Depression: What It Is To Us versus What It Is

Against Depression
By Peter D. Kramer, Penguin Books, 2005.

Peter Kramer is currently the best writer on psychopharmacology and therapy out there. He also writes novels – the latest one out this year. I’d planned to revisit Against Depression for this blog and, halfway through my reading, as if to inform this review, I went into my own mini depression. My crisis reminded me how disabling even a mild brush with depression can be. So I upped my Prozac (I generally don’t take much these days) and started a fightback. My psychiatrist friend Richard Green would always recommend this course of action when faced with any difficulty. ‘Surrounded by assassins, ’ he would mutter to himself, before mounting his own fightback against whatever was in his way.

This book worried me when I first read it, years ago, because it forced me to consider how much I’d lost (in functioning and productivity) during my own periods of low mood. It took ages for me to be offered drugs, and the ones I did finally get were seriously sedating. Then came the game-changer that was Prozac. It’s worth reading Kramer’s bestseller Listening to Prozac (now reissued in a 30th anniversary edition) to get an idea of the drug’s impact. And then there were the questions that Prozac’s efficacy raised – to what extent should mood and personality be medicated? Or, as Kramer puts it – “What did it mean that patients were willing to allow a technology to define them? If we had access to what I called “cosmetic pharmacology” – if we could prescribe to move people from a normal, but less desired or socially rewarded temperament to a better favoured one  - how ought the medical profession to respond?”

In Against Depression, Kramer argues strongly that depression is “a disease, one we would do well to oppose wholeheartedly.” To make his point, he creates two elegant perspectives on depression  - What It Is To Us and What It Is. He is troubled by the widening gap between the two. As scientific understanding of the reality of depression advances, a chasm opens between  romanticised disease, and what this disease actually is.

Kramer begins by reading memoirs of depression, and finds little that’s profound in  most of them (Styron’s Darkness Visible is an exception.) He considers the claims that great art comes out of depression, that melancholics show depth, that “mood disorder is simply a “heavy dose of the artistic temperament. He finds these claims wanting. Kramer looks at the erotic appeal of depression – depressives can be alluring. They draw others into “operatic entanglements.” He wrestles with “two thousand years’ worth of heroic melancholy,” and concludes that most heroic melancholy is actually untreated mental illness. And to be alienated- the hallmark stance of the artist or rebel – well, this starts to look like disease when it appears in Kramer’s consulting room. But he takes care to clarify what he means –  treating the alienated feelings in depression still leaves room for what he calls “contemplative alienation…joyous alienation” and the kind of revolt of the mind that leads to political action.

In What It Is To Us, depression is a disease of “moral worth and exotic appeal.” We used to romanticise tuberculosis the same way, seeing it as a disease of decadence. Nowadays, we routinely treat TB, and campaign for its eradication. But mention eradicating depression, Kramer says, and people look worried.

Standing in opposition to all this is Kramer’s What It Is (depression to the scientist and the psychiatrist). He describes a vastly changed terrain. The last three decades have seen the research focus shift – away from the role that neurotransmitters play in depression, and towards anatomy itself.

“As new technologies became available, as it became apparent that depression involves abnormalities in brain anatomy -new hypotheses came to the fore, evocative new models of what depression is.”

 To summarise Kramer’s beautiful descriptions, the new realities of depression are these. Stress and depression age the brain and make it less resilient to future stressors. Episodes of depression shrink the hippocampus (depressives may also start off with a smaller hippocampus), and prolonged stress slows down neuron repair. Overall, the brain becomes vulnerable to further episodes of depression. Each episode makes the next one more likely.

“Depression is a disease in which a host of injuries combine to cause a common downstream process that becomes self-sustaining. Certain cancers are like that…”

In later chapters, Kramer looks at the destructive power of depression – the negative effects on productivity, education, relationships, and decision-making (depressives tend to back the losing horse). There is an impact on the body too  - depression can cause abnormalities in hormone regulation, heart function and immune response. And, of course, depression increases the risk of suicide.

In closing chapters, Kramer considers what depression might become. Eradication is not in sight, because the brain is “inconceivably complex,” but he describes how genes might be engineered to work as neuroprotectors against depression and stress hormones. Kramer hopes for a future world that can provide resilience for vulnerable brains, whilst leaving freedom for emotion.

“Heading off depression preserves memories, by averting the confusion and loss of concentration that comes with mood disorder, and the obsessive, stereotyped self-flagellation that interferes with a free assessment of our own history.”

I learned so much from reading this book again. I discovered I’m more of a neurotic depressive, tending to be laid low by setbacks. I found out that mild depression (which never feels very mild) actually looks more like major depression in the newer scientific models. And Kramer explains about his own relationship to “alienated states” in a memoir near the end of the book. It’s very moving.

Final points – I’ve seen major depression up close. My mother has had at least four episodes of it, and often she’s needed electroconvulsive therapy to get better. I therefore take no issue with Kramer’s closing line of his polemic – “How glorious it will be to free ourselves from depression.”