"The themes of my last four books are some cultural construction of happiness that relates to psychiatry," Kramer told PT. Listening to Prozac is really about what we demand of people in terms of personality traits and how much happiness we have a right to expect, he said. Then, Should You Leave explores how our notions of happiness are connected to our notions of intimacy or autonomy.
The novel, Spectacular Happiness, is about how we understand happiness in a culture that also emphasizes wealth and celebrity, and Against Depression is about how a particular disease affects our vision of what the good life is and what the good life might look like if we were better at treating the disease.Disease of Depression
Against Depression has been described as a provocative sequel to Listening to Prozac. In the prologue, Kramer observes that he has written a polemic, "an insistent argument for the proposition that depression is a disease, one we would do well to oppose wholeheartedly." He warns against equating depression with a heroic artistic stance, one we think humankind might be worse off without.
When asked about the relevance of the book for psychiatrists and their patients, Kramer told PT, "For doctors recommending the book to patients or having it in their waiting rooms, the book's middle scientific section really walks patients through the contemporary scientific understanding of depression and its treatments."
Numerous scientific studies are cited linking depressive symptoms with abnormalities in the hippocampus and prefrontal cortex of the brain. Kramer also emphasizes that depression is more than a brain disease. "It is a neurologic, hematologic and cardiovascular disease. Overactivation of stress pathways causes a liability to clots and arrhythmias--and alone or together, these predispose to heart attacks, silent strokes, disturbed mood and sudden death," he wrote.
In another section of the book, Kramer asserts that the criteria for major depression are "arbitrary in every regard." In explaining that conclusion to PT, Kramer said, "Originally, I was very opposed to the narrow categorization of DSM-III, but now admit it turned out to be a brilliant idea for research purposes. We just needed this arbitrary definition. But the research that justifies the definition also demonstrates that it is arbitrary.
"You need to diagnose depression by five or more moderate symptoms for two weeks. Yet, people with four symptoms, mild symptoms or 10 days of symptoms really sit on a spectrum with the people who meet the full definition, and those who almost make it have fairly bad outcomes. I think we just know that we haven't captured depression. The way we will capture it probably is through a biological marker or set of markers.
Some of the brain research that we have seen in the past seven or eight years has really made it clear that depression is a disease--there are neuroanatomical changes that are associated with depression, either causing it or being caused by it. But we don't have the kind of consistent marker that allows us to say in the way we can say with polio, ‘You have the symptoms of the disease, but you don't have the disease,' because we don't have the biological marker.