Sonderbooks Book Reviews by Sondra Eklund

Sonderbooks Stand-out 2005
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****Against Depression

by Peter D. Kramer

Reviewed August 27, 2005.
Viking, New York, 2005.  353 pages.
Available at Sembach Library (MCN 616.85 KRA).
Sonderbooks Stand-out 2005 (#3, Musings)

This book has an interesting title.  Why would anyone need to write a book against depression?  Surely everyone knows it’s a bad thing, right?

Peter Kramer is the author of Listening to Prozac about antidepressants and their use.  Ever since he wrote that book, he’s had people ask him questions like, “What about Van Gogh?”  He’s come up against a mystique in our culture that depressives are somehow more sensitive, more creative, more in tune with the world.

In the prologue, he states, “But I think it only fair to say up front that this book is less about what to do, here and now, than about meaning.  How do we understand depression?  How shall we address it?  On these issues, I take a decided stand.  I have written a polemic, an insistent argument for the proposition that depression is a disease, one we would do well to oppose wholeheartedly.”

He says, “We may find ourselves claiming that an episode of depression is justified, in a way that we would not call a bout of asthma justified, even when the cause is clear.  We associate depression with a heroic artistic stance, one we think humankind might be worse off without.  We admire traits that can accompany depression, such as alienation, without asking in each case whether they constitute aspects of an illness.”

He goes on to make a clear case that depression is a disease.  He says, “My impression is that few people outside the research community appreciate the degree to which the scientific understanding of depression has changed in the past decade.  For forty years, researchers had been focused on the role of neurotransmitters, like serotonin and norepinephrine, in setting mood.  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.”

Researchers have found that those who have suffered depression actually have a smaller hippocampus and abnormalities in the prefrontal cortex of the brain.  “Most research on nerve cell functioning is performed on rodents.  Life is stressful for rats—the proverbial rat race, perhaps.  The average aging rat suffers hippocampal shrinkage and memory loss.  In overview, it appears that the aging process involves a vicious cycle.  Chronic stress leads to an excess production of certain hormones.  The hormones injure brain cells and interfere with cell repair, particularly in the hippocampus.  Ordinarily, the hippocampus puts a brake on the production of these same hormones.  In the face of hippocampal injury, hormones continue to circulate, extending the harm and preventing recovery.”

“A substantial body of research suggests that the factors active in aging in rats shape the brain biology of depression in humans.  The hippocampus is small.  Stress responses become unduly prolonged.  They act on neurons that have been made especially vulnerable.  Repair mechanisms are less effective than they should be.

“That last problem—failed resilience—has been of special interest to researchers.  Why don’t depressives bounce back?  In an immediate sense, the answer has to do with the stuck switch—once depressives enter a negative state, they have unusual difficulty emerging.”

He looks at other aspects of the disease of depression, such as the causes, which can be both internal and external.  He also looks at the magnitude and devastation of depression.  “If it entailed none of the disabling consequences analyzed in the international public health studies, if it had no effects on schooling and work and marriage and parenting, if it never resulted in suicide, if it caused no daily suffering, if it were as invisible as high blood pressure, depression would still earn its place among a brutal and elite group of chronic illnesses, those that act throughout the body and across the life cycle to lead to early death.  But of course, depression does harm on all those levels.  The public health findings of the last decade constitute another change in our understanding of what it is.  Depression is a disease of extraordinary magnitude—one of the most devastating diseases human beings suffer.”

There are certain conditions that are purely medical that bring on depression.  These conditions affect the same areas of the brain as “normal” depression and produce the same results.  “The medical depressions clarify the nature of depression altogether.  Effectively, to be depressed is to be in the condition of a person who has suffered small strokes in the brain or a person exposed to high doses of interferon.  To be depressed is to risk heart attack and stroke.  To be depressed is to suffer an impairment that would qualify as disease if it had no effect whatsoever on mood.”

There are many who still don’t think of depression as a disease.  Peter Kramer sums up this section by saying, “If depression arises from or causes abnormalities in the brain, if it entails predictable suffering, if it results in progressive impairment in mental function, if it produces enormous economic costs, if it leads to substantial illness in what psychiatry calls peripheral organs, such as the heart, if depression shortens life, if it has substantial genetic underpinnings, if it is a disorder of failed resilience, if it is treatable or preventable—then depression will pass, as I believe it is doing already, fully into the category of disease.  Not only in medicine but also in daily life, to understand depression as pathology will become a habit of mind.”

The rest of the book tackles our culture’s attitude toward depression, that there’s something inherently valuable or noble about it.  He talks about the mystique of the tortured genius, but makes a good case that we could still have great art even if we didn’t have depression—and perhaps have many more years of the artists’ lives.

“And still we may feel protective toward depression, as a condition we would not want to see eradicated.  One way to express this reluctance is to say that depression is natural.  Scholars have been claiming as much for centuries.  It is only natural in an unregulated (or overly regulated) political economy to feel depressed.  It is natural to feel depressed in the face of loss or adversity.

“Of course, once depression is securely ensconced in the realm of disease, the character of the natural changes.  If you have a predisposing personality type (hostility and impatience now appear to be the key traits) and a familial tendency to high blood lipids, and if you live in a culture where stress and fatty foods are prevalent, it is natural that you should suffer a heart attack.  That expectable consequence is what medicine addresses routinely, pathology whose causes we know something about.  All diseases are natural, in this sense.”

“Less and less do I see hidden benefit in depression.  Medicine knows any number of ‘stuck switch’ illnesses, where the immune system, say, attacks a pathogen and then continues to function in high gear long after the enemy has been driven from the field. . . .  A mechanism that ordinarily protects ends in destroying the body’s own cells.  That the disease occurs in a necessary, adaptive system says nothing in its favor.  Disease is system failure.  Interpersonal sensitivity and loyal attachment are admirable; acute stress responses are apt defenses to certain threats.  But mood disorder is what the name implies, dysfunction—of the very systems we value when we call emotion adaptive.”

This book is profound and thought-provoking, and examines in great detail our culture’s fascination with depression.  I found it interesting that as I was reading this book, I also took up the best-selling book A Long Way Down, about four people who meet at the top of a skyscraper, all planning to commit suicide.  Sometimes it seems that a book has to have dark themes in order to be taken seriously.

As someone who has recently started taking an antidepressant (hoping that it will also work to prevent my migraines), I found very comforting the strong evidence that depression is a disease.  Depression is a disease that actually damages the brain permanently, and can also damage the heart and other systems of the body.  Evidence shows that the brain actually gets rewired during depression, making it easier to fall into depression in the future.  I’m doing the right thing to protect my body from any further damage.

Peter Kramer sums up his book, “I do not find it at all strange to hope for a future in which the vulnerable are granted a measure of resilience—resilience in the brain and throughout the body—so that they are not punished repeatedly for their misfortunes.  That prospect, too, is beyond the reach of ambivalence.  How glorious it will be to free ourselves from depression.”

Copyright © 2005 Sondra Eklund.  All rights reserved.

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