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