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?
There's Nothing Deep About DepressionBy PETER D. KRAMER
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.
Audiences 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,'' [Viking].
A Pill For Every Ill?
Listening to Prozac
Subordination and defeat