On Depression Drugs, Diagnosis, and Despair in the Modern
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On Depression
Drugs, Diagnosis, and Despair in the Modern World
NASSIR GHAEMI
© 2013 The Johns Hopkins University Press
All rights reserved. Published 2013
Printed in the United States of America on acid-free paper
987654321
The Johns Hopkins University Press
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Library of Congress Cataloging-in-Publication Data
Ghaemi, Nassir.
On depression. drugs, diagnosis, and despair in the modern world /
Nassir Ghaemi.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-4214-0933-7 (hardcover. alk.paper) — ISBN 1-4214-0933-
X (hardcover. alk. paper) — ISBN 978-1-4214-0934-4 (electronic) — ISBN
1-4214-0934-8 (electronic)
I. Title.
[DNLM. 1. Depression—psychology. 2. Antidepressive Agents. 3.
Depressive Disorder—diagnosis. 4. Depressive Disorder—drug therapy. 5.
Diagnostic Errors. 6. Existentialism. WM 171. 5]
616. 85’27—dc23 2012036893
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To Dr. Frederick K. Goodwin
and to Dr. Athanasios Koukopoulos
What was man?
In what part of his conversing,
of his laughter and whistling,
in which of his chemical movements
lived the indestructible,
the enduring,
the living?
PABLO NERUDA
CONTENTS
Preface
Part I. Entrance
1 Lives of Quiet Desperation
2 The Varieties of Depressive Experience
3 Abnormal Happiness
4 The Age of Prozac
5 The Unknown Hippocrates
Part II. Pretenders
6 Postmodernism Debunked
7 Pharmageddon?
8 Creating Major Depressive Disorder
9 The DSM Wars
Part III. Guides
10 Viktor Frankl: Learning to Suffer
11 Rollo May and Elvin Semrad: I Am, We Are
12 Leston Havens: Holding Opposed Ideas at Once
13 Paul Roazen: Being Honest about the Past
14 Karl Jaspers: Keeping Faith
Part IV. Exit
15 The Banality of Normality
16 Two O’clock in the Morning
Acknowledgments
Appendix. Listening to Despair: An Interview by Leston Havens
Notes
Bibliography
Index
PREFACE
I intended to write a book about happiness, but as I got into the topic I
realized that I couldn’t do so unless I also wrote about despair, and even
depression, which also entailed discussing mania. So this is a book about
what it means to have depression or bipolar illness and what it means to
experience despair or happiness. I critique some views that I think are
mistaken in these debates, and I explore those thinkers, especially from the
existential tradition in psychiatry and psychology, whose wisdom needs to
be heard.
Nietzsche said he loves only that which is written in blood. This book is
an attempt to discover the meanings of depression and mania, not in a
merely abstract sense, but with the insights, hard won and written in blood,
of those whom I see and try to treat daily and of those who have taught me,
in person and in books.
I Entrance
For years I was unhappy, consciously and deliberately … so that I isolated myself more and
more, undertook less and less. … The misery and solitude and apathy and sneers were the
elements of an index of superiority and guaranteed the feeling of arrogant “otherness.”… It was
not until that way of living, or rather negation of living, developed such terrifying physical
symptoms that it could no longer be pursued that I became aware of anything morbid in myself.
In short, if the heart had not put the fear of death into me I would be still boozing and sneering
and lounging around and feeling that I was too good for anything else.
SAMUEL BECKETT
CHAPTER 1
Lives of Quiet Desperation
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 think 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.
SOME DIVIDE THE WESTERN mind arbitrarily into three epochs: the
premodern, the modern, and the postmodern. The premodern age was when
God was alive: the West believed in the Lord, either through the ascendancy
of Christendom, or even before, through the deities of Roman, Greek, and
other religions. The world had order and law and meaning, all divinely
ordained, sent to humans through books of revelation and enacted through
the divine right of kings. This was, intellectually, the Garden of Eden of
mankind. The universe was, one might argue, a much kinder and gentler
place, intellectually, in the medieval era than it later became.
The modern era began when Europeans, inspired by Islamic thinkers
(themselves rediscoverers of Greece and Rome), began to doubt the laws of
God and man. The established order was put to the test of Reason, and
Reason was seen as superior to Revelation or power. First in Italy—later in
France and England and eventually in Germany and America—the
revolution of Reason swept the West. God was taken ill. He was not dead
yet, but he had lost his personal power. He had become subservient to
Reason, needed to start the world in motion at the beginning of time but no
longer serving active purposes in the lives of men. The American Founding
Fathers invoked his name but always within the confines of rational
thought. God had become sicklied o’er with the pale cast of thought (as
Shakespeare’s Hamlet put it)—but he still breathed.
The new spirit of Reason, and the old spirit of Revelation, coexisted for
a while, but then began to conflict more directly after Darwin seemed to
disprove the word of God, and, by the end of the nineteenth century, it
became clear that the West was entering a new era. God was losing the
battle with Reason, and eventually, as Emerson and Nietzsche and a few
others noticed, God lost.
He died.
We entered the postmodern era, which we might date as beginning in the
year 1900, when Nietzsche himself died after years of chronic insanity and
later dementia.
Nietzsche was both the prophet and the critic of this postmodern world.
He saw the harm of the premodern mind; life was placid mentally, but it
was torture physically. God’s rule in the mind was benign, but in the real
world, men killed and slaughtered and died needlessly in his name. In the
modern era, the reverse had happened: physical existence had improved;
lives were more often saved than lost as science progressed; but mentally,
mankind suffered great torture. It no longer knew what to believe; it had not
yet let go of God, but it could no longer accept his word as final either.
Nietzsche approved of the new mental freedom, even if it produced pain;
the anesthesia of intellectual submission to God was not worth it. Truth was
to be preferred. Still, he also wondered whether something had been lost
with the end of the physical conflicts and challenges of the past. When life
became safe and predictable and secure, had humanity lost something
essential to being human?
To explain this dilemma, Nietzsche set up the antimony of two kinds of
persons: the Superman and the Last Man, which I’ll explain next.
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, but 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.
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. 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.
“Alas,” Zarathustra says, “the time of the most despicable is coming, he
that is no longer able to despise himself. Behold, I show you the last man”
(italics in original).
The Last Man is a creature 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.
Yet, except for the teenager himself, we do not usually state the beliefs
of the Last Man so bluntly. Indeed, as we grow up, we do not think we are
Last Men. Rather, we think we have achieved something greater, something
Nietzsche wanted to achieve, what he called Superman.
Here is Nietzsche’s version of human history: Man was once Man, pure
and simple, but Man evolved into Master and Slave, and from those two
types, Man then degenerated into the Last Man; and now his only way out
is to become Superman.
Ubermensch is the German, which can also be translated “Overman.”
Superman connotes the comic hero, the movie screen hunk, flying across
the big city, greater, much greater, than the average man. But perhaps even
the comic myth contains within it the seed of Nietzsche’s insight. For
Superman is also Clark Kent; not only is he superhuman, he is human. Or
perhaps he shows that the two can be the same: that what is human can be
superhuman.
The word Overman gives the connotation that Nietzsche might have
been seeking: to overcome man as he has become, to become more than the
Last Man, to put all of them behind—the Last Man, the Master, the Slave.
Man is not just one thing; there is no essence to him; so Man can change,
and the Overman would be the next change, the next step beyond the Last
Man, toward something better and greater than this most despicable version
of humankind.
NIETZSCHE IS UNJUSTLY CARICATURED in the notion of a will to power. He is
seen as simply exalting power over right, strength as the source of morality.
This view collapses in the public mind with the atrocious use of
Nietzschean terms by the German Nazi regime. Yet Nietzsche’s concept of
power and morality was ambivalent; he characterized it as “the Roman
Caesar with Christ’s soul.” Frequently I have laughed, Nietzsche makes
Zarathustra say, at the weaklings who thought themselves good, because
they had no power to be bad. They had no claws and forsook eating meat.
Nietzsche wants us to be strong, and then to be good, not to pretend that our
weakness represents goodness. The Last Man is weak and bad but pretends
he is good; the Overman is to be strong and good and needs no pretension.
Precisely because I deem you capable of all evil, Nietzsche says to those
whom he wants to become Overmen, I demand the good from you.
This is rational. One cannot be held responsible for being a certain way,
unless one is capable of being another way. In philosophical terms, agency
precedes responsibility. Most of us know this when we think about evil: If
we blame someone for a crime, it is because we think he could have
avoided committing it. Indeed, if one is completely insane, and thus not
able to act otherwise, we do not ascribe guilt. Nietzsche is arguing that the
same logic holds for doing good: If we praise someone for goodness, it has
to be because that person could have done something bad instead. This is
why one has to be strong first, before one can be good; one has to be
capable of evil in order to do good.
NIETZSCHE BECAME THE FAVORITE philosopher of a school of thought that has
come to be called, generically, postmodernism. Its leading figures tend to be
French (like Michel Foucault and Jacques Derrida), but there are also some
Germans (Martin Heidegger and his followers).
Postmodernism isn’t just a philosophy, though; it is a cultural movement,
with impact in the arts, literature, social sciences—and even medicine and
psychiatry, as we’ll see.
A definition first:
Postmodernism is the notion that the “modernist” goal of discovering the
truth, through reason and science (“the Enlightenment project”), has failed;
our claims to truth and knowledge, whether through science or democracy
or other ideologies, are merely culturally relative opinions, with economic
and political sources. Our ideas (to adapt Marx) are a mere superstructure to
our culture.
This way of thinking has taken root throughout Western culture. It began
with the Romantic movement of the early nineteenth century, a protest
against the rise of science, culminating most explicitly in the work of
Nietzsche at the turn of the twentieth century. Many commentators think
that it became associated with a certain nihilism, especially after the shock
of the Great War of 1914–1918, which seemed to put the lie to the
modernist notion of endless peace and prosperity. It seemed even more
vindicated by the rise of Nazism in the very heart of the most modernist,
scientific, rationalist Western nation—and the horror of the Holocaust, in
which advanced technology was applied to evil purposes.
Postmodernism flourished in interwar France, especially under the
influence of the philosopher Alexandre Kojeve, who mixed it with
Marxism. The philosophy really took off in postwar France, spawning a
generation of thinkers who fully formulated the postmodernist ideology,
foremost among them Jean-Paul Sartre and Michel Foucault. The student
revolts of 1968 are often seen as the practical flowering of the
postmodernist rejection of liberal democracy and all its rationalist/scientific
ideologies. The neoconservative reaction of the 1970s and 1980s followed,
and the past few decades have been the setting of “culture wars” between
postmodernism and conservatism among Western intellectuals.
THE POSTMODERNIST CRITIQUE IS, in great measure, a reaction to the science
worship, called “positivism,” of the nineteenth century. Yet the options are
not the two extremes of postmodern nihilism or positivistic dogmatism.
There are other perspectives, such as Karl Jaspers’s pluralism (expanded in
the Continental tradition of phenomenology) or William James’s
pragmatism (expanded later in the works of philosophers like W. V. O.
Quine, Daniel Dennett, and others). There is a spectrum; but like all
debates, the partisans at the extremes make the most noise.
The philosopher Daniel Dennett gave a remarkable lecture titled
“Postmodernism and Truth” in which he makes the point that postmodernist
professors of literary theory can afford to be relativistic because they never
get sued. Doctors don’t have this luxury. If doctors can kill, and be sued,
and held responsible for right and wrong action, then there are truths—
hence postmodernism is false.
Postmodernist thinkers, like Foucault, have interpreted Nietzsche as
arguing for a relativism of all morality, that ultimately power was the basis
of all claims to the good. Contrary to these postmodernist misconceptions,
one can say that Nietzsche was just arguing for a rational morality from the
perspective of defining the good, as opposed to a morality (as in most of the
Christian tradition) based on defining evil. Nietzsche was also trying to link
morality to human psychology, making the point that different approaches
to morality flowed from the state of humankind in different epochs of
history. There is no unchanging essence to human nature, he claimed in
agreement with Darwin, and thus our views of the moral would change
based on the state of humankind in a certain time and place. This does not
entail relativism: not all states of human nature are equally moral or
praiseworthy; Nietzsche certainly had strong feelings on this point. Indeed,
the postmodernist misappropriation of Nietzsche, just like the Nazi one,
shows us that the problem is postmodernism itself, that those who claim to
be diagnosing our ills are in fact their causes (a topic expanded in chapter
6).
Nietzsche had it right: Postmodernism is our disease today, but in case
the German thinker and the academic phrase seem forbidding, we can turn
