Book Review: Against Depression
Review by David Yarian, Ph.D.
Peter Kramer, best-selling author of Listening to Prozac, has revolutionized the way we think about antidepressants. In this new book, he turns his attention to the disease itself.
Indeed, the concept of depression as disease is central to Kramer's argument: that while cultural notions of depression vary from "feeling blue" to melancholia, to romantic notions of suffering artists who owe their creativity to their depression, the fact is, plain and simple: depression is a disease.
Kramer carefully marshals the evidence for this conclusion, On page 50: "Depression causes profound pain and impairment. It is syndromal, characterized by a reliable cluster of disabilities, such as sadness, appetite and sleep abnormalities, and problems with memory and concentration. Depression progresses, in the fashion of diseases. With recurrence, depression's symptoms become more diverse and less responsive to treatment. Depressives die young. Depression runs in families. Depression is found in every culture."
What has been lacking, until very recently, was the physiological equivalent of the "smoking gun" - physical, undeniable evidence that depression has a biological substrate, and measurable effects on the body. In May 1999 the prestigious journal Biological Psychiatry changed that: researcher Grazyna Rajkowska, a specialist in neurodegenerative disorders, reported her findings that the prefrontal cortex of depressives contain cells that have been weakened, disorganized, and disconnected.
She found anatomical pathology demonstrating decreases in cortical thickness, cell size and cell density within brain tissue. These changes had occurred in the parts of the prefrontal cortex where cells communicate via norepinephrine and serotonin - the chemicals which have long been identified as serving mood regulation functions.
Other physiological evidence has mounted, including findings that demonstrate decreased blood flow and decreased energy utilization in the prefrontal cortex of patients in the midst of depressive episodes.
High-resolution magnetic imaging studies have shown that depressed persons have lower hippocampal volumes and corresponding differences in the size of the amygdala, the portion of the brain associated with emotion.
All these studies show brain pathology which positively correlates with the intensity of symptoms and duration of disease. The more severe the depression and the longer it has lasted, the lower the blood flow to the prefrontal cortex, the smaller the amygdala, the greater the loss of the healthy glial cells which protect nerve cells from attack from any of the many stressors that can affect the brain.
According to Kramer we now stand at a cultural divide not dissimilar to that faced after tuberculosis was proven to be a physical disease. Prior to that time "TB was a disease of recklessness, longing, sensuality, serenity, decadence, sensitivity, glamour, resignation, instinct, and instinctual renunciation, that is to say, of passion or passion repressed, but in any case a disease of emotional enhanced or refined creatures." Susan Sontag explicates this process in her famous essay "Illness as Metaphor", showing how physical diseases have been romanticized, and their sufferers defined has having certain personality characteristics. After the advent of effective treatments for and prevention of TB, these cultural images began to fade.
But, interestingly, these characteristics once attributed to TB sufferers are not dissimilar to those we currently apply to persons with depressed mood. Kramer devotes several chapters to tracing the long western cultural tradition of "heroic melancholy", where depression has been viewed as ennobling, a source of creativity, integrity, insight, and sensuality.
He came to this insight in a curious way. After the success of his book Listening to Prozac he spoke to many audiences, across the U.S. and abroad. Invariably, after speaking about the benefits he saw with wider use of effective SSRI antidepressants, the question would be raised by a member of the audience: "What if Prozac had been available in van Gogh's (Edgar Allan Poe's, Nietzsche's, Kierkegaard's, Isak Dinesen's) time?" In other words, our culture cherishes the myth of the suffering artist and believes that the suffering is necessary for the art. If these artists had access to Prozac - would they have created?
This book is an impassioned plea for our culture to recognize depression as a disease - one that endangers nerve cells, disrupts brain functioning, damages the heart and the blood vessels, alters personal perspective and judgment, and interferes with parenting and family life.
Kramer would add depression to the long list of diseases (tuberculosis, leprosy, epilepsy, syphilis among others) that have been romanticized (or demonized) - until advances in medical knowledge brought treatment, prevention and relief.
This is a thoughtful and engaging book. Kramer ranges widely across history and culture to knit together a compelling picture of our current view of depression - and points to the future where medicine will more clearly illuminate the disease and offer increased avenues to recovery and prevention.
This is a book to be read slowly, thoughtfully. It is a compelling document of social criticism and scientific explanation. Interwoven throughout the book are personal stories of Kramer's patients who have helped him to understand what depression is really like. He sees the important role that psychotherapy plays in conjunction with proper medication for moderate and severe depression.
A highly recommended book for those who live with depression.