Image401.EPS

Volume 11, No 2, Fall 2016 ISSN 1932-1066

Reflecting on On Depression

The Trap of The Happy Mean

Elena Bezzubova

University of California, Irvine

[email protected]

Abstract: This reflection on Nassir Ghaemi's On Depression: Drugs, Diagnosis and Despair in the Modern World first touches upon the author's personal, clinical, historical, and theoretical facets of depression and despair as well as mania and happiness as a cogent demonstration of how seriously psychiatry needs philosophy. Ghaemi proposes biological existentialism for the role of such philosophy. This essay compares biological existentialism with an earlier conception of existential biology as attempts to resolve Cartesian anxiety inside of the methodological trap of psychophysiological parallelism. I outline three sovereign levels of addressing presentations of human life: biological facticity, clinical phenomenology, and existential authenticity to clarify the difference between the human and existential categories of happiness and despair; the clinical categories of depression and mania; and the biological categories of neurometabolic patterns. On Depression reveals how the needed integration of philosophy into psychiatry remains problematic.

Keywords: Jaspers, Karl; Kraepelin, Emil; biological existentialism; biological facticity; clinical phenomenology; existential authenticity; depression; despair; mania; happiness.

Image410.PNG

If the twentieth century arguably made writing about psychic illness a genre, Nassir Ghaemi has certainly established his recognizable tenor in this genre by exploring medical and philosophical facets of mental maladies. For about twenty years he has examined different aspects of psychiatric disorders, predominantly affective pathology with its best-known entities of depression and mania. Since this time he penned several most popular books and recently added On Depression where he offers a rich account of interesting information about and around depression and mania.1 Its subtitle, Drugs, Diagnosis, and Despair in the Modern World provides a catchy soundtrack of sonorous D's that introduce a multifaceted content by embracing a wide variety of areas: neurobiological findings, clinical vignettes, historical anecdotes, philosophical references, good poetry, and abundance of touching personal chronicles. The author's voice leads throughout this assortment, providing an engaging first-person atmosphere. A reader hears a professional who has been studying depression and mania for decades and now generously shares his expertise.

As Ghaemi informs in the preface,

So this is a book about what it means to have depression or bipolar illness and what it means to experience despair or happiness. [OD ix]

The search for such meaning is unfolded in a four-chapters-journey: from the first chapter called Entrance to the last chapter called Exit. The author leads from the early idea of melancholia to the latest neurogenetic concepts of mood disorders, and from a medical student's first encounter with patients suffered from depression and mania to a mature clinician's meditations on despair and happiness. Along this way Ghaemi evaluates different theories and their creators. The language of these evaluations resembles verdicts. The second chapter, Pretenders, plainly condemns those thinkers whose ideas Ghaemi finds misleading or merely wrong. The third chapter, Guides, pays tribute to those scholars whose ideas Ghaemi finds inspiring and helpful.

Remarkably, both groups include equally famous founders of major schools of thinking of the twentieth century. Guides comprises a founder of biological psychiatry, Emil Kraepelin, and a founder of existentialism, Karl Jaspers. Pretenders contains another founder of existentialism Martin Heidegger, a founder of psychoanalysis Sigmund Freud, and a founder of postmodernism Michel Foucault. All of them—those who are labeled guides as well as those who are labeled pretenders—belong to a distinguished group of the brightest authentic truth-stalkers. Kraepelin's vision of mental disease as a pathology of the brain is in direct contrast with Foucault's ideas of diseases as social constructs. Some might strongly support Kraepelin, yet others would rather support Foucault. The contrast between the two corresponds with the complexity of the phenomenon under investigation: mental disorder. Certainly, the seminal ideas of Freud, Foucault, or Heidegger, as is the case of all groundbreaking ideas, are open to all forms of academic critique and polemic. A thinker could easily disagree with them or categorically deny them. However, academic critique is different from morally dismissive labeling such as "pretenders." In the case where such labeling is concerned with the giants of the last century thinking, such labeling is least expected from a seasoned physician and scholar with a record of papers on ethics and moral issues.

It is interesting that the polarization of good guides versus bad pretenders stands in a striking contrast with the dominating conciliating intonation of On Depression. In discussing three classical dilemmas of understanding mental pathology: the normal versus the pathological, madness versus genius, and the biological versus the cultural, Ghaemi firmly navigates toward an approach that will smoothen acute angles, reconcile and merge together frustratingly polarizing contemporary concepts of mental disorder.

This golden mean style becomes particularly convex when Ghaemi employs psychopharmacology to examine norm versus pathology and the biological versus social dilemmas. Armed by the reliability of hard science, the biological approach supports drugs to treat individuals with depression, mania, or other mental disturbances. Drugs have influence on neurochemical metabolism, which the biological approach qualifies as a reason for depression or even as essentially depression itself. The humanistic, person-centered approach considers depression as a complex human situation that cannot be reduced to brain metabolism or other biological processes. In addition, arguing with the domination of the biological approach, the humanistic approach refers to the alarming statistics of questionable benefits but dangerous side effects of these drugs. Also it points to the commercial support by powerful pharmaceutical and insurance industries, criticizing their branding of illnesses to promote drug consumption and subsidizing Big Pharma. Broadly discussing this biological versus the cultural polarization, Ghaemi offers the golden mean resolution: there is some good in both approaches.

Perhaps one of the reasons for this happy reconciliation is that Ghaemi himself has the best from both camps. A distinguished speaker for and a major grants recipient from leading pharmaceutical giants, he has been researching their products, including drugs for depression, mania, and bipolar disorders. He has held eminent positions in the psychopharmacological establishment. On the other hand, throughout his psychopharmacological career, Ghaemi has also been actively involved in the person-centered camp. He has studied philosophy, extensively written and enthusiastically lectured on philosophical and moral aspects of mood disorders. On Depression presents many interesting stories, anecdotes and vignettes of Ghaemi's engagement in humanistic psychiatry.

Ghaemi's elaborations on the happy marriage of the biological and the person-centered culminate in the idea of biological existentialism that he has been establishing for a few years. The very term "biological existentialism" is a happy coupling of the two different ideas of the two thinkers presented in the chapter Guides; Kraepelin for the biological psychiatry aspect, and Jaspers, the author of General Psychopathology, for the existential aspect.2 Like an expert breeder, Ghaemi binds together the biological expertise of Kraepelin with the existential emphasis of Jaspers, expecting that the resulting hybrid of biological existentialism will resolve the theoretical clash and practical tension between the camp of biological psychiatry and the camp of person-centered psychiatry. The biological existentialism suits the happy-mean-style of the book and on the first glance for a lay reader; this may feel as a comfortable resolution. What could be better than utilizing the most advanced science of biomedicine in the process of practicing patient-centered humanistic psychiatry!

However, a closer look at Ghaemi's proposal of biological existentialism shows that the author does not distinguish psychiatry as an area of mental health care and psychopathology as an area of knowledge about mental disorder. Jaspers begins his General Psychopathology—so appraised by Ghaemi—with a clear differentiation between these areas (GP 1). Psychiatry is a practice, dealing with unique individuals and their concrete practical situations: medical, legal, and so on. Psychiatry is based more on expertise than on theory. In contrast to psychiatry, psychopathology is not focusing on individuals and the particularities of their presentations. Psychopathology builds the theoretical conceptual ground for understanding mental disorder and Jaspers devotes himself to the study of psychopathology.

What Ghaemi calls biological existentialism appears to be an appropriate approach that has been traditionally considered as both complex and efficient. Psychiatric care of the individual benefits from a well-balanced integration of pharmaceutical, psychosocial, and alternative methods of treatment. It also improves the accuracy of diagnostic procedure while avoiding disease manufacturing, which means pathologizing a normal depressive reaction.

Thinking about biological existentialism in psychopathological terms raises methodological and ontological issues. Objective materialism of biology and lived Existenz of existentialism present principally distant traditions of thinking. Biology thinks in terms of cause and effect determination, facts, measurement, and evidence-based methodology. Existentialism thinks in terms of thrownness, truth, experience, authenticity, and freedom. Applying Jaspers' contributions to the discussion of the difference between erklären and verstehen—biology works in the paradigm of explanation, while existentialism works in the paradigm of understanding. Biology is science; existentialism rejects the "dictatorship of science."3 Metaphorically speaking the ontological genotypes of biology and existentialism are so incompatible that their hybrid's ontological core cannot even be formed. Existenz is an ontologically primal ultimate process. Existence cannot be biological or neurogenetic, or nuclear, or in any way derivative; existence is existential.

Biological existentialism that merges biology and existentialism for the sake of practical reasoning comes close to eclectic pragmatism and resembles George Engel's biopsychosocial model. Both approaches—Engel's and Ghaemi's—remain inside of the Cartesian matter–consciousness trap. Rejecting the very dichotomy of matter-consciousness, existentialism liberates itself into freedom and openness and the responsibility of Dasein.

In addition, the meaning of the term "the biological" throughout On Depression and particularly in the very notion of "biological existentialism," as well as in the reference to Jaspers as "exactly such biological existentialist" (OD 103) is not consistent, but quite the opposite to Jaspers' interpretation of the biological in regards to biological psychiatry. Investigating the demand "for the development of a 'biological psychiatry'," Jaspers clearly states that "'biological' in this connection means an orientation to life as a whole not to any of its particular manifestations...whether somatic or psychic" (GP 591). Therefore, Jaspers uses "biological" as a theoretical category closed to life-being. Jaspers emphasizes that this "biological" does not have anything to do with the science of biology that consists of molecular biology, genetics, and so on. This distinction between Jaspers' theoretical biological and Ghaemi's concrete biological carries a measure of methodological clarification and is worth a long quotation:

[T]he question then arises what we are to understand by the term "biological." Obviously it seems not to be what the science of biology takes as its subject; that is, those ever concrete and therefore particular matters which research can explore, but rather something which philosophy of life would like to comprehend as a whole, something within which all particulars occur and from which they all derive. But this whole is no object for research, it is only an idea, a philosophical concept of comprehensiveness. It seems to me that the biology of this "biological psychiatry" therefore expresses the drive of an idea, a philosophical tendency, which perhaps does not quite understand itself but as an object for scientific research it appears quite baseless. [GP 591]

Even though biological existentialism as presented in On Depression does not provide a sufficient theoretical framework for conceptualizing the phenomena of depression, mania, or even mental disorder as such, it demonstrates nonetheless the strong need for sound methodological and epistemological foundations in psychopathology. Reflecting on Ghaemi's biological existentialism through the lenses of the Jaspersian understanding of biological psychiatry, I suggest that three levels of presentations could be observed regarding a person with mental disorder: biological facticity, clinical phenomenology, and existential authenticity. Biological facticity refers to biology in the sense of concrete science, as it is used in On Depression. Biological facticity deals with neurophysiological and neurochemical processes that could be observed in the tissues and organs of people with different forms of psychic disturbances. For example, by analyzing the synaptic metabolism of neurotransmitters. This is an area of concrete science, based on facts, measurement, and explanation. However, what biological facticity explains and categorizes is surely neither depression as a clinical syndrome and not a person with depression. The object under investigation of biological facticity is a specific biological process observed in persons with depression.

The second level is clinical phenomenology, the study of presentations of mental disturbances as they are observed in the clinical reality of daily mental care. For example, by analyzing low mood, free floating anxiety, pessimistic ideation, or suicidal thoughts. This is an area not of concrete science, but of clinical practice that is based on special skills of clinical observation, clinical listening, and clinical talk. Learning clinical phenomenology cannot be formalized as learning biological facticity. Clinical phenomenology includes strong nonverbal components and elements of intuition based on praxis. Clinical phenomenology is what used to be termed "medical semiology." Its object-matter are signs, symptoms, and syndromes. Clinical phenomenology is the level of traditional psychopathology.

The third level is existential authenticity that is concerned with a person in her entirety. This is the area of thrown existenz, based on being-with-one-another, attunement, truth, openness, and freedom. Existenz cannot be broken down into object and subject or measured by numbers and statistical parameters. The existential level is a way to perceive and to understand a person as a person in all the uniqueness and complexity of this person's life situation. Existential understanding includes understanding of presentations of mental disturbances through considering them in the totality of a life perspective.

It is both an open and difficult question, whether and how these three levels interact. In daily routine these levels could be mixed or ignored resulting in methodological confusion. On Depression provides an interesting illustration of the mixture of these levels, as it begins and ends with the discussion of clinical syndromes of depression and mania and existential experiences of happiness and despair. They are discussed as phenomena of the same level. Throughout the book this discussion is often widened to include the data of biological facticity, in particular neurotransmitter metabolism patterns. For example, the very first paragraph of the book clarifies—or perhaps intrigues—that On Depression stems from the author's wish to write on happiness that led him to mania, and then mania in turn steered him toward depression. This narration catches a reader attention, motivating her to keep reading. But methodologically and epistemologically such narration is missing the central point of theoretical thinking.

There could be some similarities in the presentations of depression and despair or of happiness and mania. However, fundamentally—and especially in existential perspective—the nature of clinical categories of mania and depression and the nature of existential experiences of happiness and despair belong to different domains. Happiness is not measured by the amount of pleasure or excitement. Despair is not reducible to clinical components of depression. Existentialism considers the highest form of being human as an ability to be true and authentic: becoming who you truly are. Such authenticity could potentially be associated with a more elated mood, or with a sober mood, or with a more reserved mood. Yet, undoubtedly, biological existentialism stimulates reflection about the fundamentals of mental disorder, as it reveals the significance of philosophical reflection for psychopathology.

1 S. Nassir Ghaemi, On Depression: Drugs, Diagnosis, and Despair in the Modern World, Baltimore, MD: The Johns Hopkins University Press, 2013. [Henceforth cited as OD]

2 Karl Jaspers, General Psychopathology, Vol. 1, transl. J. Hoenig and Marian W. Hamilton, Baltimore, MD: The Johns Hopkins University Press, 1997. [Henceforth cited as GP]

3 Martin Heidegger, Zollikon Seminars: Protocols, Conversatons, Letters, ed. Medard Boss, transl. Franz Mayr and Richard Askay, Evanston, IL: Northwestern University Press 1987, p. 278.