Commentary Magazine


Depression

To the Editor:

I am honored that my work has been given an extended critical essay by Algis Valiunas, but I want to correct one point and respond to another [“Sadness, Gladness—and Serotonin,” January].

Contrary to what Mr. Valiunas writes, I am not the “trademark proponent” of Prozac and its fellow selective serotonin reuptake inhibitors (SSRI’s). In my book, Listening to Prozac (1993), I wrote that these medications are less effective than prior antidepressants in the treatment of severe depression. For minor depression, I suggested, psychotherapy remains the most important intervention. As for the SSRI’s negative effects, although the research literature was equi-vocal, I sided with those who believed that new-onset suicidal thoughts, late-appearing neurological symptoms, and the development of tolerance for the drug were real risks.

My main interest, however, was not in Prozac’s effects on health, for good or ill, but in its effects on the modern sense of self. I had observed, in some of my patients, dramatic responses to Prozac that seemed to go beyond the amelioration of illness to the alteration of personality traits. Because there were good theoretical grounds to believe that the medication was directly responsible, I used my observations as the basis for a consideration and criticism of what I called “cosmetic psychopharmacology,” whereby medication might be used not to treat disease but to alter normal functions in desired or socially rewarded directions. I think it is fair to say that Listening to Prozac energized the study of “enhancement,” a now burgeoning field within medical ethics.

As a reviewer noted when it appeared, the book might well have been titled Worrying about Prozac. Its central concern was cultural: did society favor frenetic assertiveness as a personality style, and would medications’ ability to tweak temperament push us ever further in that direction? I favored a more neutral stance, in which the whole range of temperaments would be respected. In subsequent years, I began to hear the concerns I had voiced with respect to enhancement applied to the mainstream treatment of major depression—as if ameliorating mood disorder were also morally fraught. I wrote Against Depression in part to address that overgeneralization. I believe that depression has earned its status as a disease and that the ethical issues that attend its treatment, whether with medication or psychotherapy, parallel those that attend the treatment of other diseases.

Mr. Valiunas wants to contrast my position with that of Kay Jamison in her recent book Exuberance, but Jamison and I are largely in agreement on the main issue, namely, that sunny temperaments and emotional resilience have been underrated, particularly by intellectuals. I devote whole sections of Against Depression to this issue, asking why sanguine artists and scientists have been dismissed as lightweights. I speculate that the historical prevalence and intractability of depression have helped shape the cultural preference for “heroic melancholy,” and I discuss the potential effects on our tastes and values of (future) more effective treatments.

Jamison’s Exuberance is not at all “an answer to Kramer from within psychiatry.” It is rather a sort of naturalist reply to Leon Kass and others who seem to argue that fulfillment can arise only from anguished striving. Both Jamison and I say that people to whom achievement comes easy, or at least without agonizing self-doubt, can also lead full moral lives.

Mr. Valiunas’s praise for Jamison (who fills her book with case examples of people who look as if they inherited the traits I worried about as the goals of cosmesis) shows how much the conservative critique of psychiatry relies on faith in the natural as the good. Mr. Valiunas admires the “resilience, pluck, daring, and sparkle” of Teddy Roosevelt and others like that “riproaring statesman” in Jamison’s gallery; presumably these robust, joyous types are moral because they arrive at their temperament honestly, through “cosmic accident.” By this account, lucking into extreme resilience is admirable, while the restoration of quite modest resilience, through the medical treatment of depression, constitutes a suspect interference with what Mr. Valiunas calls “divine will.”

I want to underscore a point that, to his credit, Mr. Valiunas (mostly) makes on my behalf. I appreciate the centrality, to the aware and self-aware life, of social and existential alienation. But I do not see the disease of major depression as necessary to that perspective—just as I do not see exuberance as incompatible with it. How strange it is to have to make such a disclaimer, though; it should go without saying that one can oppose depression vigorously while understanding what is at stake in the modern world.

When Mr. Valiunas reaches back to Jamison’s account of her own manic depression, he comes closer to locating a point of disagreement. I do find that memoirs of mood disorder, hers included, tend to romanticize disease states. Mr. Valiunas quotes approvingly from her report that she learned from and found odd beauty in episodes of mania that involved psychosis and delusions. But as a society, we are in reasonable agreement that psychotic manic states are symptoms of disease. We do not refer to episodes of psychotic mania as justified—that is, as apt responses to the human condition or the state of society—as we might with depression. My new book will have achieved much of its purpose if it convinces readers that depressive episodes deserve the same status as episodes of mania. We may make creative use of them, as we make use of any extreme experience; all the same, they are bouts of illness, worthy of the efforts at prevention and treatment that would be applied toward any disease.

Peter D. Kramer, M.D.

Brown University

Providence, Rhode Island

 

Algis Valiunas writes:

By calling Peter D. Kramer the trademark proponent of SSRI’s, I by no means wished to suggest that he is a shill for the latest products of the pharmaceutical industry. Like any other good doctor, he numbers the dangerous side effects that drugs such as Prozac sometimes have, and he notes the therapeutic limitations of the SSRI’s. Despite these reservations, however, Dr. Kramer makes clear that Prozac’s effectiveness in ameliorating ordinary unhappiness has changed not only psychiatry but the very conception of the moral life. As he writes in Listening to Prozac,

Is Prozac a good thing? By now, asking about the virtue of Prozac—and I am referring here not to its use in severely depressed patients but, rather, to its availability to alter personality—may seem like asking whether it was a good thing for Freud to have discovered the unconscious. . . . In time, I suspect we will come to discover that modern psychopharmacology has become, like Freud in his day, a whole climate of opinion under which we conduct our different lives.

Surely one can make no larger claim for the significance of a drug than this.

The practical triumphs of psychopharmacology that Dr. Kramer describes have all but assured the theoretical ascendancy of neurobiology as the defining science of human nature. Certainly in the popular mind, and to an alarming degree in the scientific conception, neural wiring has acquired the cachet of destiny, which Prozac is designed to overcome. The questions that I raise in my essay, and that Dr. Kramer scants in his books, concern the consequences for philosophy and religion that the ongoing conquest of nature, including human nature, will inevitably have.

Like Dr. Kramer and Kay Jamison, I believe that exuberance has been underrated, and that to take joy in being alive is the hallmark of a life well lived. I admit that a good deal of luck is involved in who gets to be joyous and who does not, while Dr. Kramer thinks such luck to be an injustice that widespread neurochemical intervention can make right.

Sometimes that intervention is absolutely the correct thing; there is nothing inherently heroic in depressive illness, which I would be happy to see wiped out. Yet, fond as I am of my own all too rare flights of exuberance, if a pill were available to make them more lasting or more intense, I do not believe I would take it—although I would not question for a moment the wisdom of taking other pills to quell mania or relieve depression.

To manufacture a neurochemically improved or even perfected self seems a violation of my own nature in a way that correcting an obvious pathology does not. Coming to terms with certain flaws in my nature that seem essential to who I am is indispensable to such happiness as I am capable of; trying to overcome those flaws by moral effort seems natural in a way that smoothing them out by cosmetic psychopharmacology never will.

The conservative critique of psychiatry does not make nature pure and simple out to be the good, for nature can be unmistakably pernicious. But prudence distinguishes between nature’s grievous malignities and its ordinary imperfections. The former cry out for immediate relief by any means at hand; you learn to live, however uneasily, with the latter.

What I especially praised in Kay Jamison’s character was not her embrace of manic extremity. It was her making a remarkably healthy life for herself despite the occasional horrors of mania and depression. I did point out that she would have chosen mania only so long as she had lithium to control it. The triumph of psychopharmacology is to allow her such a choice; the triumph of character is to wrestle with a terrifying affliction and come out on top as often as she has.

 

 

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