creative temperament. We might lose some of the triumphs of art and culture if it were wiped away.

Yet as Kramer points out, in a book full of similarly provocative thought experiments, no one would hesitate to treat van Gogh's epilepsy. The idea of allowing those torments to continue with the hope that they might somehow lead to more or better pictures strikes us as coldblooded, inhuman. So why does the idea of treating the painter's depression make many people at least slightly uncomfortable, for exactly the opposite reason? Why do we still harbor a residual fear that eliminating someone's -- and especially a great artist's -- depression might be a betrayal of our humanity?

Kramer finds a similar reluctance in other situations, as well. He recalls attending a conference on mood disorders at which one speaker, a psychoanalyst, talked of a patient whose depression he was not treating very vigorously. "The analyst had the impression that for the whole of his life, the patient has been self-centered, blandly confident and lacking in insight ... He hoped that the loss of confidence [caused by the depression] in particular would motivate the patient to engage in a psychotherapy that would make inroads against the narcissism."

Although he once would have regarded the psychoanalyst's strategy as a valid way to prompt a patient to go deeper, now Kramer found himself "seething." Listening to Prozac, contrary to popular conception, was not about depression at all, but about the implications of the then-new trend of prescribing antidepressants to people who weren't suffering from mental illness: personality tweaking, if you will. Nevertheless, the book's success drew depressed patients to Kramer's practice, and his growing understanding of mood disorders, both as a psychotherapist and as a follower of clinical research on the subject, has convinced him of just how dangerous the disease can be, and how incompletely we realize the threat.

Against Depression is partly a critique of the West's propensity for romanticizing depression, partly a survey of the latest research on the illness and its possible causes and cures, and partly a meditation on what our culture would look like if we stopped equating depression with refinement, profundity, insight and intelligence. "Our beliefs, our art, our sense of self might change as the medical view became a cultural commonplace," he writes. "If we could treat depression reliably, we would have different artists, different subjects, different stories, different needs, different tastes." And the way he sees it, that doesn't have to be cause for alarm.

Nevertheless, it's a lot to ask that an entire culture change a significant part of its orientation and values. A case must be made for the shift. First, there are the facts. The science of depression, Kramer feels, is way ahead of the layperson's image of the disease, and to make matters worse, we're not properly aware of the discrepancy. "We retain," he writes, "a confused -- partial, anachronistic -- understanding of depression." Against Depression represents Kramer's effort to tease out some of the contradictions and befuddlements we still cling to, and to supply us with a sense of how the medical establishment now views the illness. If we have a better grasp on this, the change might seem less ominous. Kramer's book is a nudge in the direction of a depression-free world.

The most commonplace notion of depression is that it arises from a deficiency, or an inability to make use of, certain mood-stabilizing chemicals in the brain, particularly serotonin. The most widely prescribed antidepressants today, the selective serotonin reuptake inhibitors (SSRIs) are frequently seen as increasing the brain's supply of those chemicals, correcting the "chemical imbalance," or, as one friend of mine put it, filling the brain with "happy juice."

According to Kramer, research in the past decade (since Listening to Prozac was published) suggests that serotonin and similar neurochemicals may instead serve a protective function. They help shield the brain from the negative effects of the stress hormones that prompt the body to respond to threats. Certain brains are rendered particularly vulnerable to stress hormones by genetics and sometimes, in addition, early childhood trauma. This kind of brain loses the ability to protect and heal itself from the effects of those hormones, and also loses the ability to turn off the production of the hormones. The stress response system can get stuck in the "on" position, eventually weakening and diminishing nerve cells and further eroding the brain's capacity to cope with the hormones. This vicious circle results in clinical depression.

The manifestations of the disease include "low mood, apathy, diminished energy, poor sleep and appetite, suicidality, loss of the capacity to experience pleasure, feelings of worthlessness," and so on. Some depressed people can't sleep; others sleep way too much. Some feel misery; most feel something closer to emptiness. But the cause, Kramer maintains, is measurable organic damage to the brain, damage that prevents the brain from repairing itself and leaves it ever more susceptible to further damage. This is why often very slight stressors can incapacitate a depressed person or trigger an episode of depression, and why a third or fourth episode is harder to treat than the first.

Rather than seeing depression as arising from a lack of certain chemicals, Kramer defines it as a deficit in resilience, the ability to bounce back -- neurologically and emotionally -- from stress. To treat depression you don't pump the afflicted full of artificial happiness, you restore their ability to absorb and recover from the unavoidable bumps, knocks and tragedies of life. That's why, Kramer feels, doctors should vigorously treat depression (using a combination of medication and psychotherapy), as soon as possible. Delayed or insufficient treatment risks further weakening of the brain itself, although depressions will sometimes spontaneously evaporate.

This happened to one of Kramer's patients, Margaret, a no-nonsense woman with a difficult past who suddenly discovered one afternoon (despite no change in her medication) that she was better. After her recovery, she scolded Kramer for suggesting that the apathy and pessimism she had felt about her husband and daughter while depressed reflected some real ambivalence on her part. Like another patient of Kramer's who burnt the diary he kept during his depression because "I was like a torture victim confessing to fantastic crimes he never committed," she had felt possessed by a foreign entity. The depression was "an imposter" and Kramer "had been negotiating with an occupying government, of Margaret's mind, while the legitimate ruler was in exile."

Kramer leads Against Depression with Margaret's case because it demonstrates that treating depression doesn't consist of changing someone's personality, but of restoring it. Genetics and early trauma might have set Margaret up for depression, by making her brain more vulnerable to stress, but the depression was not her fundamental self, or a window into buried feelings -- in fact, it was quite the opposite.

This vision of depression flies in the face of the common belief that the depressed are deeper and more authentic than the cheerful rabble. Kramer rails against the notion that depression is the only honest, thoughtful response to a cruel world, that we must choose between despair (or a kind of sardonic brooding) and a plastic, smiley-face mask of denial.

Citing an undergraduate favorite, Albert Camus, Kramer counters with the existential model of the mythic Sisyphus, condemned by the gods for eternity to push a huge stone up a hill, whereupon it rolls down again and the process starts over. "His rebellion, his fidelity to self," Kramer writes of Sisyphus, "rests on the refusal to be worn down ... he faces endless futility without succumbing to despair." Camus himself wrote, "The struggle itself toward the heights is enough to fill a man's heart. One must imagine Sisyphus happy."

Kramer complains about museum curators who treat an artist's gloomier works as more important than those celebrating "exuberance, appetite, an appreciation of the exquisite in the ordinary," using the vaunting of Picasso's "blue period" over his erotic drawings as an example. Likewise -- and to escape for a moment Kramer's manifold references to the mandarin works of classical and high modernist art and literature -- consider that the Academy Award for best picture rarely goes to a comedy. While scientists, historians and anyone with direct experience of depression's crippling listlessness can make pretty short work of the canard that depressives are unusually creative, it's undeniable that we usually consider bleak and somber art more significant than pieces that are vital and joyous.

In some ways Kramer, a subtle and perceptive observer, is the ideal person to consider the many facets of our infatuation with depression. However, his looping and elliptical prose style can make his arguments hard to follow, and sometimes he misses the obvious.

Take language, for example. One reason why we confuse depression with personality is that in common speech people often use the word "depressed" to describe their ordinary, healthy sadness. I might come back from a dysfunctional family weekend complaining that the experience left me "depressed," even though, like Kramer himself, I've never suffered from the disease. Yet until you've been close to someone truly depressed, it can be all too easy to liken a few days in a funk to a whole other order of pain and disability.

This mix-up may look trivial -- it certainly doesn't require a thorough grounding in Cervantes and Kierkegaard to identify it -- but it may hinder our understanding of depression more than all the morose poets of the world combined. Human beings are reflexively empathic; when hearing about someone else's experiences, they tend to seek parallels in their own. They, too, were down in the dumps once, after a bad breakup, but within a few weeks, they'd regained at least some of their energy and ability to enjoy life. So why can't these depressed people just snap out of it?

Only about 16 percent of Americans suffer a major depression during their lifetimes, but many more people erroneously believe they know what it feels like. This confusion of depression with normal sorrow leads to more than just unsympathetic attitudes toward the difficulties depressives have in recovering. When Kramer talks of eradicating depression, what many people hear is that he advocates eliminating sadness -- and that would indeed be dehumanizing. Even those who don't romanticize alienated brooding would object to that.

Another reason why it's so hard to draw the line between healthy sadness and pathological depression is that depression itself often resists the effort. In this way, at least, it's very different from cancer or diabetes. Patients with those diseases might neglect their doctor's orders or even deny that they're sick, but the diseases themselves tend to insist, with ever-increasing physical pain and deterioration, on their own existence. Depression is categorically different from them in that it's a disease that attempts to persuade us that it isn't.

A well-informed, not-too-sick depressive might know how he or she would ordinarily feel, and realize that the absence of those feelings is the result of illness. Many depressives, however, can't achieve this intellectual distance from their pathological mood. They believe that they are correctly perceiving the nature of themselves and the world around them. A man of intelligence, talent and education can be convinced that he has nothing to offer the world; a mother of young children that they'd be much better off if she killed herself.

The depressed will often swear that they have at last perceived the fundamental futility and drudgery of life, a brutal fact that the rest of the world chooses, idiotically, to ignore. Kramer complains that Western culture has made a particular virtue of this type of despair, but it's not just that the depressed are thought to be deeper and more sensitive than the rest of us clods: It's that the depressed claim to have special, unrestricted access to the truth. And much of the time, we've believed them. In this light, you could even say that Western culture is itself depressed.

Furthermore, depression lies. Melodramatic adolescent posturing aside, unalleviated pessimism is as deluded a view of the world as unqualified optimism. It's just a lot easier, particularly if you fancy yourself an intellectual, to deride the optimist. Kramer, who clearly longs to participate in the grand tradition of Western "seriousness," finds himself objecting, conscientiously, on the grounds that the tradition idealizes depression. He stops a little short of accusing it of frankly collaborating with the disease, but the case can definitely be made. One of the most dangerous aspects of depression, now that there are increasingly better ways of treating it, is its ability to persuade us that it is not a disease. To help the devil in his deception is to be complicit in his crimes.

In some aspects, Against Depression is just as revolutionary as it pretends not to be; Kramer assures us that he cherishes the best of the Western tradition even as he presents a fairly damning new case for its destructiveness and limitations. In others -- namely, the book's occasional lapses into a self-defeating lack of clarity -- Kramer steps back from the fight. In the final chapter, speculating on a future free of depression, he demonstrates by example just how hard it is to visualize such a thing. "We should have no trouble imagining resilience that contains as much depth as any ever attributed to depression," he writes. After all, so many genocide survivors have shown us just that. And yet still we hesitate; are we throwing out "Starry Night" with the bath water?

The van Gogh question may not be answerable (but if you ask me, we'd surely have more paintings), so Kramer ends with another case study. A woman who had suffered the deaths of family members in a short time was finally able, via medication and therapy, to extract herself from a terrible depression. Then, her house burned down, and "with it went irreplaceable objects, mementos of love ones."

It was the kind of event ready-made to trigger another episode. Instead, "my patient took the loss in stride. Not immediately, not perfectly. There were shaky days. But quickly, ten or twelve weeks down the road, she declared herself out of the woods." It was one of those minor victories that, Kramer writes, "justify the psychiatrist's career. There is no fretting, of this you can be sure, over the imagined benefits of the depressive episode that might have been." It might be as simple as that in the end. If depression were eradicated, we might scarcely notice the absence. We might not miss it at all.

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