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 discussthe "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 impairedconcentration, 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 worksor else, relapse follows hard upon recovery. These patients struggle. I knew them whenor 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 methe 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 wellthe 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 evidentI could imagine as muchin my writing. Perhaps my readers had placed me where I belonged.
Excerpted from Against Depressionby Peter Kramer. Copyright 2005 by Peter Kramer. Reproduced by permission of Penguin Publishing. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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