Not long ago, I had a conversation with a woman fifteen or twenty years older than myself, who told me that she thinks of Prozac as “the penicillin of my generation.” She was interviewing me about my book about growing up on antidepressants, and she didn’t try to hide the fact that she found my semi-critical stance toward medication bewildering. “Wait,” she said near the end of our conversation. “I need ask again to make sure I’m clear on your answer. You mean you really don’t think that depression is a disease like diabetes?” I told her I don’t, and though I can’t be certain, I think her trailing silence conveyed a touch of the disgust we reserve for wrong ideas.
Depression has had a tough thirty years of it. Viewed just a generation or two ago as rare, clinical depression is now seen as ubiquitous and pernicious. The World Health Organization identifies depression as the leading cause of disability worldwide, and economists say it costs tens of billions a year in lost productivity. Once seen as a psychological phenomenon that usually passed on its own, even mild depression is characterized today as a biological disease; my interviewer hardly broke new ground in casually comparing it to a staph infection.
But it wasn’t always like this.
Viewed from the distance of history, it’s our current understanding of depression that looks odd. Like ours, most societies have understood that in its extreme forms, depression is abnormal and dangerous. But we are unique in our belief that even a touch of melancholy is a sickness. We’re even unlikely to admit to shades of degree: depression to us is a binary proposition, something you either have or don’t, something that means illness and never anything else or more.
By contrast, societies of the Western past were apt to recognize depression as a kind of fellow traveler—unpleasant but familiar, at times even possessing its own stubborn points of value. Much more than we do, they permitted it to be complex.
***
At first, the ancient Greek take on depression sounds suspiciously like our own ideas about serotonin. Physicians of the day believed that illnesses were caused by an imbalance in the levels of four substances, called humors, inside the body. Each substance was associated with a different property: blood, from the heart, was warm and wet; phlegm, from the brain, was cold and wet; yellow bile, from the liver, was warm and dry; and black bile, from the spleen and bowel, cold and dry. The ancient Greek term for black bile is melaina chole. An excessivex influx of it into the brain caused melancholia, which Hippocrates defined simply as “fear and dejection that is prolonged.”
But to the Greeks, humors weren’t simply held responsible for illness; they defined ordinary temperament as well. An extreme surplus of black bile could engender melancholia, causing, in Hippocrates’ words, “aversion to food, despondency, sleeplessness, irritability, restlessness.” But a minor surplus determined a personality type. Melancholics, possessing a slight preponderance of black bile, were peevish and moody. Cholerics, with yellow bile to spare, were passionate and quick to anger. Phlegmatics were stolid and deliberate; those of a sanguine humor were cheerful and happy-go-lucky.
Having a melancholic humor presented obvious challenges, but there were plenty who recognized that a touch of melancholy could be a good thing. Aristotle believed that from the ranks of the melancholics came society’s artists, scholars, and visionaries. If a person’s melancholic bent “is quite complete, they are very depressed,” he wrote in the Problemata, around 350 B.C. “But if they possess a mixed temperament, they are men of genius.” He concluded: “All those who have attained excellence in philosophy, in poetry, in art, and in politics had a melancholic habitus.”
***
Modern conversations about depression often return to the idea that the illness carried a terrible stigma in ages past. It is likely that this sense of depression’s stigmatization comes to us from the Middle Ages, when a religious tradition, familiar then but only a muscle memory to us now, identified depression as a type of sin. Called “acedia” or “wanhope” (literally, “faint hope”), it was considered a subset of the deadly sin of sloth. Its major feature was a loss of faith in one’s own worthiness of salvation and mercy in the eyes of God.
A person’s progress into wanhope could start small, with mere irritability and disobedience. Left unchecked, though, the condition could quickly blossom into suicidal despair. In Chaucer’s Canterbury Tales, the Parson delivers a droning lecture to his fellow pilgrims on the dangers of wanhope. He mentions that the trouble begins when the afflicted person starts believing himself bad at heart, “imagining that he has done so much sin that it will not avail him, though he would repent and forsake sin; through which despair or dread he abandons his heart to every manner of sin.” Sounding like an uninspiring motivational speaker, he advises that working hard and avoiding idleness are the best ways to get and stay clear of the “damnable sin” of wanhope.
If we think of sloth as physical laziness, wanhope was a kind of spiritual laxity, a shrinking away from Earthly duty and routine. It was something that happened to you, but also something that you allowed to happen, a mental or spiritual itch that you gave into. Being in a state of wanhope was not only for the future of your own soul, which would go to perdition unless you continued to make good confessions, but also for the community, which lacked the resources to support noncontributing members. If you’re looking for an ancestor of the idea that depression has something to do with being weak-willed, you may as well look for it here.
***
Like our modern concept of depression, wanhope had literally nothing to recommend it. But in the Renaissance, thinkers reached back past the Middle Ages and into Classical antiquity, where they rediscovered Aristotle’s point of view on melancholy. In Renaissance Italy, philosopher and depressive Marsilio Ficino theorized that melancholy signified a capacity for profound thought and feeling. He believed that there was a trace of melancholy in everyone, and identified it as a deep yearning for higher things, a “nostalgia for the celestial fatherland.”
The English Romantics continued the tradition. To them, melancholy was an aesthetic stance. Receptiveness to it signified sensitivity and insight, an association that will seem familiar to any contemporary fan of goth rock or classic Hollywood movies. What was sad was beautiful; what was beautiful possessed an ineffable rind of sadness. John Keats’ “Ode on Melancholy” speaks to a sublime fusion of the sad, the lovely, and the sacred: “Ay, in the very temple of Delight/ Veil’d Melancholy has her sovran shrine.” Coleridge, sounding nearly clinical, rhapsodized “A grief without a pang, void, dark, and drear,/ A stifled, drowsy, unimpassioned grief,/ Which finds no natural outlet, no relief,/ In word, or sigh, or tear.” Then as now, melancholy could signal protest. For Wordsworth, melancholy meant a way to proclaim outsider status, to rebel by withdrawing against the Industrial Age, with its exhausting, empty cycles of “getting and spending.”
***
The next great theory of depression belonged to Freud. To him, depression (he used the Greek term, melancholia) wasn’t an aesthetic mode but a state of feeling, an emotional reaction caused by loss. The loss could be of anything: a relationship, a possession, even a long-held hope or cherished belief. Often the loss wasn’t conscious, but the feeling was. Melancholia felt like grief, with the addition of bitter feelings of anger, guilt, and reproach heaped upon the self.
Freud didn’t think that melancholic reactions were healthy, per se, but he did believe that they were widespread. Vulnerability to depression was one of the hazards of loving and connecting, and particularly of over-identifying with the things one loves. Anybody could fall into melancholia from time to time, but particularly at risk were those who find their self-worth in attachments and achievements rather than inside, and of eager-to-please individuals who keep their aggressive feelings pent up inside. In an increasingly individualistic society, Freud gave us a vision of grief whose roots were interesting and personal, springing from the bonds and experiences that make us who we are.
***
Freud’s ideas, variously refined and adapted for American consumption, basically dominated our thinking about depression until the early 1970s. That’s when science, or at least the will to science, began to enter.
During the 1960s, American psychiatry hit the doldrums. Psychoanalysis had failed to live up to the outsized promises with which it had arrived on our shores decades earlier. Many psychiatrists had grown envious of other medical specialties, which had benefited from new technology after the end of World War II while their own discipline plodded on in its tweedy way. The dissenters were inspired by advances in the pharmaceutical treatment of mental illness. Thorazine, the first anti-psychotic drug, became available in America in the 1950s. Shortly after, an experimental drug for tuberculosis turned out to have antidepressant properties—legend has it that the antidepressant era began when worn-out T.B. patients began spontaneously dancing in the wards.
In the 1970s, psychiatry in America was taken over by a group who wished to think of their discipline not as a trumped-up humanity but a proper medical specialty, and to consider mental disorders as real, biologically based diseases. They re-wrote the Diagnostic and Statistical Manual of Mental Disorders or DSM, whose third edition, published in 1980, reflects a sea change away from its psychoanalytic roots.
A few years later, researchers discovered new antidepressants that appeared to work by boosting levels of serotonin in the brain. The vanguard of the psychiatric and neuroscientific communities always understood that there was not enough evidence to support the inference that an insufficiency of serotonin causes depression. But that was the account of the Prozac miracle that doctors and drug companies disseminated to the public, in countless advertisements, popular science articles, doctor-patient conversations, and PSAs.
The idea that depression is a chemical imbalance idea was a leap, but it succeeded because it made sense to antidepressant consumers and served the needs of psychiatrists in their search for medical legitimacy—real diseases with real treatments—and the needs of drug companies to establish a rationale for the use of their products. Through it, our modern definition of depression was born. This new depression was a disease, pure and simple. It was caused by nothing, signified nothing, and was best and most appropriately treated with drugs. As tranquilizers had in the 1960s and ’70s, antidepressants quickly went mainstream. Affordable and convenient, medications were able to reach many people who couldn’t afford or would not have considered talk therapy.
Yet despite the promise of definitive, modern understanding conveyed by the chemical imbalance account, the biological reality of depression still floats away from our grasp. Twenty-five years later, scientists still haven’t achieved a satisfying explanation of just how or why antidepressants work. No benchmark for a normal level of brain serotonin has been established, nor have depressed people been shown to have less serotonin in their brains than the non-depressed. Antidepressants are effective for many, especially in cases of moderate to severe depression, and we understand the brain better every year, though an unfathomable amount still remains to be learned. But on close inspection, “depression is a chemical imbalance” turns out to be is every bit as much a model, a metaphor, a story, as “depression is an excess of black bile.”
***
That’s why depression is not a disease like diabetes. Diabetes isn’t a metaphor. It was discovered, not invented. Its cause and nature are known. Depression exists—all those disparate societies acknowledged and named it. But it is among the most conceptually malleable of illnesses. Its borders are fuzzy: at the extreme, depression is eminently disease-like, a true madness, but its mildest forms are fleeting and banal, comprising thoughts and feelings that we’ve all had a taste of. Most of all, perhaps because it affects consciousness, depression cries out for interpretation. Throughout history, each culture has given depression a meaning, or meanings. Each has told a story about it, and the story reflects much about that culture’s values, fears, and aspirations. Chemical imbalance is our chosen story, and it speaks volumes about the way we would like to approach the world.
Our society doesn’t have a unique claim on the truth of depression, and I don’t suspect we ever will—because even though research should and will continue, yielding new treatments and improved understanding, the meaning of depression isn’t something we’ll discover under a microscope. However uncomfortable we are with the fact, it is something we have to make up.
So we can keep on saying that there’s nothing especially mysterious about depression, that it’s a glitch in the brain to be squelched as we would a bacterial infection. We can argue that defining depression as a physical disease is better because it’s cleaner and simpler, because it removes blame and erases stigma. That would be a story, though, and we could just as easily tell another. With equal veracity, we could say that depression is fundamentally human. We could argue that a touch of it, however unpleasant, is a fitting response to some of life’s enduring questions and society’s intractable problems. We could look back and say that there’s something in each of those strange old accounts of it that makes sense. We could believe that our tendency toward it is tangled irrevocably with the things that make us creative, spiritual, capable of love and vulnerable to loss—and that as such it deserves, if not open-armed welcome, then at least the respect that is due to an old and worthy foe. We could even say that a world without depression would be, alternately, a place we wouldn’t recognize, or a nice place to visit, but not one we’d want to live in for very long.
***
Rumpus original art by Jason Novak.
30 responses
I find these kind of critiques of ‘depression culture’ difficult, because there’s little differentiation made between melancholia (which is the same term I used as a teenager and in my early twenties— I liked how antique it sounded) and depression. I’ve had both— melancholia is almost lovely, a rich sadness that allows me to feel everything.
Depression, however, is physical to me. It’s a heavy fatigue, an unwillingness to move, to shower, to feel anything. I can feel the difference between what I’m thinking and how I’m feeling. If I weep, it’s because as much as I try, I cannot feel better. It feels like a split in my brain: the difference between how I would like to be and how I am. It feels like a sickness. It’s not even sadness, necessarily. That’s the first misconception of depression, that it means that loss and grief. It doesn’t. The feelings I struggled with while my mother fought with cancer were not the same I struggled on an ordinary July day when she was in remission and happy and healthy.
The melancholia doesn’t need to be medicated, but the debilitating depression did. I resisted going on anti-depressants for so long, barely able to get up and teach, because of pieces like these. It wasn’t until the depression became overwhelming, and after trying so many other things, that I gave in and tried it. And after a time, I found myself able to move again and be productive, to be gloriously happy and sad, lazy and busy.
Is there overmedication? Almost certainly. Is medication given where another technique would work better? Yes. But to praise depression— the clinical, exhausting illness— where you mean to praise sadness/melancholia/the range of human emotion— is incredibly problematic. The lack of differentiation here seems dangerous. There are a few nods to the ‘moderate and severe’ category, but for the most part everything here is blurred together.
Thank you for this thoughtful piece on depression which offers both a consideration of Western medical and psychiatric history and a glimpse into your personal history. As a writer, I especially found truth in these lines: “Throughout history, each culture has given depression a meaning, or meanings. Each has told a story about it, and the story reflects much about that culture’s values, fears, and aspirations. Chemical imbalance is our chosen story, and it speaks volumes about the way we would like to approach the world.”
I also wanted to offer two short, entirely non-professional, stories of my own. As my mother was dying of an undiagnosed neurological disorder in a nursing home, I told my then-boyfriend I felt depressed. He gave me his opinion as a biomedical researcher and medical doctor – he urged me to go on anti-depressants, because obviously my psychotherapy wasn’t working. He assured me I wouldn’t be stigmatized, milions of Americans used them, and that it was a chemical imbalance like diabetes (he also used this comparison). I resented this advice.
However, around the same time, my mother’s condition was causing her to become increasingly emotionally labile, incoherent, and to lose nearly all her motor control. Her doctor re-formulated her cocktail of medications and added Klonopin and Prozac. The difference was unbelievable. After Christmas, she dictated thank-you notes to me for her friends, including one to the assistant director of nursing: “Thank you for suggesting the anti-depressants. They worked.”
None of these medications could prevent my mother from dying though, and I’m not sure if they ever helped her find peace with her imminent death while she was alive. And neither have I started anti-depressants – I would rather experience the necessary grief and melancholia because I too believe they are fundamentally human. Talking helps. Writing helps too, sharing my stories and reading articles such as these.
I appreciate and respect the writer’s struggle with her illness and I admire her research into the history of depression. It reminds me of the detailed history that Andrew Solomon describes in the wonderful “The Noonday Demon.” Thank you for establishing this is a problem that has always, and will always, be with us as a society to deal with.
“We’re even unlikely to admit to shades of degree: depression to us is a binary proposition, something you either have or don’t, something that means illness and never anything else or more.”
I agree completely–there are many shades and types of mental illness. This article does not give due credit to those shades. It seems to imply major depression is the same as feeling cranky or down, and that is very dangerous.
Hippocrates’ ideas about the causes and treatments of major depression are very much in line with our current medical treatments, as the author notes. But Plato and then Aristotle, after Hippocrates, were concerned with philosophy, not physical health, and it’s important not to place the philosophy as more important than the medicine. While talk therapy is incredibly important in treatment, it’s not the ONLY treatment recommended. The medical and psychological sides both need balance–a balance that is missing from this essay.
“Modern conversations about depression often return to the idea that the illness carried a terrible stigma in ages past.”
Yes, definitely–and I believe essays like this continue that stigma by implying that thousands of people suffer from a metaphor instead of a chemical imbalance. What the triggers of that imbalance are, whether biological, social, and/or psychological, might fall into the realm of philosophy, but antidepressants do their work because they correct a chemical imbalance. That’s not going to solve a bad situation in someone’s life, but it will make it possible for the individual to then think about and act on changing the situation.
I believe that this essay’s perpetuating the notion of the romantic, depressive artist is very dangerous, especially to a creative community. Writers and other creative types have a strange stereotype to fight against, almost a reverse stigma: there is a weird cultural perception that artists are a little (or a lot) crazy. The really unfortunate and dangerous part of this stereotype is that it is not better for creative people to be suffering from depression any more than any other community.
David Foster Wallace noted the phenomenon that many smart people–perhaps especially thoughtful, analytical people, like writers–are excellent at coming up with justifications for themselves, to prevent themselves from seeking help for illness. The following testimonial for a rehab center he had visited is attributed to him. He said the people at the center helped him most because they:
“recognized bullshit, and manipulation, and meaningless intellectualization as a way of evading terrible truths—and on many days the most helpful thing they did was to laugh at me and make fun of my dodges (which were, I realize now, pathetically easy for a fellow addict to spot).”
They advised him to not make harmful decisions today when tomorrow might very well look different. (http://www.theawl.com/2011/04/inside-david-foster-wallaces-private-self-help-library)
I’ve known artists who actually think that maybe if they get help for their depression, they will be less creative–as though their mental illness is giving them some sort of creative superpower. This could not be farther from the truth. Anybody who has had major depression and come out of it again will tell you that it could not be farther from the truth. The truth is that when you’re depressed, you are not able to concentrate, to think, to have the energy to make your work. When I have a depressive episode, I’m not able to do many things, including physically read or write.
It’s dangerous to imply to a community of creative people that there is any redeeming quality to letting oneself suffer from a health problem. I hope The Rumpus’s readers will be good enough to themselves to seek help, of all kinds, but not just philosophically.
I’ve also never understood the glamorization of depression in the arts. Why do some artists believe that depression is just as conductive to the creative process as being happy, healthy, and whole is? Why should we, as a community, ever praise depression?
Kate,
I applaud what you’ve written – you’ve thoughtfully addressed some of the author’s thoughts and propositions with your own, well-researched input. Certainly, the connection between mental illness and the artistic temperament is one that needs elucidation, continued research, and, importantly, to be taken seriously.
As someone with a proper medical “diagnosis” (major depression and generalized anxiety) who has been afflicted, to varying degrees, with this depression for most of my life, and, as a highly accomplished poet, writer, and professor, I’d have to agree with you that there is absolutely nothing “glamorous” about living with a mental illness. For me, writing is a way to find peace and balance, relief and well-being, and nothing short of a deliberate act of survival. This may sound extreme to some, but I wonder if other bright, highly-prolific “artistic types” who also suffer from a mental illness that has, on and off through their lives, afflicted them in varying degrees — sort of like changes in weather, ranging from slightly cloudy days to a sudden-onset level-5+ hurricane in its ability to inspire, or entirely disable — would describe their depression/bipolar disorder/schizophrenia/etc. as something they enjoy living with.
Should we ask Vincent Van Gogh if the suffering he endured, before he pulled the trigger on the gun that killed him, was “worth” the paintings he made? I wish I could. He might say it was. He might say it wasn’t. Maybe his answer would be somewhere in the middle, and he’d have the levity and generosity to say something to the effect of what Renoir, who painted towards the end of his life in spite of extreme physical pain: “the pain will fade, but the beauty will remain.” If Van Gogh had lived in the 21st century, he may not have chosen to take his own life; chances are that he would have been treated by a psychiatrist and had access to the relief of psychiatric medication to treat his suicidal depression before his life ended so tragically. I’m sure there are those who would argue that he may not have created all of those great paintings had he been taking Paxil, and none of us can know for sure what the outcome of living in a different century would have been for him.
Still, that doesn’t make the extreme suffering of mental illness that many artistic types endure, which can feel something like a hot iron being pressed on your brain, in an emotional kind of way, without respite, something we should, as a society, or even as artists, idealize. This is nothing short of a twisted kind of voyeurism that also continues to perpetuate the ideal of the “tortured artist,” and further demean the types of compassion and support that people suffering from mental illnesses so urgently need from those around them and society at large. The “tortured artist” stereotype, far from nurturing, is one that perpetuates a dismissive and even condescending attitude towards those who are afflicted, that mental illness is something that doesn’t need to be taken seriously: when in fact, it very definitely does, not only for those afflicted, but for the families and society around them.
I was appalled to read that one writer recently attributed, in a published essay, David Foster Wallace’s suicide to an inability to “snap out of it” by going fishing or taking another kind of vacation or “time out.” Severe forms of mental illness – which can so often come and go, again, as patterns not unlike changes in weather – are far beyond a person’s ability to will themselves to somehow change their mood. Even with psychiatric intervention, someone in these depths may have to endure weeks, months, or longer, of the types of intensive treatment which are, so unfortunately, not afforded by the majority of health care plans, and, of course, remain largely inaccessible to those without health insurance. Might we compare someone in the throes of a psychiatric breakdown to someone who’s had a severe stroke, or been in a horrific car accidents? There’s no “snapping out of that,” is there? And there’s no heroism, however culturally-propitiated, in “riding it out” by oneself, without seeking help or treatment. Likewise, easing, if not entirely stripping, the sexiness of “the suffering (depressed) artist stereotype might just help make it a little more okay to be a lot less bent on toughing it out by oneself in a psychiatric crisis.
As a final note: I report, with disappointment, that just recently, I saw a poster on the wall at a highly-respected outpatient mental health facility that will remain anonymous, that said something to the effect of “it’s okay to have a mental illness: all of these great, famous artistic people who accomplished great things also had a mental illness!” I was appalled to note that most of those on the list are also well-known for the fact (omitted on the poster) that they also committed suicide, many at relatively young ages and long before their full body of life works had been achieved/realized.
Sigh.
Can’t we do better than this?
Let’s all help debunk the myth that mental illness is the country club of diseases, some kind of Hollywood or rock star of the panoply of the huge range of afflictions of body, mind, spirit and health that exist and touch all of our lives in one way or another. It’s not. Backstage, and beneath the makeup and glitter and loud amplifiers, it’s human, and it hurts, and it cripples, and it kills, just like anything else. Let’s all seek to give it the respect and support that it not only deserves, but merits, just like any other illness or disease. It’s high time for the relationship between artists and mental illness to be re-considered, no matter however glamorous the “tortured artist” costume might be to some.
we used to have town drunks and village idiots, too. ah, for the goode olde days of humours.
I think a lot of this discussion is missing the clear distinction between melancholia and clinical depression I thought was clear in the article.
I have generalized anxiety disorder (Klonopin) and talking to the pill doctor one day he said I had a “melanchonlic personality.” I immediately scanned his shelves for a jar of leeches. But he was right. He put me on various serotonin management drugs but I was not pleased with a side effects. (Anorgasmia and prolonged erections? At my age? Is this healthy?)
My worst symptoms of depression was the desire to take a nap or go to bed early, maybe not to read or do other pleasurable things. (Anhadonia, and only episodically). And I have good reasons to feel depressed: a fractious divorce from someone who should be on mood stabilizing drugs with manipulation of the children, etc.; severance from my job at age 54. Hell I was *entitled* to be episodically depressive, and it wasn’t affecting my ability to function at work or to write.
I finally got off of them for a while and was doing perfectly fine. I went in one day and told him I had figured out why I was sometime symptomatically depressive: I was “crashing” from an panic/anxiety episode. I grew up in the 70s and lets just say I recognize the condition. (At this point he had me on klonopin and lamotragine, an anti-convulsent used for manic-depression and off label for anxiety disorder mood management). When I told him my epiphany about crashing he said, “let’s try a little citalopram.” . I slumped and took the presecription, but only after he assured me it was not related to the seronotin drugs. I know one local novelist taking SSRIs for fibromyalgia that she simply couldn’t write on the drugs and stopped taking them. I was having the same experience on them, and on the cocktail I was on.
I will always need the klonopin. GAD runs in my family, I have it since I can remember–up to the full blown panic attacks that feel exactly like a heart attack–and I think this is as analogous to diabetes as prolonged and not episodic clinical depression. Yes, I could probably function without the klonopin but why suffer?
I can live with episodic melancholia. I believe it does play a role in my creative life (as does the mildly manic side of my personality that can blossom into anxiety and panic). I think the point here is the way we are over-medicating people at the margins of clinical depression, using drugs which big pharma and the doctors don’t really understand the actual workings of.
I think it’s time to post the piece I’ve worked on on-and-off for the last two months, “Confessions of a Pill Eater,” up to the blog.
Anyone commenting on this ‘tortured artist’ business is misrepresenting the writer and missing the point of the essay
I’m with Kate Abbot. Essays like this promote the idea that those of us who take medication for debilitating depression are weak, that we are telling a made-up story about our experiences.
Yes, there’s overmedication. Yes, grief is important to feel and process. Yes, sadness and grief and sorrow are part of the human experience, and not something to medicate away.
But depression (which is beyond grief, or sorrow, or sadness) is a crippling condition. It is pain and grayness and despair. It is disordered thinking, it is an inability to see reality as it is. It is, very often, a terminal illness, one that results in suicide because the pain is too much (and because we lose the ability to see or understand that others care about us and find us valuable).
I’m a writer who used to not write because of my “melancholia.” I wrote when I was forced to (grad school), or felt some sort of divine excitement moving in me (mild mania). But I didn’t sit down to write for real, for earnest, until I broke down and got on the lowest dose available of Prozac. I’m stable now–I can work almost every day, no matter what, and that debilitating edge of anxiety is gone. (I also combine it with yoga, exercise, and diet.) I’ve had writing residencies, I’ve had interest in my novel, nearing completion, and I have a large-ish body of work that’s about ready to go out–and all because I finally got the steadiness of mind that I needed. SRIs are miraculous drugs. They saved my nephew and neice’s life (abusive dad), and a close friend of mine managed to get out of the depressive trough he was in and find a wife thanks to Lexapro. Meanwhile, I’m living with stage 5 kidney disease and looking at a transplant; without the Big P, I’d be seesawing between despair and “wanhope.” With it, I can interact with non-depressives, write, and do what I have to do to survive. And, believe it or not, they don’t kill creativity or turn one into a smiling zombie. Not even close.
This. http://www.thevine.com.au/life/thoughts/against-depression/
I agree with Ealasaid
Caitlin – that is a great essay, great response to this article. Thank you.
” With equal veracity, we could say that depression is fundamentally human. We could argue that a touch of it, however unpleasant, is a fitting response to some of life’s enduring questions and society’s intractable problems.”
I still think there is a little righteous indignation clouding what the essay really says. There is a difference between a melancholi disposition my (my pill doctor, the 30 minutes if that maintenance and prescription guy) used that term, whether clinically or as short hand for something in the diagnostic manual. I was seeing him about anxiety disorder, not depression. I complained of intermittent depression but I have damned good reasons–a bitter divorce, getting severanced at age 55–but he insisted I add anti-depressants. Later he added an anti-convulsent (lamotrigine) off label, which is usually used to epilepsy and also for manic-depression. He was trying to eliminate my “melancholic temperament” which in no way resembled bleak, clinical depression. It began to affect who I was. Friends became concerned. I became somewhat reclusive. I stopped writing.
I was being treated for fucking melancholy and episodic depression as if I were in fact clinically depressed. I need to be treated for Generalized Anxiety Disorder for the rest of my life. It runs in the family. Sometimes the panic attacks exactly mimic a heart attack which of course just forces my body deeper into panic. I need my klonopin as much as many people here need their anti-depressants. Perhaps I just read this article differently that others. Yes I’ve read every word about David Foster Wallace (the current cause celeb in this debate) and John Berryman (probably my favorite poet). There are people who clearly need medical help. But then again there is a body of people, many of them creative, who’s worke is fueled by a melancholic disposition or by the maniac side of GAD. I think that’s true in my case of both. Then there are people who are far enough off the scale to require medication (as I do got GAD).
http://toulousestreet.wordpress.com/confessions/
Several years ago my doctor asked if I was anxious about anything. At the time I was experiencing a lot of turmoil at work, but I thought that was just a normal thing. He put me on very low-dose citalopram. I had the common side effects of several weeks of mild nausea and slowed sexual response. They passed with time, and I was gradually aware that my mood was more stabilized, and that gradually things going haywire seemed to bother me less.
I had a conversation with the senior warden at my church; she is a mental health professional familiar with drugs and their uses. I found out something that seemed applicable to me: that children who grow up in high-stress environments undergo a permanent “rewiring” of the brain that affects their emotional health. From the time I was seven years old I was, along with my father, a primary caretaker for my mother. Both of my brothers bailed out and joined the Air Force as soon after high school as they could; that left me with my crazy-maker mother. She had had polio when she was sixteen, and started developing multiple sclerosis ten to fifteen years later. The MS remained undiagnosed for many years, even as she lost the ability to walk or even hold a fork or a spoon, and developed vision and speech difficulties.
She used her illness as a weapon to control my father and myself. She was manipulative, jealous, controlling, demanding, and hateful. She and my father would get into vicious fights over the infidelity she was sure he was guilty of; she and I would get into fights over trivial matters, and she would tell me to “get out of the house.” Never mind that I was still in grade school! Nothing was ever done well enough to please her. And sometimes the rage would come spilling out of my father, and I would be the target of a beating far out of proportion to whatever I had done. When I was nineteen, I finally grabbed my father’s hand when he was about to strike me and said, “Don’t you ever do that again!” That brought him up short. But it was still six years before I escaped their house, I had been so manipulated to not believe in my own strength.
It took me years to recognize how I had been harmed; therapy helped. It’s over thirty years since my mother died, and I still keep coming to new realizations.
I am grateful for medication, even at a low dose, that has helped me feel “normal” at last, and that has helped me to know that for years I was under the cloud not of “melancholia” but real depression of which I had not been aware.
Thank you all for the intelligent comments. It saddens me that some of you have found this essay to be hurtful and backwards. I feel called upon to try to put into words what I was after in it.
On the most basic level, I’ve always been fascinated by old historical accounts of depression. It has always interested me how depression is both historically durable (people have been feeling it forever), and historically malleable (probably the experience itself, and certainly what people make of it, can vary depending on the culture that you’re in). To me that stuff is just inherently challenging and engaging, and I hoped to convey some of that simple excitement in the essay.
I also wanted to point out that even though we don’t always think of it this way, our modern belief that depression is a physical disease is also an account. It isn’t as scientifically proven as it is often made to sound. And though it’s been presented to many of us as *the truth,* it is in many respects a cultural product, just like those older versions.
That doesn’t mean that depression doesn’t exist or isn’t serious business, or that the disease model is wrong or useless. I know that many people find it incredibly helpful, empowering, uplifting. And I respect that deeply.
But I also know that the disease model doesn’t work the same way for everyone. While some find it empowering and comforting, it strikes others in just the opposite way. They find it discomfiting, overwhelming, and—ironically, since it is often touted as removing stigma—stigmatizing. (I’m one of those people for whom it really didn’t work; there’s more on that in my book.)
The point isn’t that one reaction to the disease model is correct and the other incorrect. But it does concern and irritate me that this model has been presented so widely, often in a very over-simplified, unsophisticated form, as objective fact. I wanted to point that out, put it in context, ask why we define depression in this way and what’s at stake when we do. I believe the biomedical model of depression has been oversold and overly reified. It has done some good, as many comments here attest. But in my opinion it’s also created some problems of its own. For one thing, I think it’s sometimes applied too widely. For another thing, as a wise scientist said to me once, even presuming a strong biological component to mental disorders, the fact is that treating them is not as simple and straightforward as treating colds or infections. If we take the disease model as an excuse to pretend that it is, then most people will not be getting the quality of care that they need.
What I didn’t want to do was argue that some particular older model of depression was superior or more correct. Nor did I want to glamorize depression in itself. My whole point was that the depression story can be told in a variety of ways, and that different ways of telling appeal to different people and meet different needs. Yes, I like reading history and reminding myself about the power of social construction. Yes, there are aspects of certain older ways of thinking about depression that appeal to me, at least as ideas. And I’m not into guesswork and metaphor masquerading as good science. But do I really want to live in the Middle Ages? A thousand times, no.
I didn’t want to argue that depression isn’t real or that there’s no difference between it and ‘ordinary’ sadness—even if I did want to pick away a little at the claims of those who say they’ve got this difficult question all figured out.
And I definitely didn’t want to argue against the use of medication. I’m not against medication. I don’t think that simply embracing depression can somehow magically make it go away, or sublimate it into creative power. I don’t think that depression is always useful or worthwhile to feel or laden with wisdom for us. I am also not into policing the question of “need” when it comes to medication: I think people should use medication if they want to, if they feel it helps them, and tell anyone who casts aspersions on that to mind their own damn business. Medication can be empowered and empowering.
I believe we should fight against depression by all the means we can devise. Not everyone’s means will be the same, though, and the stories we tell ourselves about what we’re doing in this fight won’t be the same, either. I think the availability of different stories and the freedom to craft, from the bits and pieces available, the one that works for us, is a beautiful thing. And a sense of that freedom was what I was trying to get at, however awkwardly, throughout the essay and especially at the end.
In hindsight, the title was probably too cheeky, and I guess I’m just going to have to live with that. Even though it’s been comforting to me in recent years to think of depression more as an outgrowth of my otherwise-pretty-great personality than as an alien invader, I don’t truly think that depression in itself is worthy of praise, or that there’s virtue in just giving ourselves over to it when it comes. But I know, I know. No takebacks.
Finally, as further reading on the history of the concept of depression and a well-reasoned critique of the disease model, I recommend ‘The Loss of Sadness’ by Allan Horwitz and Jerome Wakefield, who put a clear, elegant, and scholarly spin on many of these ideas.
Katherine, thank you for explaining your thought processes behind the essay, and for being so gracious about those of us with complaints.
I think part of what clouds the matter (at least for folks like me) is how often people get criticized and condemned for using medication or for having depression at all — a lifetime of snide, belittling, and sometimes downright nasty comments can make it very difficult to approach any attack on the disease model of depression with anything resembling objectivity or generosity of spirit. This baggage isn’t your fault, but that doesn’t mean it isn’t bumping along behind me, banging my ankles and making me cranky.
I’m a massive bibliophile, and will check out The Loss of Sadness, thank you for the recommendation.
I enjoyed the article, thank you Kathrine.
It’s all in the interpretation. Each interpretation of what we read is deeply personal and related to our own world of experience. Rather than judge what is written by another, just remain open and learn. There is always more to learn.
Hello Katherine, I also appreciate seeing your comments here on this active discussion thread. I’d also like to apologize if I sounded harsh in my comments posted on Aug 14. It certainly wasn’t my intention to sadden you, and in fact I did take another long look at your essay, and plan to also read your book.
I’d also like to say here is that you have done a commendable job in bringing forward a great entry into appears to be a very important topic. Just look at all of the comments your story has generated just here on Rumpus!
I’ve been perusing various sources to learn more about depression, in the past few days….looking at dictionary definitions, doing google searches on keywords associated with depression, medication, psychiatry, etc., and realize that more than anything, there is much work to be done in the field of depression of understanding, educating, living with, medicating, and most of all, articulating. It’s inevitable that different people will have different ideas, approaches, and discussions in what I hope to see as an evolving, and widening, and necessary discourse. Something as slippery yet tenacious as the evasive nature of depression itself merits, more than almost anything else I can think of, the skills of our finest writers, along with the availability of evolving medical research.
Here’s to a continuing and lively discussion….and thank you for your work.
Think about depression as a spectrum with severe depression on one end and ecstatic joy at the other.
Most humans exists somewhere in the middle in a bell curve distribution.
At the extreme end of major depression, it borders on suicide. It needs psychiatric hospitalization.
Many more people exist on the milder form of depression.
I believe modern society with its anxiety and disappointments skews the curve to sadness.
Depending on how severe your depression is, you may benfit from prozac or other antidepressant treatments.
See also: Madness & Civilization by Michel Foucault.
Katherine,
Thank you for clarifying some of the points from your original essay.
While I agree that science has yet to explain exactly how antidepressants work, it is also true that science cannot really explain how acetaminophen works to relieve pain and yet one would not say that the disease model of pain is oversold.
In addressing the idea of the disease model of depression, I agree that thinking one has only to prescribe an antidepressant to a person and have that person be magically healed is an oversimplification and not necessarily supported by the data. As is so often the case, the data are conflicting about which treatment is superior or if a combination of medication plus psychotherapy is the most effective. However, the fact that depression can respond to treatment other than medication does not imply that a disease model is wrong. There are other diseases that respond to treatments other than medication such as Type II diabetes, heart disease, and chronic migraines. These are all conditions that can benefit from so-called “lifestyle changes” as well as medications and I doubt that many people would hesitate to call them diseases.
In terms of the connection between serotonin and depression, I agree that while serotonin is not the whole answer (which is why there are antidepressants that target the dopamine and norepinephrine systems as well), it most certainly is part of the answer. A very basic search of pubmed (a database for biomedical articles) will point you to a large number of articles linking a gene associated with the serotonin system to depression. Many of these articles also look at environmental causes of depression, but that does not negate the fact that serotonin is involved somehow.
For these reasons (and many others), I disagree with your argument that the physical disease model of depression is oversold. I feel the problem is a bit more complicated than that and stems from the idea that as a society we seem to think that treatment of a disease (any disease) can and should be accomplished by taking a pill. This is seen in other areas of medicine, too, such as the demand for antibiotics in situations where the disease would resolve on its own or when the disease is clearly viral and therefore not affected by antibiotics. However, we would not say that because a virus such as a cold cannot be cured by a pill or that treatment with decongestants isn’t making you feel better or that behavioral changes can make the duration of the cold shorter a cold is not a disease. And, perhaps, a having a slight cold cannot be described as being a real burden or can actually be beneficial because it makes you realize that maybe you’ve been overdoing things and should take a little break, but, again, that doesn’t mean a cold is not a disease.
Finally, as you have pointed out, the disease model of depression can be both empowering and problematic. Instead of having “laziness” or “no ambition” or any number of other character flaws, you can say, hey, I have an actual disease. You wouldn’t say to a person with cancer, “Hey, you can stop the growth of the tumor anytime you wanted to,” and neither can you say to a person with major depression, “Hey, you could get out of bed anytime you wanted to.” And for many people I know, just knowing that they have something specific, that they can point to a cause of their problems makes them feel significantly better. However, one often trades the stigma of having a bad character with the stigma of having a disease. And, laziness does not get you denied life insurance, but having major depression can (ask me how I know). So, no, being able to say that depression is a disease doesn’t necessarily make a person’s life easier. But, unlike thinking that depression is “all in your head” I think the disease model does more good than harm.
Thank you for this thoughtful article and comments…such a joy to read respectful and careful dissent, much more articulate and reasoned that I can be. I have fought depression all my life and nearly lost my life to it post partum; I don’t know if people who haven’t experienced it have any idea of what it is like. At any rate I finally gave in to my therapist’s urging to try 20 mg of prozac a day. It’s my inner ninja, deflecting the demons and keeping me up on my feet…thank god for it. But I also understand the worry about the effects of these drugs on young people and the need to examine all aspects of their use, so thank god also for sensitive forums such as this one.
Elisabeth,
I feel you are adding some excellent and well-substantiated ideas to this discussion. To add more to your thoughts, I’d like to note that for many people who are afflicted (for lack of better word) with a mental illness in one form or another, there is an incredible amount of merit to the argument for strengthening the “disease” model of depression/mental illness, if for this reason alone: for employee rights in the workplace, for medical benefit rights, for civil rights, legal rights, and so on.
I, like many other people, I’m sure, sometimes face a difficult and cruel dilemma in our workplaces: that we very often can’t disclose the nature of our illness/condition to our employers because we will lose our jobs. Others can openly and, most importantly, safely disclose medical conditions that necessitate some accommodations on the part of the employer – such as reduced hours, etc., – including but not limited to conditions such as chronic fatigue syndrome, which is, like depression, also a nebulous and difficult to *prove* illness.
Nonetheless, someone with chronic fatigue syndrome, in my workplace, isn’t going to lose their job based on the criteria set forth in my workplace collective bargaining agreement; however, the language is just slippery enough, in the same worker’s contract, that someone with depression would be ill-advised to say anything about their illness, and ask for any type of accommodation for it.
I’d like to see a world where mental illness can come out of the closet, to be taken seriously enough to warrant social compassion and support, along with legal protection, rights and more resources for those who experience it. The idea is to build on treatment and support, so that people who experience it in its many different forms (whether the individual feels it’s an illness or chooses to identify it for oneself as a gift) can live lives that are as healthy and productive (even artistic!) as possible.
If I could, I’d run from depression as far as I could. I’ve tried. But the shadow, sometimes faint and sometimes dark, never really disappears entirely. I like to think I’ve tamed it, that it informs my work, and it does on many days. But it also sometimes catches me off guard and knocks me off my feet. It’s part of who I am, and I don’t feel ashamed, nor would I say that, 95% of the time, do I feel sick. I feel that the great majority of people who know me would be shocked if I said the words “me” and “depression” in the same sentence. Undoubtedly, depression has, for all of its anguishes, done me a lot of good, as well, because it’s informed so much of who I am, what I write, how I live. And I think I have a pretty cool life!
And so, I’d have to say that I am in favor of working with depression, and not against it. I am in favor of continued medical research that will hopefully develop new and better forms of treatment and insight into the biological and social causes of depression. This doesn’t mean that I vote for pathology, nor do I vote for brushing depression off as some kind of designer illness du jour. There’s a balance somewhere in all of this, and I’m holding out for that….
This was an interesting an thought-provoking article. Still, it’s not a matter of what stories we tell ourselves. There is a real physiological, physical, and functional reality to depression, albeit incompletely understood. That pharmaceutical companies and doctors oversimplify and overprescribe does not change this reality.
As mentioned by others, there’s an abundance of studies showing physical changes in parts of the brain, differences in levels of neurological activity, genetic linkages, and rates of brain cell regeneration with depression.
It’s hard to imagine that anyone who has experienced profound depression could imagine it’s not an illness. Psychiatrically it’s classified as a “mood disorder” but in reality it’s a full-body experience, draining the sufferer of energy, blunting the senses, and producing a general and overwhelming physical malaise.
Maybe it’s not the actual level of serotonin or other neurotransmitters. Perhaps it’s a change in those levels, a deviation from what’s normal for that individual.
Yes, drugs are probably overprescribed for mild or misdiagnosed cases. Nonmedical factors are neglected in typical U.S. healthcare. Personal history, diet, exercise, social contact, talk therapy, exposure to sunlight, and good sleep hygiene all affect depression but, as noted, this is completely consistent with the medical model.
One point of caution not mentioned so far – in some individuals, SSRIs themselves can produce a sort of apathy that, while less painful than depression, can itself interfere with an individual’s ability to be productive and engaged in life.
Science is predicated on the assumption that there is such a thing as reality — it’s not all a matter of opinion, of how you look at things. Implying that any and all stories we tell ourselves are equally good is not helpful. I did find this article interesting and helpful though. The historical background gave a good overview of the roots of some our misunderstandings, and illustrated in many ways how far we haven’t come.
I find this essay to be an oversimplification of an extraordinary complex topic. Perhaps the problem is this essay seems to be a summary of a full-length book. I do plan to read this book, because the historical perspective and “stories” about depression are fascinating. I wish this essay concentrated on this aspect.
However, when you state, “viewed from the distance of history, it’s our current understanding of depression that looks odd” – could it be, because we have the tools to begin the of study of clinical depression in a more detailed and exacting way not available in previous times? You say odd, I say revolutionary.
When you say, “But we are unique in our belief that even a touch of melancholy is a sickness. We’re even unlikely to admit to shades of degree: depression to us is a binary proposition, something you either have or don’t, something that means illness and never anything else or more.” That is indeed a story or perhaps, more like advertising from the media, but as such, has very little to do with the physical disease model of depression, whose main importance imho, is the study and research into things we do not know – yet.
You talk about stories and historical perspectives about “depression”, which is really interesting, but then you make a statement that is just as naive as the drug companies “chemical-imbalance-take-a-pill-for-feeling-blue,” and that is, “depression is not a disease like diabetes.” Sure, neither is schizophrenia.
It’s the things you leave out in this essay, that point to a bias, and an inkling that this isn’t just about stories.
Finally, when you say, “Depression has had a tough thirty years of it” please understand that that may be a little too tongue-in-cheek for people who suffer from clinical depression.
Melancholia is NOT depressions. It is a common and normal state sometimes found in each of us as a normal reaction to life events. And, yer, there ARE personality types predisposed to it. That’s all normal.
Depression. Not feeling a little down. Not feeling low or sad. Not even crying real tears. Depression. Real and true depression. One of the most insidious, destructive of disorders. So little understood even by the professionals who claim to treat it.
Real depression is devastating. It lays waste to lives, to relationships, to hopes and dreams. Not just those of the depression sufferer. It destroys families, friendships, loves and relationships. It affects everyone it touches including the loved ones of those who suffer it’s destructive effects.
I can not describe what depression is to others but I can tell you what it is to me. First and foremost it is extremes. It is everything taken to extremes. It is sadness but sadness to the extreme, the bottom of the pit. It is hot burning tears rolling down your cheeks and you don’t know why. It is hopelessness taken to it’s extremes, to the point where even the hope of hope becomes an impossibility. It is crazy, insane thoughts, the urge to take your own life. It is worthlessness, despair taken to it’s limits, self hatred and self despite beyond anything I can even begin to describe. It is the black pit of hell come to suck you in, alive if necessary but all the better if dead. It is a total and complete loss of energy, of will power, of the will and drive to live. It is pain taken to a new level. It’s the inability to focus because the pain blinds all. It is heart wrenching, soul rending, mind blowing in it’s intensity. It is unreasoning, it needs no reason to be. It just is.
It is NOT something you can just get over. You can’t just snap out of it, keep yourself busy to keep your mind off it. It’s impossible to simply deal with it and continue to live. It’s not something that you can grab yourself by the bootstraps and drag yourself out of. Regardless of what some may think it’s not something you’ve talked yourself into. It’s not something you WANT to be. You’d move heaven and earth to make it stop. It’s not a state of mind that you’ve worked yourself into. While life events may serve as triggers they are not the root cause.
These reviews and insights into depression were very helpful for me. Although I am a seasoned software engineer, I got another degree in Psychology to help discover the reasons why I felt so bad when things were really quite good in my life. Growing up in the 70’s, if you were on any drugs for anything other than an infection or a broken bone, you were considered crazy. Divorces were common when an older woman just went “crazy” and families were ashamed for having any crazy relatives. It was and still is considered a shameful choice to not be right in your mind and to let a little mood swing alter your life. Those were the thoughts and mind set of my entire family and until I found a great psychiatrist and was finally put on the right medications, my life was spiraling out of control. Reading these articles and then replying with my own thoughts and hidden shame was very cathartic – so thank you to all who contributed. To this post!
Articles like this cause a lot of hurt and do a world of damage. If you are fortunate enough to have a “nice place” to live, just enjoy your good fortune. Don’t tell the less fortunate that they should just enjoy life like you do. After all, you wouldn’t tell an amputee to just go out for a nice long run with you
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