As I focused on the discrepancies in value that attach to depression, I began to enjoy my situation more. Around me swirled an eddy of arguments and assumptions about depression. I was in an odd current, full of flotsam and jetsam. I began to save scraps that seemed evocative. I found myself trying to fashion a mental sculpture, a multidimensional collage, from shards that had floated into reach.
Perhaps one stray piece can serve as an example of the fragments I collected. I had finished my talk and was back in the audience at a regional conference on mood disorder. A psychoanalyst was next to present. He described his treatment of a middle-aged patient who had come for help with depression that had arisen out of the blue. The main features were leaden paralysis, obsessive self-doubt, and low self-regard. The analyst had the impression that for the whole of his life, the patient had been self-centered, blandly confident, and lacking in insight. So the doctor allowed the episode to continue. He hoped that the loss of confidence in particular would motivate the patient to engage in a psychotherapy that would make inroads against the narcissism.
I might once have considered this presentation unremarkablean example of a psychoanalyst "optimizing" a patient's level of discomfort in the service of a process of self-exploration. But nowwith my own patients' mood disorders so clearly in mindI was seething. Is there another disease with which a doctor would make this choice? If a patient had cancer or diabetes and seemed psychologically the better for ithumbled, taken down a notchstill, we would treat the condition vigorously. Nor would a comparable argument, to let the syndrome be, arise in a discussion of other mental illnesses, such as anorexia or paranoia.
I found myself thinking about the particulars of depression in this patient, the one who turned to the psychoanalyst for help. What do we make of its unexplained appearance at midlife in a previously confident man? Perhaps the mood disorder resulted from a specific medical condition, outside the brain. Anemia can cause depression. If it did here, would the analyst tolerate a blood disorder, to provide the benefit of low self-worth? If the patient recovered spontaneously, might the doctor recommend therapeutic bloodletting? The thought was an angry one, I knew, but I was familiar enough with the brutality of depression to feel riled by the pride the speaker took in his choice, to let the patient flounder.
Causation asideanemia or no anemiathe decision to leave depression untreated raises any number of ethical and practical concerns: Who will take responsibility for the harm depression does to the patient's marriage or career? Who will guarantee against suicidesince self-injury is always a risk when mood disorder drags on? And isn't it simply bad faith, when a person asks for help with an illness, to remain silent about potential treatments? The moral jeopardy (for the doctor) is only magnified when the hoped-for collateral benefitalleviating a personality defectconcerns a problem that the patient might not acknowledge.
I took my disgust as a sign that I fully accepted depression as disease. How not, given the recent accumulation of evidence? Scientists were demonstrating that depression is associated with specific abnormalities in brain anatomy. Depression was being implicated as a risk factor for stroke and heart disease. And depression is its own risk factor; the longer you are depressed now, the more liable you are to chronic and recurring mood disorder, with its harm to brain and blood vessels and the rest. Surely depression had earned its status as disease in this particular sense: doctors ought not be content to let it persist.
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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