Against Depression

Praise for Peter Kramer’s

Against Depression

[Kramer] may have done more than anybody else to illuminate the clawing, scabrous, catastrophic monotony that is depressive illness….[An] eloquent, absorbing…book.

—The New York Times Book Review

"[Against Depression] successfully advances the cartography of a (quite literally) gray area between physical and mental illness."

—The New York Times

Kramer examines depression with a cool, intelligent and sympathetic eye.

—The Washington Post

Kramer presents a powerful argument against romanticizing (and thus tolerating) depression.

—People

By turns poetic and academic, and always deeply felt, [Kramer’s] book is a polemic against a society that accepts depression as a fact of life.

—O, the Oprah Magazine

[An] ambitious new foray into the always roiling nature versus nurture debate…. [Kramer] is a lucid and shrewd popularizer of complex ideas.

—Elle

Heartfelt…[Kramer] explores the gap between common perceptions of depression and the scientific understanding of it…. While not predicting that depression will be eliminated any time soon, Kramer brings hope to those afflicted by it. A clear, valuable exposition of the progress researchers are making in understanding an all-too-common disease.

—Kirkus Reviews

A provocative take on the science and mythology of depression.

—Seattle Post-Intelligencer

Highly recommended.

—Library Journal

Kramer’s curiosity drives the book forward as he ponders why we value artwork and literature built on despair…. The book maintains the perfect balance between science and human interest…. An important addition to the growing public health campaign against depression.

—Publishers Weekly

A paradigm-shift…The book has the power, I think, to defang depression, to open eyes to how it is both more than we thought, and less.

—Detroit Free Press (one of the Ten Best Books of the Year)

Peter Kramer is an analyst of exceptional sensitivity and insight. To read his prose on virtually any subject is to be provoked, enthralled, illuminated.

—Joyce Carol Oates

Here one of our most thoughtful psychiatrists attends a wide-spread psychological malady—the bouts of melancholy that afflict so many individuals, laying them low in mind and spirit. This book offers much critical wisdom, even as it is written with a grace and sensitivity that will endear its words to the reader.

—Robert Coles, professor of psychiatry and medical humanities, Harvard Medical School

"In Against Depression, Peter Kramer opens our eyes once again to a fresh, important, and humane understanding of the human condition. His bold rethinking of the inner state we call ‘depression’ gives us a clear scenario for freedom from the grip of this soul-searing disorder."

—Daniel Goleman, author of Emotional Intelligence

Our treasured sense of self is often challenged by neuroscience—how do you wedge ‘Self’ in among neurons and synapses and neurotransmitters? No one has written about [our sense of self] in a more sensitive, thought-provoking and accessible way, and has touched more people in the process, than Peter Kramer.

—Robert Sapolsky, professor of biological sciences, Stanford University

There is nothing romantic in the suffering of depression. Kramer shows us the horrific reality of the illness, dispelling myths that pervade popular culture. This book should usher in an era when the disordered chemistry of the brain is viewed with the same concern and care that mark the treatment of any malady.

—Jerome Groopman, M. D., Recanti Professor of Medicine, Harvard University, and author of The Anatomy of Hope

PENGUIN BOOKS

AGAINST DEPRESSION

Peter D. Kramer, a clinical professor of psychiatry at Brown University, is the author of Should You Leave?, Moments of Engagement, Spectacular Happiness, and the international bestseller Listening to Prozac. Dr. Kramer is also the host of the public radio mental health program The Infinite Mind. He lives in Providence, Rhode Island

Against Depression

PETER D. KRAMER

PENGUIN BOOKS

PENGUIN BOOKS

Published by the Penguin Group

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First published in the United States of America by Viking Penguin, a member of Penguin Group (USA) Inc. 2005

Published in Penguin Books 2006

Copyright © Peter D. Kramer, 2005

All rights reserved

THE LIBRARY OF CONGRESS HAS CATALOGED THE HARDCOVER EDITION AS FOLLOWS:

Kramer, Peter D.

Against depression / Peter D. Kramer.

p. cm

Includes bibliographical references and index.

ISBN 978-1-1012-0114-5

1. Depression, Mental. 2. Depression, Mental—Treatment. I. Title.

RC537.K725 2005

616.85'27—dc22 2004061228

Except in the United States of America, this book is sold subject to the condition that it shall not, by way of trade or otherwise, be lent, resold, hired out, or otherwise circulated without the publisher’s prior consent in any form of binding or cover other than that in which it is published and without a similar condition including this condition being imposed on the subsequent purchaser.

The scanning, uploading and distribution of this book via the Internet or via any other means without the permission of the publisher is illegal and punishable by law. Please purchase only authorized electronic editions, and do not participate in or encourage electronic piracy of copyrighted materials. Your support of the author’s rights is appreciated.

For Grossmutti,

the Omas and the Opas,

and Eric and Lore

Contents

Prologue

What It Is to Us

1. The Final Memoir

2. Return

3. What If

4. Ambivalence

5. Altogether

6. Charm

7. More Charm

8. Eros

9. Obvious Confusion: Three Vignettes

What It Is

10. Altogether Again

11. Getting There

12. Magnitude

13. Extent

14. Convergence

15. Resilience

16. Here and Now

What It Will Be

17. The End of Melancholy

18. Art

19. The Natural

20. Alienation

21. After Depression

Notes

Index

Prologue

I HOPE THAT THIS BOOK will prove helpful in ways that are concrete and immediate. I mean, helpful to people who have decisions to make about depression—whether and how vigorously to treat it, in themselves or in someone they love. Certain chapters can be put to that sort of use. Sometimes I tell stories from my practice, in order to say how depression looks to a doctor who tries to lessen the harm it does. I discuss recent research and biological treatments, practical and visionary, to bring into focus a new picture of depression, as it is emerging in contemporary science.

But I think it only fair to say up front that this book is less about what to do, here and now, than about meaning. How do we understand depression? How shall we address it? On these issues, I take a decided stand. I have written a polemic, an insistent argument for the proposition that depression is a disease, one we would do well to oppose wholeheartedly.

You may think that we have no need of such an argument. Increasingly, our governments, state and federal, require that depression be accorded full status as a disease, for purposes of insurance coverage and disability determination. Public health groups wage campaigns against depression. There can be no controversy over a belief we already own.

But I think we do not own it, not in the sense that we own the belief that cancer is a disease, not automatically and intimately, as a habit of mind. There is a perspective on depression that I call what it is to us, by which I mean, among other things, what we seem to be saying when we reveal our thoughts unthinkingly. We may find ourselves claiming that an episode of depression is justified, in a way that we would not call a bout of asthma justified, even when the cause is clear. We associate depression with a heroic artistic stance, one we think humankind might be worse off without. We admire traits that can accompany depression, such as alienation, without asking in each case whether they constitute aspects of an illness. That we often seem to value depression is part of what leads me to believe that, in terms of what it is to us, depression is not disease altogether. Of few other diseases can it be said that to reframe their significance is to confront what we should and do care about as we try to live good lives.

It is in the nature of polemics that they arouse objections. Reading, we protest: but, but, but…. Occasionally, here, I pause to debate opposing views. More often, I remain fixed in the effort to convey an individual perspective, what it is to me, as a person who has had many encounters with depression in those I care about, both in my role as a psychiatrist and in my private life. Now and again, my polemic has the form of memoir. Sometimes, I lapse into science fiction, imagining a society that has conquered depression.

Throughout, my interest in meaning—what are we to make of depression?—has shaped my choice of subject matter. For example, I say less about psychotherapy than about medication. I hope that it is clear from my case vignettes, and from the research findings I do mention, that psychotherapy retains an important role in the treatment of depression. But while most recent studies of psychotherapy have been reassuring—they confirm what was already well established, that different types of therapy work—to my reading, they have not been evocative. They contribute only marginally to the new scientific understanding of depression, the perspective I call what it is.

Equally, I have held back on discussing certain innovative bodily interventions. These include stimulation of the brain, through magnets or electric currents. The novel treatments may prove useful; but so far the research they have inspired has not affected our views about the disease.

In general, one criterion has guided my selection of research findings: does the material alter fundamental beliefs about depression? Studies reported in the last ten or twelve years have transformed the prevailing theories of mood and mood disorders—and thereby widened the distance between what it is and what it is to us. That gap, between science and values, is my topic.

About word choice: For the most part, I honor the distinction between disease, a pathological condition of an organism, and illness, the poor health that results from disease. But I am not overly scrupulous about this distinction, a tendency that I think is excusable in the case of what we call a mental illness, where we mean a disease that affects the mind. Also, for variety, I sometimes write mood disorder where I mean depression. In psychiatry, mood disorder can refer to a broad range of conditions, including anxiety states as well as manic depression and its variants, the bipolar affective disorders. In this book, the phrase mood disorder almost always means depression; the few exceptions should be clear in context.

Speaking of which: depression, in this book, refers to what psychiatrists call unipolar major depression, the condition characterized by extended episodes of low mood, apathy, diminished energy, poor sleep and appetite, suicidality, loss of the capacity to experience pleasure, feelings of worthlessness, and similar symptoms. I discuss bipolar affective disorder only in passing, in a consideration of heroic melancholy and creative genius. There is just too much to think about as regards depression, narrowly taken. As I put down my pen, I am in despair about how much I have left out.

Even more than has been true in my writing other books, I have composed this one in the course of conversations with colleagues. Ken Kendler tolerated regular telephone consultations for the many months in which I was assembling my thoughts about new scientific studies of depression. The following scholars and physicians were generous with comments, information, theories, drafts of unpublished manuscripts, or the sharing of preliminary research results: Bruce Charlton, Dennis Charney, Paula Clayton, Ronald Duman, Carl Elliott, Anna Fels, Philip A. Fisher, Alice Flaherty, Alexander Glassman, Alan Gruenberg, David Gullette, Leston Havens, David Healy, Stephan Heckers, René Hen, Steven Horst, Ronald Kessler, Donald Klein, Brian Knutson, K. Ranga Rama Krishnan, Lisa Monteggia, Charles Nemeroff, Dennis Novack, Harold Pincus, Paul Plotsky, Grazyna Rajkowska, Johan Schioldann, Yvette Sheline, Michael Stein, Craig Stockmeier, and E. Fuller Torrey. I have been aggressive in shaping disparate scientific studies into a coherent story about what depression is. Any mistakes I have made are my own.

Chuck Verrill, my literary agent, shepherded this book from its inception in the days following the 9/11 attacks, when all publishing efforts seemed uncertain. Pam Dorman, the executive editor at Viking Penguin, maintained her faith in the book at every stage. Beena Kamlani’s editorial contribution cannot be overstated. She encouraged and confronted me, in her kindly manner, at every juncture and at every level of composition.

Against Depression is the fifth book that my wife, Rachel Schwartz, has seen me through. Only she (and sometimes I) can appreciate how much tolerance, grace, and patience have been required.

My parents, my grandparents, and my surviving great-grandmother came to this country as émigrés from Hitler’s Germany, just before and during World War II. In their lives and in their persons, they demonstrated—and in my parents’ case, continue to demonstrate—that resilience can coexist with a full measure of emotional complexity and depth. With love, with gratitude, with admiration, I dedicate this book to them.

What It Is to Us

One

The Final Memoir

SHORTLY AFTER THE PUBLICATION OFListening to Prozac, twelve years ago, I became immersed in depression. Not my own. I was in my forties and contented enough in the slog through midlife. But mood disorder surrounded me, in my contacts with patients and readers. Messages from parents with depressed children and husbands with depressed wives filled my telephone answering machine; letters dense with personal history crammed the mail slot. In their volume, in their particularity, these contacts were sobering, overwhelming, disorienting. Less intimate overtures came my way. Reporters and talk-show wranglers approached me about the significance of drug company initiatives, antidepressant-related lawsuits, and mental health legislation. Colleagues invited me to join colloquia on particular therapies. Advocates of partisan views of mood disorder e-mailed me with propaganda, asking me to sign on.

Immersion has a passive sound to it. I experienced my relationship to depression in that way, being swamped by a tide. I would have denied that I had brought this condition on myself. Yes, in my book I had discussed depression—but only en route to raising issues that stood at some distance from the treatment of mental illness.

Listening to Prozac grew out of a claim that certain of my patients had made: On this medication, I am myself at last. These men and women had taken an antidepressant and experienced a dramatic response. Their episode of depression ended—and they reported another change as well. Temperamentally cautious and pessimistic, even before their first encounter with depression, these patients moved, on medication, toward assertiveness and optimism. This self-assured state, so they believed, represented their identity, themselves as they were meant to be.

I had used this report—myself at last—as a jumping-off point for speculation. What if future, similar medications had the potential to modify temperament in people who had never experienced mood disorder? There were reasons to believe that even current antidepressants might sometimes alter personality traits, making the hesitant decisive. Given access to such drugs, how should doctors prescribe? The inquiry moved from medical ethics to social criticism: What does our culture demand of us, in the way of assertiveness? Assessing my patients’ attitude toward antidepressants required, I thought, attention to grand, perennial questions. How do we identify true self? Does the path matter, in the journey to contentment?

It was the medications’ extra effects—on personality, rather than frank disease—that provoked this line of thought. After all, for centuries, doctors have treated depressed patients, using medication and psychological strategies. When those efforts succeed, restoring health, we are grateful. The ethical dilemmas that interested me lay elsewhere. Strange though it may sound, I never imagined that I had written a book about depression.

But authors cannot predict or control the fate of their books, any more than parents can determine the direction of their children’s lives. Listening to Prozac emerged into an era of marked interest in depression. Everything about it had the power to fascinate: diagnosis, treatment, health care politics, gender issues, intimate experience. When Listening to Prozac found readers, it became the best-selling book about depression. In stores, it was shelved beside how-to manuals on recovering from mood disorder or living with those afflicted by it. I had never intended for my book to be useful. But readers wrote to say that Listening to Prozac had guided them to one or another resolution of their depression—through taking medication or steering clear.

As with a book, so with its author: where his readers locate him is where he finds himself. The book’s career made me an authority on depression.

One unnerving development was my exposure to memoirs of mood disorder. The bedside table groaned under the weight of typescripts and bound galleys. There were accounts by sexually depleted depressives, promiscuous depressives, urban single mothers, small-town family men, femmes fatales, gay lotharios, celebrities, journalists, ministers, and psychologists. The collection represented an outpouring of autopathography such as no prior generation had known. I was asked to endorse these books, to review them, to vet them for publishing houses, to assess their worth in the midst of a bidding war.

A psychiatrist is pleased—overjoyed—to see a mental illness shed some of its stigma. But as a reader, I became ever less enthralled. Despite the superficial variety, the memoirs of depression struck me as distressingly uniform. Their constant theme, their justification, was confirmation of the new reality, that depression is a disease like any other. The authors’ self-exposure was an act of witness, converting former private shame into current openness about an unexceptional and unexceptionable handicap. This much was welcome—a testimonial for the public health view of depression, often accompanied by advice to readers to seek evaluation and, if needed, treatment. But then more often than not, in these memoirs, hints of pride showed through, as if affliction with depression might after all be more enriching than, say, a painful and discouraging encounter with kidney failure. Expressions of value would emerge: Depression gave me my soul. The spiritual gift was not the insight that might arise in the face of any adversity. Despite their insistence on its ordinariness, the memoirs made depression seem ennobling.

I had admired the first handful of these books, not least for their courage. But the tenth confession is not so brave as the first. Soon I reached my limit. Awash in memoir, I told myself that I should complete the set. The memoir to end all memoirs. The final autopathography. A personal account of depression by someone who has never (this would be my claim) actually suffered the ailment.

If this project moved beyond the level of private joke, it was because depression had, in fact, perturbed me, as disease and suffering always perturb those who grapple with them. In my case, the point of confusion was this issue of romance—the glamour of depression. For the practicing psychiatrist, depression is grim enough.

It is true that among the major mental disorders, depression can have a deceptive lightness, especially in the early stages. Depending on the prevailing symptoms, the depressive may be able to laugh, support others, act responsibly. Depressed patients participate actively, even compulsively, in their own treatment. And depression, especially a first episode in a young adult, is likely to respond to almost any intervention: psychotherapy, medication, the passage of time. In my medical school days, if an inpatient psychiatry ward had spun out of control, a cagey chief would hold off on admissions until a good-prognosis depressive was referred. The hope was that the new arrival’s recovery would restore morale, for staff and patients alike.

But the depression I dealt with in my practice had settled in to stay. The unrelenting darkness was a function of the length of my tenure here. I have seen patients in Providence, Rhode Island, for over twenty years. In a small practice, failure accumulates. As I wrote more, I let my clinical hours dwindle. The result was that patients who were not yet better filled many slots, along with those returning to treatment. And the popularity of Listening to Prozac meant that the loudest knocks on the office door were from families with a depressed member who had faltered elsewhere. Circumstance made me a specialist in unresponsive mood disorder. I worked amid chronic despair.

Many psychiatric practices have this quality as they mature. Light depression is depression in young adults; those patients were the ones ward chiefs favored. Suicide is always a risk; we worry over it and guard against it. Still, most patients in their twenties and early thirties do well. Often, a trigger for the acute episode is apparent, so there is something to discuss—the precipitating event and its relationship to prior disappointments. Psychotherapy plays a central role in treatment. The doctor feels of use. But as the patient ages, bouts of depression recur with greater frequency. Later episodes can appear spontaneously, without apparent reason. They last longer, respond more poorly to any intervention, remit (when they do) more briefly. Certain functions may remain continuously impaired—concentration, confidence, the sense of self-worth.

Even with first episodes, there will be patients who respond poorly or incompletely. These hard-to-treat depressives linger in a practice. I will refer them for outside opinions. I will consider new and experimental interventions. Often, nothing works—or else, relapse follows hard upon recovery. These patients struggle. I knew them when—or just after, when life’s promise was still evident.

For the psychiatrist, then, depression becomes an intimate. It is poor company. Depression destroys families. It ruins careers. It ages patients prematurely. It attacks their memories and their general health. For us—for me—the truth that depression is a disease is unqualified. Depression is debilitating, progressive and relentless in its downhill course, as tough and worthy an opponent as any a doctor might choose to combat.

In an important respect, my clinical practice stood at a distance from the testimony of the memoirs: I had never treated a seriously afflicted patient who, on recovery, said anything favorable about depression. Yes, in the grip of mood disorder, a patient may allude to a sense of superiority. The resilient are missing something; they do not get it. This belief brings comfort in a time of suffering. But the idealization rarely outlasts the depression. When she feels better, the patient will question her own prior thought process. What was that about? She mistook illness for insight. She had been, quite literally, making a virtue of necessity. In retrospect, depression has no saving grace.

Outside the consulting room, the tendency to attach value to depression is common enough. Depression can appear to embody an aesthetic or moral or even political stance. There is a left-wing viewpoint, in which depression represents moral distance from the culture, asthenic self-abnegation, minimalism in contrast to mercantilism. There is a right-wing perspective on depression as well—the notion that one should tough out the suffering, without resort to easy remedies like psychotherapeutic support or medication. From either angle, left or right, there is virtue in experiencing illness rather than seeking prompt and thorough treatment. At least, it seemed to me that I heard, in passing, claims of these sorts, claims that would sound peculiar in relation to any other disease.

They outraged me. I discovered in myself a protectiveness toward the depressed, a wish for clarity on their behalf. I would have said that I had intended, on setting up my office, to conduct a broad psychiatric practice, extending to anxiety disorders, attention deficits, minor mental retardation, schizophrenia, marital discord, you name it. But if psychotherapy teaches anything, it is that, more than we are at first inclined to acknowledge, we are responsible for our circumstances. Chance plays its part, but we collaborate. As a child, I had been exposed to transient, low-level depression in relatives. I may have set out, in wandering fashion, to protect those I loved. This passion might be evident—I could imagine as much—in my writing. Perhaps my readers had placed me where I belonged.

As I focused on the discrepancies in value that attach to depression, I began to enjoy my situation more. Around me swirled an eddy of arguments and assumptions about depression. I was in an odd current, full of flotsam and jetsam. I began to save scraps that seemed evocative. I found myself trying to fashion a mental sculpture, a multidimensional collage, from shards that had floated into reach.

Perhaps one stray piece can serve as an example of the fragments I collected. I had finished my talk and was back in the audience at a regional conference on mood disorder. A psychoanalyst was next to present. He described his treatment of a middle-aged patient who had come for help with depression that had arisen out of the blue. The main features were leaden paralysis, obsessive self-doubt, and low self-regard. The analyst had the impression that for the whole of his life, the patient had been self-centered, blandly confident, and lacking in insight. So the doctor allowed the episode to continue. He hoped that the loss of confidence in particular would motivate the patient to engage in a psychotherapy that would make inroads against the narcissism.

I might once have considered this presentation unremarkable—an example of a psychoanalyst optimizing a patient’s level of discomfort in the service of a process of self-exploration. But now—with my own patients’ mood disorders so clearly in mind—I was seething. Is there another disease with which a doctor would make this choice? If a patient had cancer or diabetes and seemed psychologically the better for it—humbled, taken down a notch—still, we would treat the condition vigorously. Nor would a comparable argument, to let the syndrome be, arise in a discussion of other mental illnesses, such as anorexia or paranoia.

I found myself thinking about the particulars of depression in this patient, the one who turned to the psychoanalyst for help. What do we make of its unexplained appearance at midlife in a previously confident man? Perhaps the mood disorder resulted from a specific medical condition, outside the brain. Anemia can cause depression. If it did here, would the analyst tolerate a blood disorder, to provide the benefit of low self-worth? If the patient recovered spontaneously, might the doctor recommend therapeutic bloodletting? The thought was an angry one, I knew, but I was familiar enough with the brutality of depression to feel riled by the pride the speaker took in his choice, to let the patient flounder.

Causation aside—anemia or no anemia—the decision to leave depression untreated raises any number of ethical and practical concerns: Who will take responsibility for the harm depression does to the patient’s marriage or career? Who will guarantee against suicide—since self-injury is always a risk when mood disorder drags on? And isn’t it simply bad faith, when a person asks for help with an illness, to remain silent about potential treatments? The moral jeopardy (for the doctor) is only magnified when the hoped-for collateral benefit—alleviating a personality defect—concerns a problem that the patient might not acknowledge.

I took my disgust as a sign that I fully accepted depression as disease. How not, given the recent accumulation of evidence? Scientists were demonstrating that depression is associated with specific abnormalities in brain anatomy. Depression was being implicated as a risk factor for stroke and heart disease. And depression is its own risk factor; the longer you are depressed now, the more liable you are to chronic and recurring mood disorder, with its harm to brain and blood vessels and the rest. Surely depression had earned its status as disease in this particular sense: doctors ought not be content to let it persist.

Interacting with colleagues, submitting to interviews, treating patients, I became increasingly aware of a gap between two aspects of depression: what it is, insofar as we can put together recent research findings, and what it is to us, depression as we approach it informally. Our habits of mind lag. They have roots in traditions that take depression, or its distant cousin melancholy, as a sign of heightened awareness, social disaffection, moral insight, and creative genius.

I grew up in that tradition. In my college years, traits that resemble (and sometimes just are) symptoms of mood disorder were in vogue, alienation especially. I read widely in the literature that takes a journey through the slough of despond to be a prerequisite for full humanity. I saw bravery in the melancholic postures of my classmates, anhedonic, self-destructive young men and women who wore their depression with panache. Even now, in my years of close contact with depression, I was not immune to being charmed—except that when I caught myself in this attitude, it seemed utterly mistaken.

When I spoke in public, I began to challenge audiences about our double-mindedness. I used a test question: We say that depression is a disease. Does that mean that we want to eradicate it as we have eradicated smallpox, so that no human being need ever suffer depression again?

In posing this challenge, I tried to make it clear that mere sadness was not at issue. Take major depression, however you define it. Are you content to be rid of that condition?

It did not matter whether I was addressing physicians or pharmacology researchers or relatives of patients gravely affected by mental illness—all proponents of the medical model of depression. Invariably, the response was hedged. Just what do we mean by depression? What level of severity? Are we speaking about changing human nature?

I took those protective worries as expressions of what depression is to us. Asked whether we are content to eradicate arthritis, no one says, well, the end-stage deformation, yes, but let’s hang on to tennis elbow, housemaid’s knee, and the early stages of rheumatoid disease. Multiple sclerosis, high blood pressure, acne, schizophrenia, psoriasis, bulimia, malaria—there is no other disease we consider preserving. But eradicating depression calls out the caveats.

To oppose depression too directly or completely is to be coarse and reductionistic—to miss the inherent tragedy of the human condition. And here it is not only the minor variants—the psychiatric equivalents of tennis elbow—that bear protecting. Asked about eliminating depression, an audience member may answer with reference to a novel that ends in suicide. Or it may be an artist who is held forth, a self-destructive poet. To be depressed—even quite gravely—is to be in touch with what matters most in life, its finitude and brevity, its absurdity and arbitrariness. To be depressed is to adopt the posture of rebel and social critic. Depression is to our culture what tuberculosis was eighty or a hundred years ago: an illness that signifies refinement. Major depression can be characterized as more than illness, or less—a disease with spiritual overtones, or a necessary phase of a quest whose medical aspects are incidental.

I retained sympathy with these claims, but in decreasing degree. It took only a year or two of immersion for me to discover that I had moved a fair distance toward philistinism.

Two

Return

OFTEN,DEPRESSION ABATES by imperceptible degrees. But occasionally change is sudden—darkness into light. Medical practice contains its share of drama. A coma patient wakens. A stroke victim, mute since the event, speaks. Oncologists may witness the spontaneous remission of a seemingly terminal cancer. But for the doctor, little rivals this particular return to life, depression’s end—especially if the episode has been a long one.

The psychiatrist’s relationship to the patient is intimate. If psychotherapy plays a role in the treatment, the two will have sat across from each other, week after week, perhaps for years. By virtue of the disorder, the patient may have been guilt-ridden and scrupulous, disclosing all. The inquiry reveals emotion and its origins, immediate and distant. The doctor may have traced the patient’s inner life more minutely than his own—the coloration will be subtler, the dark corners more closely examined. And then the day arrives.

I was walking from your office to my car, and just like that, the depression ended. In an instant, the sense of living in the world returned. I sat in the driver’s seat and let sensations fill me. A passerby rapped on the window and asked if I was all right. I said: At long last.

Or, I got out of bed, and I realized it was not with me. At breakfast, I told myself, this can’t be. Breakfast! When last have I been able to stomach food in the morning? I poured myself a bowl of the kids’ cereal.

Or, I buzzed Bill’s office, to tell him. He was annoyed at the interruption. In the past, I have tried to humor him, to define myself as healthy when I knew I was not. How could I convince him that this time was different? Bill, I said, "I’m coming by. It can’t wait for lunch. I want you to see me now."

Memory of these moments sustain us, in the bleak hours. If we can keep this patient alive, if she can cling to the structures that support her, the happy day may come.

Lifting is a verb patients use. They speak of depression rising, like a fog. My mind was clouded, they say. Then they comment on an insidious quality depression has: it dulls awareness of its own force. Depression damages the ability to assess the self. I did not appreciate how distorted my thinking was.

Equally, the report may be in the passive voice, of a burden having been lifted. A weight off the back, a load off the mind. Again, a past distortion of awareness is apparent. Until it was removed, I had no notion how heavy it was.

For me as well, the gravity of depression is evident in the lightness, the