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

On Depression

A Geneaology

S. Nassir Ghaemi

Tufts University School of Medicine

[email protected]

Abstract: In this book, I argue against the two most common views on depression: first, depression seen through the DSM diagnostic lens as a disorder to be treated by clinicians, and second, depression seen through the postmodernist lens as a social construct. My view is that there are kinds of depression that represent disease, and kinds that do not. In the former case, a biological approach is legitimate; in the latter case an existential approach is best. The general approach to psychiatry that can maintain this insight I call biological existentialism. I try to explain that existential approach, through the ideas of various thinkers and teachers of that school, and I also critique both the DSM-centric approach of the psychiatric establishment and the postmodernist nihilism of their critics.

Keywords: Jaspers, Karl; Kraepelin, Emil; happiness; depression; psychiatry; existentialism; postmodernism; biology; despair; diagnosis.

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There are three strands of what led me to write On Depression.1 One relates to my initial desire to write about happiness. The theme of happiness has been a focus of much writing and research in recent years, especially as influenced by the positive psychology movement. The concept of happiness has been also a central concern for many philosophers over the centuries.

As I tried to plan such a book, though, I realized that my contribution might be best delivered by discussing depression. Perhaps I could contribute to our understanding of happiness by contrasting it with its opposite, depression and even despair. As I began to write about depression and despair, though, I realized that I mostly had material to discuss about depression itself, not necessarily about happiness. I also realized that there was a large amount of literature on depression, with some people writing from a postmodernist perspective, denying any medical or scientific reality to depression as a psychiatric disease. I felt that I could contribute to that discussion, and gradually my focus shifted away from happiness and more toward a better understanding of depression.

Another strand was my feeling that I wanted to write a book that was explicitly about the existential approach to psychiatry. I had alluded to existential ideas in prior works, but I had not solely focused on them. I also felt that no one had written a book about depression in recent decades from the existential psychiatry perspective, and that there was no real discussion of the concept of despair and how it relates to and is distinct form clinical depression. So, when I wrote about my thoughts on depression and despair, I decided to focus on an interpretation from the existential tradition in psychiatry.

Lastly, a third and final strand in this book was my wish to make a clear and direct critique of postmodernist cultural assumptions as related to psychiatry. I focused that critique on what I had learned in recent years in the course of debates around DSM-5. I also directed that critique to critics from outside psychiatry, who were in my view postmodernist ideologues, and yet the discussions about their views rarely brought out these philosophical presuppositions directly.

So, in sum, On Depression was meant by me to be a book about depression from an existential perspective, a critique of postmodernist thinking, and an indirect contribution to understanding happiness.

I organized the book around specific people I had either known well myself, or whom I had read about. I felt this would allow me to be more personal where I could be, consistent with the existential approach to psychiatry, and it also allowed me to pay homage to some of my mentors and friends who had passed away, such as Leston Havens and Paul Roazen and Leonard Ehrlich. At the same time, the focus on existential psychiatry allowed me to write more about thinkers in that tradition, some of whom I had not written about previously and who are not well known to many readers, like Elvin Semrad and Rollo May. My chapter on Karl Jaspers focuses on his views on religion and faith, about which I had not previously written, but since this was the specialty of Leonard Ehrlich, from whom I had learned so much, I felt it would be an homage to Leonard to explore that aspect of Jaspers' ideas.

I began and ended the book with discursive essayistic writing, a style that I had not used in most of my prior academic works, and I hoped in doing so to make the book more accessible to a larger reading audience. I knew that the multiple strands in the book would make it less popular than if I had maintained only one focus, but I felt that I wanted to write a book with those multiple strands, to get those ideas out in print in a book, and thus to provide a resource for interested readers to be able to think about existential psychiatry, and to be able to critique postmodernist thinking in our field. Some of the basic ideas are as follows:

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 is not a disease: it can be a reflection of personality traits, a tendency to be anxious and moderately sad all the time, with brief periods of mood worsening. Or it can be just a reflection of life, and death, the existential despair that we all experience, whether we want to admit it or not.

The job of the good physician, the good clinician, is to identify when depression is a disease, and when it is not. We get nowhere in the modern practice of psychiatry because we reject the whole concept of disease, and then we either always, or never, diagnose depression; and we always, or never, treat it with the right medications or psychotherapies.

There are some psychologists and psychiatrists who honestly described that existential despair, and tried to relate it to the clinical expressions of depression: scholars 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 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 was not true, and then unearthed what we need to know about his insights; like the philosopher and 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. There also are pretenders to wisdom, 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-5), who literally made up hundreds of diagnoses to influence clinical practice for their own purposes.

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 is not simple, but there is a 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 is not, there are some guides to follow, and some pretenders to avoid, and some wisdom worth hearing.

Reply to my Critics

I appreciate the thoughtful commentaries of Drs. Cabrera, Bezzubova, Marin, and Adsett. Their constructive, supportive, and critical comments are wise and tactful. This commentary applies to their essays as a whole, based on topics.

Biological Existentialism

This concept generated a great deal of interest among the commentators. The main point I was trying to make in this respect is how ideas have been made opposites that need not be so. In particular, there seems to be a heritage in the existential and phenomenological literature, both in philosophy and in psychiatry as well as in psychology that opposes this school of thought to biology and science. I think this opposition, which is in most cases assumed rather than proven, grows out of the fact that most philosophers and psychiatrists have learned their existentialism at the feet of Jean-Paul Sartre and Martin Heidegger, not at the ones of Karl Jaspers. Most commentators do not even distinguish Jaspers from these other existential thinkers. This is not the case with regard to the commentators of my book, who know the Jaspers literature well. But I wanted to point out to the larger world that Jaspers' existentialism differs a lot from that of Sartre and Heidegger. The latter thinkers led the world toward postmodernism, while Jaspers fought postmodernism explicitly. Jaspers did so by repeatedly emphasizing the legitimacy and importance of science as a privileged means of knowledge, something that Sartre and Heidegger and Foucault explicitly reject.

Unfortunately, those who are attracted to existential and humanistic approaches to psychology and psychiatry tend to dislike science and biology, or at least tend to only pay lip service to the latter. I wanted to take seriously both existential thinking and biological thinking. Jaspers provides plenty of guidance for this merging of science and existentialism. Elena Bezzubova may be correct that Jaspers himself, or in some of his writings, can be found disagreeing with some of my interpretations. But I am not interested in an exegesis of Jaspers. I am interested in the truth. Amicus Plato, sed magis amica veritas—Plato is my friend, but truth is a closer friend.

Nonetheless, I think that the thrust of Jaspers' thinking is consistent with the biological existentialism I explore. I think it is also not correct to describe existentialism in any single way; there are multiple approaches to existential thinking. So existentialism cannot be said to essentially involve authenticity or a concept related thereto. It involves many different concepts.

To argue, as Bezzubova does, that the clinical syndromes of depression and mania are in some way different categories of things than that those of existential sadness or happiness are, is a claim that needs to be supported, not simply presupposed. My view is that there are many reasons, both conceptual and empirical, to reject such an assertion. In doing so, I would suggest that my view is more monistic than her perspective as it regards the mental and physical dichotomy.

The Happy Mean

Bezzubova describes my perspective as seeking a mean between the extremes of many different aspects regarding the topic of depression. Daniel Adsett, however, sees me correctly as providing an alternative to the two opposite extremes of positivism and postmodernism. I do not reject the idea of seeking a mean, and I am pleased that my book is seen as having a mostly conciliatory tone. But I would be happier with calling it a dialectical resolution of the two extremes, which are to be regarded as false on their own merits, hence my use of the designation "pretenders," which I knew would irritate defenders of those extremes. I value Aristotle, but perhaps we should add a little G. W. F. Hegel here.

I know there are valuable insights to be had in postmodernism: some psychiatric categories are social constructs (but not all of them). I know there are truths in biological reductionism: some psychiatric conditions are diseases (but not all of them). I am not saying, though, à la the eclecticism of the biopsychosocial model that these conditions involve a little bit of both. I have critiqued and rejected biopsychosocial eclecticism at book length.2 Instead it is not about a mean, but rather about clear thinking. When should we take this approach versus another? That is the attitude I take.

As Adsett notes, this attitude puts me into a place to reject the two common views of depression—the DSM-centric diagnosis and drug treatment view versus the postmodernist view—as being equally wrong, but for different reasons.

An Attack on the Psychiatric Establishment and Its Critics

My book is an attack on the psychiatric establishment, namely on those who devise and defend DSM and who advocate extensive use of antidepressants. It is also an attack on those who, on postmodernist grounds, criticize the psychiatric establishment with regard to the above matters. I write at length about how postmodernism has become the central ideology of our day, for better and for worse. I think it is important to improve psychiatry and to reject many false ideas held by the mainstream today. But to do so in the service of a false postmodernist ideology would only make matters worse. My book is an attempt to make that critique and to do so constructively, based on solid science and sound thinking. Casimiro Cabrera and Alina Marin see my purpose here, and connect it to my prior books as well as to my ongoing engagement with the psychiatric establishment and its postmodernist critics. It feels like a critique of capitalism that also rejects the communists. We need to find another way.

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 S. Nassir Ghaemi, The Rise and Fall of the Biopsychosocial Model, Baltimore, MD: The Johns Hopkins University Press, 2007.