Nassir Ghaemi looks at the complexity of depression to help unearth some simple frameworks to help people develop “the courage to hope.”
In the cacophany of pretensions about psychiatry, an intelligent man (or woman) is bound to be confused by competing claims. The worst part is that it is true: there are no simple answers. But there are answers. On Depression is my attempt to describe those answers while refusing to oversimplify the complexity.
Depression is not one thing; it is many things. Sometimes it is a disease, as in manic-depression; in this case, it comes and goes in severe episodes which are impossible to stop or control without the right medications. Sometimes it’s a reflection of personality traits, a tendency to be anxious and moderately sad all the time, with brief periods of mood worsening. Sometimes, it’s just a reflection of life, and death, the existential despair that we all experience, whether we want to admit it or not.
There are some psychologists and psychiatrists who honestly described that existential despair, and tried to relate it to the clinical expressions of depression: people like the psychiatrist Viktor Frankl, who wrote about the despair of being in Nazi concentration camps and how that experience provides insight for human existence generally; like the psychologist Rollo May, who saw taught that the relationship between people is more important than their theories; like my teacher, psychiatrist Leston Havens, who taught that wisdom meant holding opposed ideas in your head at the same time; like my friend, historian Paul Roazen, who showed us that what we thought we knew about Freud wasn’t true, and then unearthed what we need to know about his insights; like the philosopher/psychiatrist Karl Jaspers, who taught that knowledge in science should be valued enough that we also appreciate our ignorance.
These are our guides to help us understand depression, in the larger context of understanding human existence, as well as psychiatric illness. I describe their ideas.
I also describe the pretenders to wisdom that you should avoid, the ones who prove that error is multiple, while truth is one. Some err in the direction of denying everything: the postmodernist claim that biological approaches to psychiatry are all wrong. Some err in the direction of affirming everything: the believers in the psychiatric diagnostic manual (DSM-III, IV, and recently 5), who literally made up hundreds of diagnoses to influence clinical practice for their own purposes, as I document.
Both extremes are wrong, and one better understands these fallacies by appreciating the true nature of the depression as a disease, especially how it manifests itself in manic-depressive conditions, and how our beliefs about “why” one gets depressed at a certain time frequently are false rationalizations.
The story isn’t simple, but there is story to tell, and it can be told simply. If you want to understand depression, in yourself and others, and know when it is a disease needing medical treatment, and when it isn’t, there are some guides to follow, and some pretenders to avoid, and some wisdom worth hearing.
What follows is an excerpt from the book On Depression: Drugs, Diagnosis, and Despair in the Modern World (Johns Hopkins Press, 2013).
The most salient feature of our world is that God is dead. Or at least he appears to be dead. Perhaps he is on life support. Or maybe he has become an embalmed version of what he once was, appearing lifelike, but really dead. Nietzsche, formally and most famously, pronounced God dead. But perhaps the truth is closer to what Emerson said, less famously, half a century earlier: we live as if God were dead.
To many, the world is a flat and soulless place. It is a land in which to despair, a land for the already dead, pretending to be alive. To say that God is dead is to say that the spiritual impulse that once drove mankind has petered out. God inspired not just his believers, but Voltaire in his unbelief, and Marx in his messianism. God is dead because hope has died, because the world has become meaningless, because the ideals of the Enlightenment perished in gas chambers.
In a word, we are living in a postmodern world where nothing is true and nothing is false; the rational response to such a world is despair. Most of us don’t despair, though, because we don’t know what it means to say that the world is postmodern and God is dead. In fact, we know it so well–that the world is postmodern and God is dead–that we aren’t conscious of what we know…
Here is our dilemma in the Western world today: We are a hopeless and cynical people, and we think we are beacons of happiness. We have given up on the noble and the ideal, yet we think our absence of ideals is noble. We think we are great countries, exporting the best values all over the world; yet we have lost our own values; we don’t measure up to the greatness of our own forefathers.
We are, in Nietzsche’s phrasing, Last Men, who think they are Supermen (Bloom, 1988; Fukuyama, 2006).
Nietzsche writes his thoughts on this topic in the epic genre, putting his words in that of the hero of his story, the Persian prophet Zarathustra, who comes upon the people of his age, and sees that they have declined (Nietzsche, 2000). He looks about him and tries to show his decadent people that they have fallen away from what was best in them. He sees that they have reached the end of their cultural existence, that they are the last men of their history:
“Behold,” Zarathustra says, “I show you the Last Man, who is the most despicable man of all, because he cannot despise himself.”
The Last Man is the man of the postmodern world; he has given up the comfort of faith, and he has taken the efforts of Reason to be illusion. He is left with nothing but the self-satisfied feeling that he knows better than the believers and the rationalists. What he knows, however, is only that there is nothing to know. The content of his being is only negation – the negation of others, the refusal to stand up for anything, the disbelief in all except his own right to disbelieve. This is the American teenager within each one of us: a pure relativism that knows little, and thinks that there is little to know….
….There are many depressive varieties to be explored. For some people, clinical depression is always there, to a greater or lesser degree, but it never goes away. Under the stresses of life, the constant low-level depression becomes worse, if only for a few weeks or a few months; it is like a constant dull headache which suddenly becomes sharp now and again. Someone dies; I have a tough meeting with my boss; a bus almost hits me; a bully bothers my child in school. These stresses happen to all of us: we don’t develop clinical depression as a result. But some people, who constantly have the dull headache of low-level depression, will sink into deep depressive funks after the meeting with the boss, and not come out until months later, at which time they go back to their usual life of the dull headache—the baseline mild depression. We used to have a word for this condition, no longer used in psychiatry today: “neurotic depression.” Usually the baseline depression is admixed with some anxiety symptoms, a general worry-wart attitude, a pessimism and fear about life. Hence the term “neurotic.” I think the old term—now discarded for the fancier terms “dysthymia” and “generalized anxiety disorder” — was more true to reality. There is a depression there, but it is neurotic and chronic.
Some people have a different kind of depression: Sometimes they are deeply sick, severely depressed, suicidal and non-functional; these black depths last months and months, but rarely longer than a year. When not deeply melancholic, these persons are well (or near-well, with a slight sadness: dysthymia). They are not a little depressed, or generally anxious; they are well, like you and me and that 90% of the population that never experiences clinical depression of any kind. In other words, they have depressive episodes, that come and go, and they have periods when they are completely (or near-completely) healthy. This is episodic depression, and it either happens alone (called “unipolar”) or with manic periods (called “bipolar”).
There is a third group: Some people are fully healthy, without a symptom of depression, and then have a severe depressive episode, and then never have another one for the rest of their lives. About one-third of persons with a severe depressive episode are in this category: they have a single episode their entire lives.
A fourth group is fully healthy until they have a stroke, or a heart attack, or develop cancer, and then for the first, and last, time in their lives they have a depressive episode. If the medical illness is cured, they never have another depression.
All four of these varieties of depression are currently given the same label in psychiatry: “Major depressive disorder” (MDD) (Ghaemi, 2008b; Shorter, 2009). Some of their differences may be signalled by adding other labels (e.g., “major depressive disorder with the comorbidity of generalized anxiety disorder”), but the MDD label is the diagnosis.
There is little doubt we have a spectrum here: it ranges from neurotic low level depressive and anxiety symptoms that are chronic, to a single depressive episode (with or without a medical cause), to recurrent depressive episodes.
It has become de rigeur to state that depression is a disease. I would say the opposite: most depression is not a disease. That part of it that is recurrent and episodic, or due to a specific medical cause, is disease. But that part which is not episodic, which is chronic and admixed with anxiety, becomes indistinguishable from personality; though it seems similar to the disease of recurrent severe depression, it does not have similar biological causes, nor similar benefit from biological treatments.
…. There is something that happens in the middle of the night, when you turn around and see nothing but darkness, and you think about how alone you are in the universe, and a deep dread navigates its way up inside you. This is the despair of the night, a despair that calls up what Napoleon called two o clock in the morning courage.
The most hectic person, the most frenzied fellow, deep down, if he wakes up at two in the morning, knows it is dark, and he is alone.
To continue with life in the face of that knowledge requires courage. Courage is the virtue that provides the solution to the problem of despair. To make the choice to live and not commit suicide, to make important choices in life about marriage and work, to accept failures and keep trying—all this requires courage. It is not enough to have reasons to do such things; it is not enough to have knowledge about why it might make sense to live and to make such choices; the real power behind being able to make those choices, the real antidote to despair, is the virtue of courage.
Courage is not an emotion, and it’s not a thought. It’s a virtue, what Aristotle called a kind of practical reason. It’s a mix of emotion and reason, something we learn and are taught as we grow from childhood to adulthood, something we can understand rationally but which we can only enact emotionally and spontaneously. It’s something we develop consciously, and once we have it, it’s something which comes to us when we need it.
It is this courage which allows us to make the important choices of life. By choosing to live, we take risks, though, and those are two inevitable aspects of living: we make choices and we take risks. We need to accept both realities. Courage allows us to do so.
There are those who, instead of denying despair in return for superficial hope, deny hope in return for unremitting despair. These are the most chronically depressed; the choice is made for them by powers beyond their control; they find themselves in despair and do not know why. They feel too deeply the depth of their aloneness, and they do so not only at two o clock in the morning but also at two in the afternoon. For them, the reality of death and the passing of things leads to a deep paralysis, an inability to engage at all in daily life. These are wise souls, but they are too wise. They do not have the courage to hope, for it takes a certain grandiosity to believe, despite all the risks, that the gambles of life are worth taking.
People want to live a life without despair. They want to be perennial optimists, with nothing but hope ahead, above, and behind them. Hope is good, but hope cannot be baseless. We are more often wrong than we are right, yet neither should this fact keep us from seeking to be right.
A life without despair would be a life without hope, for hope cannot exist except as an antidote to despair. If you think you never despair, it’s probably because you haven’t woken up at two o clock in the morning and looked around. One might think that one could stay asleep, and wake up sensibly at eight, and live life without despair. But the activities of that life, uninformed by the two o clock courage, are mere comings and goings, a series of events that are authored by oneself but could have been authored by others, a reaction to the everyday needs of life without appreciation of the needs of the years and the decades. Before one knows it, in such a life, one is 30 and no longer 20, then 40 and no longer 30, and one’s friends have moved, and some have died, and one’s parents have grown old, and the streets and buildings are changing, and then, perhaps at age 50, somewhere around two o clock in the morning, one senses a gnawing unease.
This unrest would seem to be the opposite of happiness, and it is. But if we can hold two opposed ideas in our heads at once, we might see that the two are somehow connected.
photo by wellohorld / flickr