Review of "Against Depression"

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