By Peter Kramer
Viking Press. 353pp. ISBN: 0-670-03405-3
Peter Kramer is a rarity–a psychiatrist who writes with literary polish. He’s the author of four books, including a well-reviewed novel. But he’s most widely known for his 1993 bestseller, Listening to Prozac.
To his chagrin, that book turned him into an expert on depression and, in the popular mind, a promoter of SSRIs. While his intention in writing the book, he says, was more philosophical, people tend to remember his observation that Prozac makes patients feel “better than well” or like their “real selves” again. Readers conveniently overlooked his concern with what he called the new “cosmetic psychopharmacology.” What happens when nondepressed people start looking to a drug like Prozac to remake their selves? What does character mean if it comes out of a capsule?
After Listening to Prozac, Kramer became a public figure, and discovered that readers kept asking him the same question: what would happen if great artists took Prozac? His questioners seemed to imply that depression was linked to emotional depth and intellectual profundity. But this wasn’t the depression Kramer regularly encountered in his consulting room. That was more of a soul-sapping state, which left his patients crushed and numb. Something was awry in the public’s perceptions.
In his new book, Against Depression, Kramer has written a polemic against the disease. Therapists and their clients may ask why anyone needs to denounce depression–it’s so clearly bad news–but Kramer argues that, while we may pay lip service to depression as a disease that blights lives, we tend to place it in a category separate from life’s other afflictions. His book is a passionate inquiry into both our scientific understanding of depression and its place in the culture.
Over the past decade, as depression has become less shameful, people have felt increasingly emboldened to go public with their experiences of it. At first, Kramer applauded this unveiling, but he soon became disturbed by the “hints of pride” he detected in these public confessions, “as if depression might be more enriching than, say, a painful and discouraging encounter with kidney failure,” or some kind of “spiritual gift.” When one memoir writer (he mentions no names) claimed that “depression gave me my soul,” Kramer was irked at the idea that this illness was being deemed ennobling.
By contrast, he calls depression the “the most devastating disease known to humankind,” one that steals vitality from sufferers throughout their life, not just at the end of it, robbing millions of what he calls “disability adjusted life years.” Sixteen percent of Americans suffer major depression in the course of a lifetime; in a given year, up to seven percent do. And half to two thirds of them will have recurring bouts.
Kramer writes at length about the effects depression has on the brain. Here his talent for synthesis shines through and his polemic becomes the best kind of science writing for the layperson. The data can be summarized fairly succinctly: depression shrinks key parts of the brain, and depletes our brain cells. It can also prevent new neurons from growing.
So what’s a doctor to do with depressed patients? (Kramer rarely addresses his nonmedical colleagues). We all know people for whom the conventional treatments, including SSRIs, don’t work; others for whom the medications work at first and then stop. In some cases, even electroconvulsive therapy may not provide relief. Mostly practitioners just press on, living with the intractability of some depressions, as do their patients, and worrying about the risk of suicide.
But Kramer makes a special point of emphasizing what might be called the “seduction of depression”–how some depressives can slither about and attract you even while in pain. He tells us the story about his patient Betty, a coy, intelligent, eager-to-please woman, who, in the end, wants to hold on to the best parts of her depression without really being cured, as Kramer, the empathic psychiatrist, finds himself entranced.
He concludes that “doctors learn to take the charm [of depression] with a grain of salt,” admitting that he learned this clinical lesson late in his career. Perhaps the writer in him made him more susceptible. Although the case of Betty is as wonderfully written as his other clinical tales, one has to wonder, how many therapists have been so immobilized by their own patients? In the end, it seems that his warning about the seductions of depression may be most relevant to him.
Perhaps that’s because Kramer is, by his own admission, a “depressive manqué,” who’s spent years “fending off depression.” Though not depressed, he’s melancholy by temperament–a condition that’s a “distant cousin of depression.” So there’s an element of the doctor talking to himself about the seductions of depression, as if to keep reminding himself of its severity and its cunning.
Throughout his book, Kramer’s larger concern is what can only be called the cultural status of depression. He mentions Goethe, Carlyle, Kierkegaard, Poe, Hemingway, T. S. Eliot, Walker Percy, and a host of other painters and writers, who all lived and created (when they weren’t depressed) in the tradition of “heroic melancholy.” He faults some critics for not taking seriously enough cultural figures like the chipper John Updike, a complete but nondepressive writer, and, from the world of psychology, Carl Rogers, who, he says, has been undervalued as a major theorist because he was too upbeat.
Yet, in trying to make his case, Kramer sometimes seems to go too far. Must all melancholy be dismissed as a terrible temptress? Melancholy can make you dull and stupid, but it sure forces you to reflect, to think. Why am I this way and not another? What’s wrong with me and the world? Such thoughts are the basis of much literature, and would be wasted on the blithely happy–those supremely resilient souls who have better things to do than keep scratching their psychic itches.
What does all this mean for therapists, especially for those without their MDs? While Kramer claims he’s an “enthusiast” for therapy, he believes that the talking cure has gone about as far as it can. He thinks the future treatments for depression will be better meds and genetic engineering. But for now, he talks and prescribes, when he has to. And he sees his patients long term.
The culture may indulge depression, but it’s my guess that most therapists take it dead seriously. As beautifully written as it is, Kramer’s book may protest too much. Even positive psychologists, so notoriously averse to pathologizing, wax on and on about depression as a great personal and social ill. So Kramer may have more allies than he thinks. Maybe something isn’t so rotten in the state of Denmark after all, to paraphrase one of our culture’s favorite depressives. Everybody’s just doing the best they can with this awful human affliction. It’s hard to imagine anybody–especially therapists–not really wanting a cure.
Richard Handler is a radio producer with the Canadian Broadcasting Corporation in Toronto, Canada.