Book Review - Against Depression | by Peter D. Kramer Viking, 2005 Review by Jennifer Radden, Ph.D. Jun 15th 2005 | |
Peter Kramer's
instinct for a memorable narrative is unerring, we know from his earlier
writing. This instinct, combined with name recognition (" best known
psychiatrist in America," according to advance publicity), means that the
broad framework of his latest book, Against Depression, is already
familiar. In response to repeated questions appearing to romanticize the
pathology of great artists ("what works of genius might have been lost if
Van Gogh had been dosed with Prozac?" and so on) Kramer sets out to show
depression for what, he is sure, it is -- nothing more than a disease, a
scourge, and a medical and public health problem of unmatched proportions.
To this
end, in a long, rather discursive book, he develops his case. Depression is a
disease; he summarizes the range of intriguing biological findings from the
last decade which support such a claim, outlining a model of brain function
wherein resilience, the ability to bounce back from life's inevitable slings
and arrows, is apparently compromised in some people. He takes on the long-held cultural tropes which link depressive
states, and the related states earlier known as melancholia, with artistic and
intellectual achievement, creativity, and with a profounder understanding and
wisdom than is vouchsafed to more sanguine folk. He sketches a future time at
which depression will be recognized to be no more attractive,
"charming," or profound, than are tuberculosis or heart disease today.
And finally, he hints at a utopian era when, due to genetic and perhaps also
social engineering, depression has gone the way of the Black Death or, in the
West, leprosy.
In many respects, this is an
admirable and welcome book. Kramer's clearly-written, even-handed discussion of
the causes of depression, for example, provides a nuanced and layered counter
to the oversimplified explanatory stories still sometimes issuing from the
respective nature and nurture camps. As Kramer explains recent brain science,
it will be biological fragility (the result both of genetic tendencies and of
damage and deficit), together with some trigger from experience (a loss, a
defeat, a trauma), which generates an episode of the disease, and each such
episode, in turn, will contribute its own, additional damage. This eclectic and
multi-causal "stress and impaired resilience" analysis allows Kramer
to propose a range of remedies for depression: a future in which the fragility
gene can be identified and removed before it causes harm; the prescription of
those combinations of psychotherapy and anti-depressant medications which have
been found to help some weather their depressive episodes; public policy and
reform aimed at reducing the social causes and triggers of depression such as
want, war, and abuse. Much here is sensible, mainstream and unexceptional.
For
Kramer depression is a disease understood according to the neo-Kraepelinian
model, a categorical entity whose underlying, stable core process is the cause
of its clinical features, the characteristic signs and symptoms we observe
through its apparently episodic course (or "career"). One of the more
controversial themes in the book is provided by this analysis, for depressive
states, particularly, seem to invite a dimensional rather than a categorical
analysis. They shade from more to less severe, and from less severe to mild,
for example, and show themselves in acute episodes as well as long term traits
and temperaments. They are the quintessential conditions of gradation and even
boundlessness, seemingly rendering arbitrary and artificial the lines we
attempt to draw around them.
Kramer takes this
particular conceptual bull by the horns. Studies of depression have shown, he
points out, that the number, severity and duration of depressive episodes
"sit on a continuum of risk", i.e., depression is solidly continuous,
in the manner of high blood pressure. And the milder depressive symptoms form a
"halo" around depression, so that even low-level depression precedes
major depression or follows it, and all these instances of depression are, as
he says, "part of a single picture". Spectrum diseases are common in
medicine, he insists, and "we understand their manifestations as pathology all along the spectrum."
(My emphasis.)
We may concede with
Kramer that the vast range of mild to severe symptoms of depression all form a
unity, and a categorical whole. Yet further along this apparent continuum lie
qualitatively similar states and traits we want to classify not as disease,
mild or severe, but as normal and perhaps adaptive responses to stress and
loss. Kramer sometimes acknowledges this fact, making space for states of
sadness, grief and loss and for bleaker temperaments, but he does not do so
entirely consistently, and his account is somewhat muddy on these points. Thus,
the milder temperamental condition known as dysthymia is part of the disease
category, by his reckoning and "can be a devastating condition". He
speaks of himself, in contrast, as a person who, without qualifying for a diagnosis
of even low-level depression, is reasonably depressive or melancholic in terms
of "personality style or humor" ("I brood over failures. I require solitude"). Clear enough thus
far. But then he goes on: "in the face of bad fortune, I suspect that I
might well succumb to mood disorder".
The latter remark may be read to suggest
that the "mood disorder" or disease of depression is something we are
all heir to. If so, then on the diathesis stress model Kramer has adopted,
where preexisting vulnerability combines with some adverse experience to yield
the depressive response, the implication is that we all bear within us the
potential for disease.
The view that melancholy tendencies are
universal, the lot of humankind, can be found in as great an authority as
Robert Burton, writing in the seventeenth century. From Melancholy
Dispositions, Burton asserts, "no man living is free" and melancholy
in this sense is "the Character of Mortalitie." But Burton wanted to
set aside those states which are part of our human legacy, and distinguish them
from melancholy the "Habit", even though, in some people, "these
Dispositions become Habits" and eventually, disease. The difference
between that melancholy which is the human condition and the melancholy of
disease was for Burton a difference in kind, not degree. Kramer too, had
proposed a strict categorical analysis of depression, but his later remarks
seem to jeopardize any attempt to hold separate the category of suffering which
is the normal response to stress and loss.
If we are all heir to
depression, then depression cannot easily be regarded as a disease. If it is so
regarded, then insufficient conceptual space seems left for normal responses to
life's troubles.
Accounting for our
squeamishness in acknowledging that minor states of distress be labeled as part
of the monolithic disease of depression, Kramer remarks that for most of the
twentieth century, "... under the rubric of "neurosis," yet more
minor depressive states might be labeled illness. I suspect that... we may have
tolerated a loose understanding of mood disorder because we did not imagine
psychotherapy to be radically effective...Contemplating treatment via more
hard-edged means -- think of genetic engineering, think of a campaign of
eradication -- demands that we own our beliefs regarding minor depression and
its status as disease." Kramer seems to suppose the prospect of genetic
engineering to eliminate milder states of distress will reconcile us to
according those states disease status. But surely it is precisely the prospect
of such radical "cures" which alarms us most about this blurring of
the line between depression the disease (including its disease penumbra), and
milder states of distress which seem normal and, indeed, part of what make us
most, and perhaps most appealingly, human.
The
argument in Against Depression breaks
into two broad facets, establishing first what depression is -- a disease --
and then what it is not -- heroic. The broad strokes are exciting, imaginative,
and often compelling in this second aspect of Kramer's argument and reveal a
sensitive and informed awareness of cultural and literary traditions. Before
turning to these discussions aimed at showing that we must divest depression of
its charm, let me express a general historical concern.
The heroic view of
melancholy which dates to ancient times and texts, found one of its strongest
expressions in the Romanticism of the early nineteenth century. Arguably, we
are seeing a modest resurgence of that view in the present era, expressed in
works such as Kay Jamison's Touched with
Fire and heard in the newly articulate voices of depression sufferers
recounting their own experiences. Yet to some considerable extent through the
last part of the nineteenth century and most of the twentieth centuries, the
de-romanticizing of depression that Kramer supports was taking place. Though still remembered, the glamorous
associations of melancholy were considerably muted and even eclipsed when - and
arguably because -- depression became "gendered," a women's condition
in epidemiological terms, and, in cultural ones, linked with disvalued feminine
traits. Kramer's account makes no mention of these historical shifts, or of the
nineteenth century gendering of depression. (He does put forward a Darwinian explanation
for the gender link between women and depression, citing it as a possible cost
of women's caring roles, but then again, such theorizing fails to take into
account the broad "gendering" of depression not evident until the end
of the nineteenth century.) These omissions, to my mind, detract from the
effectiveness of his overall argument against depression as heroic.
Our long Western fascination with
melancholy and the cultural traditions linking melancholic states with
brilliance, creativity and other valued and heroic states and achievements
contain, Kramer recognizes, distinguishable hypotheses. Some of these are
causal, others not; some point to achievements, others to traits of mind and
character; others still to ideas and ideals. A real asset of this book is the
way these different strands of the "charm" argument are subject to
separate discussion and analysis. Nonetheless, the many-headed hydra that
constitutes the "charm" argument(s) proves a daunting adversary,
which Kramer's efforts are less than equally successful in defeating.
Though not the most
persuasive of these various ways of explaining the charm of melancholy, the
causal claims pointing to creative achievements may be the best known, and come
to us weighted with the authority of long-held lore. The geniuses of the
Renaissance would not have achieved greatness, it has been insisted, without
their black moods and bile; the dour states of "spleen" were the
noxious side effects of creativity and brilliance, unwanted, but unavoidable.
Other causal claims, these often asserted in the literary memoir of depressives
(their autopathographies, in Kramer's term), allow that through depressive
suffering people discover truths about themselves and the universe. Kramer
deals with each of these causal claims. For example, the evidence linking
depression to creativity is, he shows, "shaky," especially since, on
the face of things, depression "looks like a straightforward
handicap". No formal studies confirm the link between depression and
creative achievement, in his view, and whatever link there may seem to be
invites a more nuanced interpretation of the causal story. For instance, difference
helps in the creative process, and depression is "a form of
difference"; if self-consciousness is the subject of art,
"depressives are ideal chroniclers"; literary achievements might
arise by default:" Mustering the stamina for a regular job may be difficult ,"and so on. As he sees it, there
is likely "a complex process of mutual adaptation, between the disease and
the medium".
A first step is to
separate out analogous claims about the glamour and achievements of those
suffering manic-depression (apparently stronger because of the energy and
inflated self esteem of the manic phase); if we accept this restriction -- there
are some who challenge the concept of unipolar depression as a separate
disorder, and would not -- then Kramer's assessment seems reasonable and
appropriate to the kinds of achievement identified in these claims.
Claims about the
profundity and depth of character alleged to result from depressive episodes
leave Kramer equally dubious. In his estimation, and their own avowals
notwithstanding, a close study of depressives' autopathographies does not
indicate that depression brings depth and profundity to the character of the
sufferer. But questions of method arise here and complicate Kramer's
assessment. An outside observer, however skillfully trained, does not readily
assess depth and profundity of character, any more than the value of a life.
And we usually accord to the person herself the role of judge on these matters,
on Mill's grounds: the individual knows best the personal values and interests
integral to any such assessment. These judgments are not open to the easy
objective tests by which we measure artistic achievements. Arguably, Kramer too
quickly dismisses the claims made in these memoirs, for all that they smack of
banality, and unseemly "hints of pride".
His dismissal of the
Aristotelian association between melancholy and greatness in the public world
may be similarly premature, moreover. Recent historical work on Abraham
Lincoln's severe, debilitating and recurrent melancholic states indicates a
twentieth century historical revisionism tantamount to a "cover-up" (Joshua
Wolf Shenk Lincoln's Melancholia: How
Depression Challenged a President and Fueled his Greatness, 2005). While
only one, the example of Lincoln encourages general suspicion over biographies
of great men written in an era when depression had been much, though not
entirely, de-romanticized, and come to be relegated to a woman's condition,
unworthy of great men.
The tie between
depressive states and greatness, meaning and human truths goes beyond these
sorts of causal claim. For example, depressive or melancholic states are
believed emblematic of the attitude it is appropriate
to adopt in the face of the meaninglessness of life in modernity -- emblematic of, not, or not merely,
responsible for. Kramer rightly leads us to Kierkegaard here, noting that the
isolation one feels in depression is what it is believed one "ought to
feel in a mechanical, chaotic, and uncomprehending universe". He calls the
tragic view of life the "grand hypothesis of melancholy -- not only that
it creates art, but that it describes our
place in the universe." (My emphasis.)
That said, Kramer's
conclusion, that by eliminating depression, we could expect to see an end to
this tragic view and see, as he says, the linkage with heroism as "a ...
delusion," may also be over hasty. The philosophical attitude towards life
known as the tragic attitude, while neither arising from the depressed mind,
nor giving rise to it, may still represent, or find unique resonance in,
depressive subjectivity. Thus, other, stronger versions of the associative link
between depressive states and cultural "structures" such as the
tragic attitude point to something different from causal claims: something
closer, perhaps, to a mimetic relation. Though not causally necessary for
profound understanding of the world, subjective states of melancholy and
depression may echo and seem to correspond to such states.
The tragic view is in this sense epistemically independent
of depressive states. For that reason,
we need not suppose changes in our view of depression will alter its currency
or popularity. There are passages in Against
Depression expressing
both this recognition that the relationship is not causal, and the
recalcitrance of the associative link between depressive states and the tragic
view. "The despair that is a symptom of depression mimics the
despair that might accompany full awareness of the absurdity of our
lives", Kramer observes. Yet he seems to resist the implication of this
view, asking: "Why is depression, in particular, the fit metaphor? "
His answer: "If we recognize depression as a particular disease, we will
no longer treat it as the all purpose affliction, the stand-in for suffering in
general". Depressive states resemble the states appropriate to the tragic
view, this seems to suggest, because as a reversible and arbitrary accident of
cultural history, we have forged a link between the two.
My disagreement with
Kramer here is that feelings of depression, at least, are a stand-in, or metaphor, for suffering in general. Depression
may be a disease, but it is a disease whose central symptoms involve moods,
feelings, attitudes and beliefs, and not, for instance, bodily sensations. So
it is no ordinary disease. Thus some of the trouble here lies with the disease
framework by which each sign and symptom of the condition is understood as an
inseparable part of a whole: the disturbances of sleep, appetite, energy, as
much as the depressive subjectivity. Only these latter, "mental"
states making up depressive subjectivity correspond to the states of we think
it appropriate to adopt in the face of our troubled world, and a more careful
statement of the thesis that depression is somehow deeply reflective of those
attitudes would protect it from some of the force of Kramer's critique.
The
affinity between depressive states and the tragic view of life is one form of
non-causal relation. That between depressive states and a certain aesthetic, is
another. When depression, "like dysentery and epilepsy and the rest,
declares itself a disease" Kramer predicts," our valuation of
depressive art might seem an anachronism, the remnant of a tradition required
to mitigate and justify otherwise inexplicable sorrow". Later, affirming
his own literary preference for the more sanguine writing of John Updike,
Kramer contrasts the "mutedly optimistic and American style" with
that which is "thoroughly bleak and European." These differing
aesthetics, he implies, are matters of taste, and can be expected to change,
through time. Yet just as philosophers might want to assert the truth of
the tragic view of life, which at once ensures its causal independence from and
its mimetic relation to depressive states, so it seems legitimate to accord
more enduring value to the bleak, European aesthetic, and to rank it over its
sunny "American" alternative.
Tracing as it does to works as profoundly grave as Aristotle's Poetics, it seems unlikely that our
traditional aesthetics will be soon undone by changes in our attitude towards
depression.
In
addition to his attempts to rebut each of the several "charm"
arguments identified here, Kramer eventually offers his personal and
autobiographical credentials as a man of feeling, sensitivity and profundity --
as homo melancholicus, one might even say. And indeed, some passages in Against Depression convey a strangely
melancholy tone. Kramer speaks as if the tragic (bleak and European) aesthetic,
linked as it has been all these years through a mistaken valorizing of
depressive states and traits, will wither and be replaced by something more
upbeat when depression comes to be understood for what it is. Yet he finishes
his chapter on the end of melancholy with the elegiac comment that "in our
lives, depth seems to endangered and happiness so overblown, so commercial, so
stupefying, that we may be inclined to cling to some version of melancholy,
never mind what doctors say about depression".
Ironically, in his
nuanced approach, Kramer exemplifies the ambivalence and self-doubt whose
devaluation in the melancholy self of Western literary and philosophical
traditions, and eventual decline, he has tried to persuade us to anticipate
without regret. But that is perhaps what sets his book apart and makes it, as
was Listening to Prozac before it, a
wonderfully stimulating and enjoyable one to read.
© 2005 Jennifer Radden
Jennifer Radden, Ph.D., Department of Philosophy,
University of Massachusetts, Boston.
Radden is editor of The Philosophy of Psychiatry: A Companion,
and The Nature of Melancholy: From Aristotle to Kristeva and author of Divided Minds and Successive Selves: Ethical Issues in Disorders of Identity and Personality
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