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.
"That's our next step with depression. We would like to be able to say, 'Yes, you have five symptoms for two weeks at a moderate level, but actually you have an imitator, whereas the person across from you has only four symptoms but we know from the biological marker that it really is depression.'"
Beyond the scientific questions and debates that Kramer explores in Against Depression, he also raises moral, ethical and philosophical issues. "The idea I'm considering is what it means to embrace the notion that depression is a disease and what kind of window that gives us on our culture. For two millennia or more, human beings have been looking at other human beings with depression or experiencing depression themselves, thinking about it and writing about it, but not being able to influence it very much. Depression relates to all kinds of theories about what the good society or bad society is," he said. "The book is really about how it would change our thinking as a culture just to begin thinking of depression as a disease, and how it would change it more if we really got better at treating or ideally preventing it."
For his next book project, Kramer is writing a brief biography of Freud. It will be part of a biography series called Eminent Lives, edited by James Atlas. The book will probably not be published until 2007, Kramer said, since he has "a lot more reading to do about Freud." Beyond writing books, Kramer has written reviews, commentaries and articles for The New York Times, The Washington Post, Slate and Salon, as well as many medical journals.
Currently, Kramer still works as a clinical psychiatrist four afternoons a week, and many patients come because they or their referring clinician have read one of his books. "Because of Listening to Prozac and Against Depression, probably most of the new referrals are people with ambulatory mood disorders. Should You Leave brings me some couples for counseling," he said.
This year, Kramer also was named host of "The Infinite Mind," a National Public Radio show focusing on mental health. Already, he has covered such issues as Asperger's syndrome, electroconvulsive therapy, and food and mood. In prior years when he was a guest host, two of his programs--"In Any Language: Mental Health Care for Immigrants" and "Domestic Violence"--won awards.
Looking toward his future, Kramer expects to put more of his energies into writing.
"I am a doctor for the long run. I really do enjoy it," he said. "But I could imagine myself retiring from medicine and just writing, whereas I could not imagine myself retiring from writing and just practicing, so I think the more loyal tie is to writing. Both feel very much like privileges."
1. Epstein R (2001), Is everybody happy? Peter Kramer wrote the manual to Prozac; now he's trying his hand at fiction. Psychology Today. Nov.