Monday, March 24, 2008

NYT Magazine: There's Nothing Deep About Depression


Published: April 17, 2005

Shortly after the publication of my book ''Listening to Prozac,'' 12 years ago, I became immersed in depression. Not my own. I was contented enough in the slog through midlife. But mood disorder surrounded me, in my contacts with patients and readers. To my mind, my book was never really about depression. Taking the new antidepressants, some of my patients said they found themselves more confident and decisive. I used these claims as a jumping-off point for speculation: what if future medications had the potential to modify personality traits in people who had never experienced mood disorder? If doctors were given access to such drugs, how should they prescribe them? The inquiry moved from medical ethics to social criticism: what does our culture demand of us, in the way of assertiveness?

It was the medications' extra effects -- on personality, not on the symptoms of depression -- that provoked this line of thought. For centuries, doctors have treated depressed patients, using medication and psychological strategies. Those efforts seemed uncontroversial. But authors do not determine the fate of their work. ''Listening to Prozac'' became a ''best-selling book about depression.'' I found myself speaking -- sometimes about ethics, more often about mood disorders -- with many audiences, in bookstores, at gatherings of the mentally ill and their families and at professional meetings. Invariably, as soon as I had finished my remarks, a hand would shoot up. A hearty, jovial man would rise and ask -- always the same question -- ''What if Prozac had been available in van Gogh's time?''

I understood what was intended, a joke about a pill that makes people blandly chipper. The New Yorker had run cartoons along these lines -- Edgar Allan Poe, on Prozac, making nice to a raven. Below the surface humor were issues I had raised in my own writing. Might a widened use of medication deprive us of insight about our condition? But with repetition, the van Gogh question came to sound strange. Facing a man in great pain, headed for self-mutilation and death, who would withhold a potentially helpful treatment?

It may be that my response was grounded less in the intent of the question than in my own experience. For 20 years, I'd spent my afternoons working with psychiatric outpatients in Providence, R.I. As I wrote more, I let my clinical hours dwindle. One result was that more of my time was filled with especially challenging cases, with patients who were not yet better. The popularity of ''Listening to Prozac'' meant that the most insistent new inquiries were from families with depressed members who had done poorly elsewhere. In my life as a doctor, unremitting depression became an intimate. It is poor company. Depression destroys families. It ruins careers. It ages patients prematurely.

Recent research has made the fight against depression especially compelling. Depression is associated with brain disorganization and nerve-cell atrophy. Depression appears to be progressive -- the longer the episode, the greater the anatomical disorder. To work with depression is to combat a disease that harms patients' nerve pathways day by day.

Nor is the damage merely to mind and brain. Depression has been linked with harm to the heart, to endocrine glands, to bones. Depressives die young -- not only of suicide, but also of heart attacks and strokes. Depression is a multisystem disease, one we would consider dangerous to health even if we lacked the concept ''mental illness.''

As a clinician, I found the what if challenge ever less amusing. And so I began to ask audience members what they had in mind. Most understood van Gogh to have suffered severe depression. His illness, they thought, conferred special vision. In a short story, Poe likens ''an utter depression of soul'' to ''the hideous dropping off of the veil.'' The questioners maintained this 19th-century belief, that depression reveals essence to those brave enough to face it. By this account, depression is more than a disease -- it has a sacred aspect.

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