Beyond Blue

What is depression?

Jacob Sullum from the December 1993 issue

Good Mood: The New Psychology of Overcoming Depression, by Julian L. Simon, La Salle, III.: Open Court, 307 pages, $52.95/$18.95 paper

Listening to Prozac, by Peter D. Kramer, New York: Viking, 409 pages, $23.00

I get depressed on Sundays. I’m not sure exactly why. Maybe it’s emotional conditioning, the anticipation of work, or the burden of free time. Maybe it’s a biochemical phenomenon. Whatever the cause, I tend to feel unaccountably sad on Sunday afternoons.

No big deal. But if you knew a way to avoid the Sunday-afternoon blues–say, an attitude adjustment or a handy little pill with no unpleasant side effects–I’d be interested.

Julian Simon also used to be depressed on Sundays–and every other day of the week. This was a big deal. As the distinguished University of Maryland economist describes it in Good Mood, he was depressed "for 13 long years from early 1962 to early 1975. When I say that I was depressed I mean that, except for some of the hours when I was working or playing sports or making love, I was almost continuously conscious of being miserable, and I almost continuously reflected on my worthlessness. I wished for death, and I refrained from killing myself only because I believed that my children needed me....Endless hours every day I reviewed my faults and failures, which made me writhe in pain. I refused to let myself do...pleasurable things...because I thought that I ought to suffer."

Simon’s problem and mine are obviously quite different. Indeed, according to the definition of depression that he uses–prolonged sadness, accompanied by feelings of low self-worth, helplessness, and hopelessness–my experience does not even qualify. It is merely "the garden variety of the blues that come and go in a day or a week."

Still, Simon’s overwhelming, 13-year-long depression and my mild, occasional dysphoria are both cases of mysterious sadness with a variety of possible psychological and biological explanations. And both might respond to psychotherapy or drugs. Simon, in fact, overcame his own depression through the cognitive-therapy methods he describes in his book. These techniques, which focus on changing self-destructive ways of thinking, are intended for people who are depressed in the noncolloquial sense. But they probably could do some good for just about anybody who suffers because of unreasonable selfcriticism. Simon’s approach certainly appeals to me as a way of dealing with everyday problems of living, although I have never experienced anything approaching the ordeal that he went through.

Simon did not try anti-depressant drugs, but he writes that "I...probably would and should have tried such drugs during my long depression if they had been as well-established as they now are." Prozac, the anti-depressant that psychiatrists are most enthusiastic about these days, was not available until December 1987. Since then it has helped many severely depressed people escape psychological states as bad as or worse than Simon’s. And as psychiatrist Peter D. Kramer details in his thoughtful, elegantly written book, Listening to Prozac, even mildly depressed people like the drug, which has few significant side effects. (An appendix to the book persuasively debunks reports of suicides and murders allegedly caused by Prozac.) Kramer describes several individuals, active and productive but vaguely unsatisfied, who found they enjoyed life more while taking Prozac. Psychiatrists generally do not prescribe Prozac for the Sunday-afternoon blues, but who knows? It might just do the trick.

The apparent versatility of cognitive therapy and Prozac suggests that deep, incapacitating depression sits on the same continuum as the chronic blahs and the periodic blues. If so, psychiatrists have some explaining to do. A continuum view of depression raises uncomfortable questions about their scientific claims and legal privileges.

Both Simon and Kramer call severe depression a disease. For Simon, this label is largely metaphorical. He speaks of controlling the "symptoms" of depression (which he agrees anti-depressants can do), as opposed to curing the "disease" itself (which he thinks requires psychotherapy). But in describing the various factors that might lead to depression, Simon gives little weight to biology. For Kramer, depression seems to be an illness in the same sense that cancer is; it can be traced to a physical abnormality, whether in the structure of the brain or in the production and use of neurotransmitters and hormones.

A continuum view of depression is not necessarily inconsistent with the notion that severe depression is a disease. Diabetes and hypothyroidism, for example, are matters of degree; in these and other cases, doctors have to decide, somewhat arbitrarily, when an organ’s functioning is far enough from the norm to constitute an illness. But depression is different from such conditions in a crucial respect: No one can identify the physical defect that supposedly underlies it. As Kramer admirably demonstrates, people can and do speculate about a biological mechanism. In the end, however, they have to admit (if they are honest) that no one really knows how depression works or what causes it.

Kramer offers a great deal of intriguing speculation about the biological roots of both depression and personality. The main effect of Prozac, for example, is to boost the level of the neurotransmitter serotonin in the synapses between brain cells, suggesting that a deficiency of serotonin leads to depression. But there are problems with this hypothesis: Some depressed people do not respond to Prozac, and some respond to drugs that do not act on serotonin. Anti-depressants that raise serotonin levels do so within hours, but people who take them generally do not feel an effect for weeks.

"Biologists do not know what depression is," Kramer concedes. "The reigning model at the cellular and chemical level, the biogenic-amine hypothesis [tying depression to shortages of serotonin and norepinephrine], is demonstrably false or incomplete. Understanding of minor mood disorders, or normal variants, is even more primitive....About affective and social temperament, the experts know least of all....The biological study of the self is so primitive as to be laughable."

In light of this ignorance, does it make sense to call depression a disease? Thomas Szasz and other critics of the medical model have long complained that psychiatrists tend to view every thought, emotion, and behavior they do not like as the symptom of a hypothetical illness. Although he is by no means ready to join the dissenters, Kramer, too, seems troubled by this tendency. The qualms surface in his discussion of Prozac’s impact on personality.

Kramer reports that a sizable minority of depressed people who take Prozac undergo marked personality changes. One of his patients, for example, "became less bristling, had fewer rough edges." He also lost interest in pornographic movies, which he had long insisted that his wife view with him. Another felt less serious about life and less driven to self-sacrifice for the sake of others. A third overcame lifelong shyness and began to date regularly. Kramer finds these changes vaguely disturbing, and much of his book is an attempt to identify the reasons for this unease.