A few months back, I wrote an article about my struggle with chronic clinical depression. In it, I discussed how transcending this disordered state of mind involved understanding its meaning and its purpose—that is, what the depression was telling me about what was wrong or missing in my life that left me with no other way to cope than by slipping into a paralyzing stupor.
Since that article was published in the Positive Living Newsletter, I've received e-mails from many readers, all struggling with depression (or some other mood disorder) and all asking me if what I meant to suggest was that there is some redeeming, positive value to depression. Indeed, a few people have even asked me to comment on their book manuscripts—confessionals in which they painstakingly recount the history of their depression and, in hindsight, find that the disorder made them better people.
After reflecting on my article and these e-mails, it dawned on me that I might be sending readers down a slippery slope. Just because depression—like any syndrome—can alert us to an underlying disease state or deficit in our lives doesn't mean that there is any meaning or positive value in the syndrome itself. Indeed, people still romanticize depression as something that carries a special message besides the obvious (that something in your life/mind/body is dysfunctional or in disarray). Some people have gone so far as to say that depression has made them "stronger" or even happier—as if in the absence of disease they were weak or unable to appreciate those things in their lives that would give them joy and a sense of personal satisfaction. This sentiment resembles the one I notice on websites that promote eating disorders: that a disease can make you complete and fulfilled.
If anything, it's indulging in this strange logic that is a part of the depressive syndrome itself. At worst, it's a sign that our faculties are progressively deteriorating; at best, it's our way of coping with a disease by rationalizing away the pain and suffering and spinning it into something positive and enriching. "What doesn't kill you makes you stronger, right?" Well, in the case of clinical depression, an abundant body of research shows that it can kill you: the mortality rate for depressives is higher than that of the general population, and not just because depressives are at the highest risk of suicide.
So how did we start seeing a disease as a blessing? And what has spawned the outpouring of confessionals that line the psychology and "spirituality" sections of bookstores?
Peter D. Kramer, clinical professor of psychiatry at Brown University, has some ideas. In his latest book, Against Depression (Viking Adult, 2005), Kramer dispels any doubt that clinical depression is either less or more than a disorder, a sign of disease and pathology. He draws on his extensive experience with depressed patients to show not so much what depression is (the symptoms are well-known, as evidenced by the painstakingly detailed confessionals) but what it means to us. He aims, in other words, to explore how people understand depression.
According to Kramer, it's easy to see how depression can seem deceptively benign, even positive. Especially in its early stages and "[d]epending on the prevailing symptoms, the depressive may be able to laugh, support others, act responsibly. Depressed patients participate actively, even compulsively, in their own treatment" (p. 6). Some patients are even charming and funny, in that self-deprecating sort of way. Yet in actual fact, depression is a destructive disease. Kramer discusses imaging studies that attest to the anatomical abnormalities that underlie the disease and that cause further damage in the brain. And personal and clinical experience unequivocally shows how depression destroys a person's memory, sense of self, family, career, zest for life—even the will to live.
Depression's severity can also be overlooked because people don't think it's as visibly salient as other medical conditions. One can see a cancerous tumor or a gangrenous leg and know that it's diseased; but depression can easily be mistaken as harmless because the physical signs of pathology are hidden inside the skull. Furthermore, because many of the symptoms are behavioral and emotional, people mistake depression as somehow being willful ("Oh he's just sulking") or as a sign of inherent character flaws ("He can't handle life because he's weak"). Kramer writes about one patient who said that she was "weak" and that "others bear real burdens and they don't whine." To him, this patient
saw conditions like near blindness as afflictions imposed from without, while her depression struck her simply as an aspect of who she was, a contemptible person with a limited tolerance for setbacks—and the setbacks were not the depression but particular disappointments that overwhelmed her when she was depressed (p. 44).
Indeed, as Kramer shows in his review of groundbreaking psychiatric research, the brain pathology that underlies depression is very real, even if we can't see it directly, and the behavioral and emotional symptoms caused by this pathology are often more painful and incapacitating than those of more visible conditions like cancer. Yet those with depression fail to recognize the gravity of the disease because it is, if anything, a disorder of perception. Those who have recovered from it often comment that they had no idea how distorted their thinking and self assessment was while they were depressed: "The gravity of depression is evident in the listlessness, the unburdening that I feel when someone I am treating recovers" (p. 13).
Another reason that depression's severity is underestimated is that some of its symptoms resemble traits, attitudes, and values that we hold in high regard. In Kramer's view, part of the romance or "glamor" of depression lies in cultural tradition:
In my college years, traits that resemble (and sometimes just are) symptoms of mood disorder were in vogue, alienation especially. I read widely in the literature that takes a journey through the slough of despond to be a prerequisite for full humanity. I saw bravery in the melancholic postures of my classmates, anhedonic, self destructive young men and women who wore their depression with panache. Even now, in my years of close contact with depression, I was not immune to being charmed—except that when I caught myself in this attitude, it seemed utterly mistaken (p. 10).
Depression is to our culture what tuberculosis was eighty or a hundred years ago: an illness that signifies refinement. Major depression can be characterized as more than illness, or less—a disease with spiritual overtones, or a necessary phase of quest whose medical aspects are incidental (p11).
More than a few depressed people claim that depression made them especially perceptive or thoughtful about people and the world around them: I could see things that I couldn't see before. Yet for various reasons, this enhanced perception is usually distorted. Consider what people say after treatment: I didn't realize how warped my thinking was until the depression lifted. I saw everything and everyone, including myself, negatively. There was no flexibility in my thinking. It was all or nothing, and all was dark, bleak, pessimistic, and hopeless. The world sucked. Consider also that some people who seem particularly reflective during depressive episodes suddenly cease to be when their depression lifts (indeed, a truly reflective person would see the world in less absolutist ways). Kramer says this about one of his patients: "Recovered, Margaret was an altogether less complex person than she appeared in the midst of her depression . . . The rounded, the immediately present person was a largely untroubled one" (p. 26).
On another level, some depressed people feel that their disease has given them something to feel superior about. As he discusses the memoirs of depression that he has read, Kramer notes that
hints of pride showed through, as if affliction with depression might after all be more enriching than say, a painful and discouraging encounter with kidney failure. Expressions of value would emerge: Depression gave me my soul [emphasis in original] . . . [The] memoirs made depression seem ennobling" (p. 5.).
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 well—the 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" (p. 8). The resilient are missing something; they do not get it (p. 7).
Yet part of the pathology of depression is that some people need this disease to feel that they have some sense of purpose or meaning in life. I live to suffer. Why is it that nothing else in life—only a disease—can bring meaning to some people? There are certainly schools of philosophical and religious thought that emphasize pain and suffering as the ultimate goals in life, but if you look at the majority of people who are clinically depressed, few of them are any more philosophical or religious than the average person. Furthermore, while pain and suffering may be one of the reasons we were put on this planet, the people whose lives are centered on this belief are not dysfunctional in the way that depressives are. Even the most brutal masochist can find pleasure in life (even if the pleasure comes in the form of physical pain); the depressive is satisfied by nothing and just wants to die.
No discussion of the meaning of depression would be complete without drawing attention to the long-standing misconception that depression, creativity, and art go hand-in-hand. We've all heard the refrain: Some of history's most creative people were depressed. Look at Van Gogh, Edgar Allen Poe, Nietzsche. According to Kramer, it's this link which continually feeds the idea that depression is enriching and, hence, need not be treated. But while mental disorders certainly do seem to be disproportionately represented among people of great creative and intellectual achievement (for reasons too numerous to explore here), the majority of creative and intellectual people are not depressed. In fact, the paralyzing nature of depression is more likely to doom than to nurture the realization of one's creative and intellectual gifts.
While giving talks on this topic, Kramer realizes that many people still hold the centuries-old belief that "depression reveals essence, to those brave enough to face it. Depression is more than an illness—it has a sacred aspect . . . [Too many people] understand mood disorder as a heavy dose of the artistic temperament, so that the symptoms of depression are merely personality traits" (p. 39). But depression, as a clinical mood disorder, is not the same as depressive traits. Characteristics like moroseness, a tendency to ruminate, and an interest in the dark side of life may certainly increase one's risk of developing a mood disorder—especially if the person is already predisposed because of other factors—but the majority of people with these traits are not, nor will they become, clinically depressed.
In fact, recent research in the journal Emotion (Vol. 5, No. 2) has suggested that depression and creativity may actually be independent, with a personality trait—rumination—being the bridge between the two. One of the factors underlying creativity is the ability to combine and recombine ideas in new and interesting ways. Rumination involves thinking about something over and over again, which is helpful in generating new ideas. If a person who ruminates also happens to have some special talent—musical, artistic, intellectual—he may end up having the kind of advantage that makes for a successful writer, musician, or intellectual. But rumination is also correlated with a risk for depression, which may explain the higher incidence of depression in creative people than in the general population. None of this means, of course, that depression somehow causes creativity or even enhances it. It's a depressive trait (rumination)—independent of depression as a mood disorder—that accounts for the relationship between depression and creativity and, therefore, the illusion that depression itself has intrinsic value.
It's unfortunate that Kramer doesn't look at a more insidious reason for our failure to accord depression its full due as a bona fide disease: the current vogue for postmodern perspectives on illness, particularly illnesses that are not as physically visible as other diseases. The current fashion is to consider mental disorders as "social constructions". Depression is a disorder only because people have arbitrarily (because of their own biases or agendas) decided that a certain constellation of symptoms is abnormal. In this perspective, a central question is what is "normal" and "abnormal" and who makes the decisions? If a disease is merely a constructed label, how can we take it seriously?
People go down a slippery slope when they follow this line of thinking. As mentioned earlier, depression is actually a syndrome—a constellation of symptoms that cause distress in individuals. The medical community has attached a label to this syndrome because extensive research and years of clinical experience have shown that the constellation of symptoms are not random (they are all correlated) and that they occur together enough times to suggest a distinct underlying causal mechanism (most likely a pathology of brain, mind, or some combination). Depression is a social construction only in the sense that doctors have given the distressing symptoms a label; it is not a social construction, as commonly believed, in the sense that people have just arbitrarily grouped together various random symptoms and given them a pejorative label to satisfy their own personal agendas (although in the case of other disorders, especially the personality disorders and psychopathy, this argument is more valid because the subjective nature of the symptoms—as opposed to depression's more concrete symptoms—make it easier for people's personal, cultural, and political biases and agendas to influence the selection of symptoms that will be considered abnormal and representative of some underlying pathology).
Consider also the frequency with which people with mental disorders—depression included—have something "amiss" in their lives, if at the very least a lack of resources needed to cope with the issues that life throws at them. Depression cannot simply be a figment of doctors' imaginations because the symptoms of the disorder and the lack of coping skills and resources that many of its sufferers experience co-occur too frequently to be dismissed as mere chance or coincidence. What also cannot be dismissed as coincidence is that the people who meet the diagnostic criteria for depression experience significant distress and disruption in their lives. Indeed, few people who are successfully treated for depression go on to say that they enjoyed it or that they wished to experience it again. If depression were merely a social construction—something to be laughed off because it doesn't really exist or is only a fancy of the mind—then few people would be bothered by it. Why, after all, would we be upset by a mere word or by some arbitrary grouping of symptoms?
But let's say for a minute that depression (or any mental disorder for that matter) is a social construction, in the fullest sense of the term. Let's imagine that all that existed in the world was whatever our society agreed existed and that the notion of abnormality was completely relative (i.e., only in the eyes of the beholder). In such a world, it would still be obvious that certain people would behave more "differently" than others and that some behaviours would appear "stranger" than others. It would also be obvious that certain people would simply be unable to participate in the same society that decides what is and isn't abnormal; such people could not, in other words, participate in the creation of their society's frames of reference. It probably wouldn't be a coincidence that such people would be experiencing symptoms of what we currently consider mental disorders. The person who is so despondent that he comes to delusionally believe that everyone hates him would not be in much of a position to work with others in agreeing on any definition of normality or abnormality. In this sense, abnormality (including depression) would certainly exist, even in a world made up of social constructions.
So if depression has no value—if it doesn't create great art, if it doesn't make one especially perceptive, if it doesn't reveal one's soul—why do people cling to the idea that it might not be as bad as some disease like cancer of AIDS? The simplest explanation—the one that Kramer suggests and that I know to be true because of my own struggle with depression—is that ascribing value to this horrible condition is sometimes the only way to cope with it. If a disease is so awful and unbearable, why not spin it into something positive or virtuous? What is there to lose?
Before you think that this article is a complete negation of my previous one, let me say that none of this would mean that the process of overcoming depression was not itself enriching. While the disorder itself had no redeeming value for me, there was meaning to be found in the recovery. Indeed, in the face of depression I was forced to look within myself and muster up whatever resources I could to deal with those circumstances that made coping with everyday life nearly impossible. That I was able to listen to my depression, and thus transcend it, was a reminder of how I've been blessed in this life. But the blessing was in no way the depression itself, no more so than cancer or an amputated leg would be a blessing.
And while my recovery made my appreciation of life and my health that much stronger, there's no way I would consider depression itself a part of life that I would appreciate. Whatever meaning any of this had, only a small part was to be found in the depression itself (namely the realization that something was missing in my life); most of the meaning came from the life that I could finally live, and enjoy, after recovering from this debilitating disease.
Copyright © 2006, by Eddy M. Elmer
Permanent URL: http://www.eddyelmer.com/articles/dpxmean.htm