The depression wars.

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Nov. 3 2005 5:38 PM

The Depression Wars

Would Honest Abe have written the Gettysburg Address on Prozac?

Book cover

In his new book, Lincoln's Melancholy, Joshua Wolf Shenk convincingly argues that Abraham Lincoln struggled with major depression. But Shenk is using the cover of presidential biography to hunt bigger game: namely, the certainties of our 21st-century psychiatric establishment and its narrowly clinical view of depression. Lincoln's Melancholy comes on the heels of the psychiatrist Peter D. Kramer's Against Depression. Taken together, these two books capture our current cultural ambivalence over mental illness. Shenk doesn't take depression lightly—he's suffered from it himself—but he's interested in it as "a multifaceted phenomenon," one that confers "potential advantages along with grave dangers." For Kramer, musing on the potential advantages of depression is as foolhardy as musing on the potential advantages of diabetes. Kramer sees depression as a disease, pure and simple, a view that the latest scientific research only further confirms. So why, he asks, do we continue to romanticize it?

While it's true that we can treat depression more effectively than ever before, our best biochemical explanations of its workings still resemble educated guesswork. Even Kramer, who describes, approvingly, our latest neuroscientific theories in his book,takes pains to point out that they are still "myths"—reasonable accounts of phenomena that elude complete understanding. In addition, we know about as much (or as little) about how antidepressants operate as we understand about depression itself. Despite the popular conception of Prozac as a wonder drug, the SSRI generation of antidepressants is only fitfully effective. One recent study of trials submitted to the FDA for the six most widely prescribed antidepressants—Prozac, Paxil, Zoloft, Effexor, Serzone, and Celexa—showed that the drugs were only significantly more effective than placebos less than half the time.

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Because of the lack of scientific certainty, the debate over depression turns on questions of language. What we call it—"disease," "disorder," "state of mind"—affects how we view, diagnose, and treat it. The fight over depression and pharmacology has come to resemble the other shrill and intractable debates of our day, such as stem-cell research or cloning. Where you stand depends partly on your political and religious leanings and partly on your intuitive feelings about scientific progress. As a public health hazard, however, the stakes couldn't be higher—something that both Shenk and Kramer acknowledge. Depression affects more than 100 million people a year, and it's the world's leading cause of disability. In 2000, about 1 million people worldwide killed themselves—about equal to the number of deaths that year from war and homicide combined.

Book cover

One of the more potent brickbats in the depression wars is the notion that depression fuels creativity. In fact, Kramer says the impetus for writing Against Depression came in the years after the success of his Listening to Prozac, which examined how antidepressants affect people's sense of self. Whenever he gave a reading or lecture, someone in the audience would invariably ask, "What if Van Gogh had taken Prozac?" This question, of course, is shorthand for, "If we medicate depression, will we dampen the creativity that often exists alongside it?" Who knows, Kramer suggests in Against Depression—maybe a happier Van Gogh would have gotten more painting done. Plus, for every tortured creative genius (Hemingway), you can also point to a sanguine one (Trollope). It's just that Western culture tends to overlook the latter; the contented have the hard lot of never being granted much mystique.

Shenk considers Lincoln in the context of the depression-creativity nexus (he's a good fit), but, more provocatively, Shenk argues that depression fueled Lincoln's productivity. This idea flies in the face of prevailing cultural myths, which portray depression as an incapacitating condition and the depressive a wilting flower. As Shenk points out, Lincoln is by no means the first or only extraordinarily productive depressive. He taps an unexpected authority, Kramer himself, who wrote in Listening to Prozac:

Throughout history, it has been known that melancholics, though they have little energy, use their energy well; they tend to work hard in a focused area, do great things, and derive little pleasure from their accomplishments. Much of the insight and creative achievement of the human race is due to the discontent, guilt, and critical eye of dysthymics.

This matter is never broached in Kramer's new book. The passage describes Lincoln wonderfully, though. Lincoln's law partner, W.H. Herndon, once observed that Lincoln "crushed the unreal, the inexact, the hollow, and the sham." Lincoln's "fault, if any," Herndon said, "was that he saw things less than they really were." What Herndon is describing here, Shenk says, seems similar to what psychologists term "depressive realism": the idea that depression can stem from fundamentally accurate perceptions—a worldview that, in some situations, can be an advantage.

To make his case, Shenk points to a landmark 1979 study of "depressive realism" during which researchers created a game-show-like experiment in their lab:

Individual subjects were placed in front of a panel with a green light, a yellow light and a spring loaded button, and were instructed to make the green light flash as often as possible. In one segment, they would win money every time the green light went on. In another, they would lose money when it didn't. A screen in the room showed their score. Afterward, subjects were asked how much control they had. … Among the "normal," non-depressed subjects, it depended on whether they were losing or making money. When they were winning money, they thought they had considerable control. … When they were losing money, they thought they had virtually no control. In other words, these subjects took credit for good scores and dished off blame when scores were poor. … The depressed subjects saw things differently. Whether they were winning or losing money, they tended to believe they had no control. And they were correct: the "game" was a fiction.

Shenk also quotes the science journalist Kyla Dunn on the experiment: "One cognitive symptom of depression might be the loss of optimistic, self-enhancing biases that normally protect healthy people against assaults to their self-esteem. In many instances, depressives may simply be judging themselves and the world much more accurately than non-depressed people, and finding it not a pretty place."

Ultimately what Shenk and Kramer are fighting over is the utility of the tragic vision of life. Which brings us to an undated letter F. Scott Fitzgerald sent his daughter, Scottie, before she went off to college. Make time, Fitzgerald wrote, "to form what, for lack of a better phrase, I might call the wise and tragic sense of life." He went on:

By this I mean the thing that lies behind all great careers, from Shakespeare's to Abraham Lincoln's, and as far back as there are books to read—the sense that life is essentially a cheat and its conditions are those of defeat, and that the redeeming things are not "happiness and pleasure" but the deeper satisfactions that come out of struggle.

Kramer's probably partly right when he blames Western culture's "insistence on grief as depth" for our persistent romanticizing of depression. And when Kramer derides the notion that "when we are in touch with ourselves, we are all melancholics" as one more instance of "mistaking illness for insight," that quote by Fitzgerald—his career broken, his health failing—becomes a little more chilling.

But, as Gary Greenberg pointed out in a smart piece in Harper's Magazine on Kramer's book this August, the Big Questions—"Whether pessimism is really pathology, or whether we should take drugs to cure our pain, or whether you really have to suffer to sing the blues"—can never really be answered, and any answers would never be agreed upon in our polarized culture. And the elephant in the room in this debate is the drug industry itself. These companies fund most of the ad campaigns designed to educate the public about mental illness; they pay for the vast majority of depression and neuroscientific research; and they stand to make huge profits by helping us alter our biochemistry. Writers and philosophers and learned doctors can argue over the tragic vision until the end of time, but it's the pharmaceutical companies that are shaping it for us as we speak.

Field Maloney, who comes from a hard-cider-making family, is writing a book about wine in America. He likes to drink beer.

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