On Depression: Drugs, Diagnosis, and Despair in the Modern World

by S. Nassir Ghaemi

In a culture obsessed with youth, financial success, and achieving happiness, is it possible to live an authentic, meaningful life? Nassir Ghaemi, a psychiatrist with a wide grasp of philosophy, reflects on our society's current quest for happiness and rejection of anything resembling sadness. "On Depression" asks readers to consider the benefits of despair and the foibles of an unexamined life.

Too often depression as disease is mistreated or not treated at all. Ghaemi warns against the "pretenders" who confuse our understanding of depression--those who deny disease excessively for instance or those who use psychiatric diagnosis (the DSM system) "pragmatically" and unscientifically. But sadness, even depression, can also have benefits. Ghaemi asserts that we can create a "narrative of ourselves such that we know and accept who we are," leading to a deeper, lasting level of contentment and a more satisfying personal and public life.

Depression is complex, and we need guides to help us understand it, guides who comprehend it existentially as part of normal human experience and clinically as sometimes needing the right kind of treatment, including medications. Ghaemi discusses these guides in detail, thinkers like Viktor Frankl, Rollo May, Karl Jaspers, and Leston Havens, among others.

"On Depression" combines examples from philosophy and the history of medicine with psychiatric principles informed by the author's clinical experience with people who struggle with mental illness. He has seen great achievements arise from great suffering and feels that understanding depression can provide important insights into happiness.

Genres: Psychology, Nonfiction, Psychiatry, Mental Health, Self Help, Health, Medicine

232 pages, ebook

First published May 8, 2013

About the author

Nassir Ghaemi MD MPH is an academic psychiatrist specializing in mood illnesses, depression and bipolar illness, and Editor of a monthly newsletter, The Psychiatry Letter (www.psychiatryletter.org).

He is Professor of Psychiatry at Tufts Medical Center in Boston, where he directs the Mood Disorders Program. He is a also a Clinical Lecturer at Harvard Medical School, and teaches at the Cambridge Health Alliance.

In the past, he trained and worked mostly in the Boston area, mainly in Harvard-affiliated hospitals (McLean Hospital, Massachusetts General Hospital, and Cambridge Hospital). He has also worked at George Washington University, and Emory University. His medical degree is from the Medical College of Virginia/​Virginia Commonwealth University.

His clinical work and research has focused on depression and manic-depressive illness. In this work, he has published over 200 scientific articles, over 50 scientific book chapters, and he has written or edited over half a dozen books. He is an Associate Editor of Acta Psychiatrica Scandinavica, and is a Distinguished Fellow of the American Psychiatric Association.

After his medical training, he obtained an MA in philosophy from Tufts University in 2001, and a MPH from the Harvard School of Public Health in 2004.

Born in Tehran, Iran, he immigrated to the US at the age of 5 with his family and was raised in McLean, Virginia by his father Kamal Ghaemi MD, a neurosurgeon and neurologist, and his mother Guity Kamali Ghaemi, an art historian. A graduate of McLean High School (1984), he received a BA in history from George Mason University (Fairfax, Virginia, 1986).

He is an active writer, and besides his books, newsletter, and scientific articles, he writes a column for Medscape.

Reviews

[Sandra · Rating 4 out of 5]

Very good book, better and certainly different than I expected. Its charm and intrigue, for that matter, lie in Ghaemi's unexpected approach. Ghaemi is a skillful writer, and so although I probably won't comment more on his fine ability to construct sentences and paragraphs and chapters, that was certainly one of the book's assets. I'd like to read it again, and since it's short (232 pages, including notes) that's an actual possibility.

Part I, "Entrance," consists of five chapters (1. "Lives of Quiet Desperation," 2. "The Varieties of Depressive Experience,3. "Abnormal Happiness," 4. "The Age of Prozac," 5. "The Unknown Hippocrates"). They were interesting and thought-provoking, not least because I have experienced depression and have also accompanied others who were "depressing" (Cheri Huber's interesting use of the word as a verb in her book "Depression"). This is most definitely not self-help. Philosophical, historical, ethical, yes; like a really long, very interesting New Yorker article.

I thought of a few people to recommend the book to, but while I was reading Part II, "Pretenders" (6. "Postmodernism Debunked," 7. "Pharmageddon," 8. "Creating Major Depressive Disorders," 9. "The DSM Wars") I thought, "I'll need to warn them that I found Part II fascinating, but many may find it irrelevant or too specialized." Ghaemi goes into various schools of thought regarding the DSM, the use of anti-depressants, and related topics; there's a detailed account of ongoing personal feuds resulting from differing opinions on situational/personal-historical versus biological causes of depression. Ghaemi argues convincingly that the DSM really has very little to do with actual diagnosis and treatment; the DSM was created so doctors could have billing codes for insurance purposes. This could be potentially freeing information for many. Depressed, anxious, compulsive, manic etc. individuals often grab onto a particular diagnosis and affix it to themselves securely; Ghaemi points out that we are complex beings, and an insurance billing code doesn't necessarily need to determine how we perceive ourselves.

For instance, I found that "neurotic" describes me as well as anything else, but since the term "neurotic" has gotten a bad rap, it is rarely used any more (or at least doctors don't seem to tell patients that they are neurotic). The manic-depressive diagnosis is also probably far more common but also less catastrophic than most people seem to take it. And this section made me wonder whether the wholesale prescription of anti-depressants to the American people should continue. Wonder being the operative word: Ghaemi raises questions but comes down on the side of both biological and situational/historical causes.

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") seemed like a logical structure -- a discussion of scholars and practitioners who can guide us in understanding and treating depression (our own or others').

The fascinating thing about Part III is Ghaemi's idiosyncratic approach. Each chapter describes the work and approach of guides who Ghaemi has found critically useful in his work, and although not everything seemed relevant to readers who might pick up such a book, Ghaemi's interests and passions determined the choices. The Karl Jaspers chapter, in particular, is really about philosophy and not psychiatry, if one is willing to say that such subjects are discrete at all (but note that an earlier chapter deals with postmodernism, so he's wading in both psychiatric and philosophic territory); Paul Roazen mostly writes about the history of psychiatry, but rather than seeming irrelevant, I am as likely to seek out Roazen's writings as any of the other people mentioned, . Thus these chapters were well-written and intriguing: like any other teacher, Ghaemi is most interesting when he digresses a bit according to his own interests, and his digressions may be more revealing than the expected material.

Part IV, "Exit" (15. "The Banality of Normality," 16. "Two o'clock in the Morning"), provided a summary and presented more philosophical grist for the mill. And the endnotes are well worth following; there are many strands I'd like to follow up on from endnotes.

I'm definitely, for better or worse, a polymath (read: "Jack of all trades and master of none"), and a well-written book on *almost* anything make me want to master the subject (never happens; I'm usually off to the next topic). For me, this book was ideal; very substantive but not too long, and full of ideas new to me as well as topics for some future reading. Some day. Maybe. I hope.

Highly recommended.

Ch. 2: "The depression realism hypothesis is this: Depressed persons are not depressed because they distort reality; they are depressed because they see reality more clearly than we nondepressed persons do." 27

Ch. 11: "Anxiety is a normal aspect of human existence; it is, Kierkegaard says, the “dizziness of freedom,” the recognition that we have some choices to make in life. We always have choices . . . . Even choosing to live rather than to commit suicide is a daily choice we all make, consciously or unconsciously. We choose to do this or that, to study this or that, to work here or there, to marry him or her. Each choice is a step ahead toward our goals, but it is also a closing off of other roads. It is a birth, and a death. This is why we are anxious; anxiety arises, May says, at the borderline between being (what happens after we choose) and non-being (what we gave up). Being and nonbeing are in fact inseparable; one cannot be had without the other. They define each other. This is why life is enmeshed with death, why we cannot live fully until we accept death fully, why the greatest enemy of life is denial of death, why such denial is psychological murder. 101-102

Ch. 15: "So if temperament is driven by genetics and biology and it only partly explains personality, perhaps the other piece is character, driven by culture and family environment." (162) and "What is normal is not within psychological or social control; it is partly biological. Normality, like disease, is a matter of the body, at least in part. And it can be quantified on normal curves, where most of us are in the middle, and a few at the extremes. Being smack dab in the middle of the normal curve for personality traits produces Grinker’s homoclites: highly normal people who are highly mediocre. Being at the extremes of personality traits may produce some depression or some mania, and this may be 'dysfunctional' in many ways in society and yet super-functional in other ways.
Who can say which is better?" 163

Chapter 16: "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." 171 [Although I don't believe we are ultimately alone in the universe, faith and hope also require vast reserves of courage, especially at 2:00 in the morning!]

[Sigurd Ruud · Rating 1 out of 5]

It was difficult at times to follow the structure of the book, and the chapters felt disjointed. It felt more like the author wanted an opportunity to publish a set of loosely associated themes and ideas. What was particularly painful to read was his haphazard use of the term “postmodernism” and “postmodernists”, without going explaining what he meant by statements such as that the majority of the American population has been permeated by this philosophy. He does almost offer a definition, coming from a book called “On bullshit”. I’d echo the other review here, reading phrases such as “Those postmodernists who disparage science should stop taking their antibiotics and avoid their vaccines in childhood, if they want to be logically consistent” doesn’t really inspire anyone philosophically or intellectually.

The author didn’t flesh out his ideas enough in my opinion. E.g., in the chapter on Leston Havens, he writes that “If the clinician doesn’t change, then the therapy can’t be successful. Every treatment is in part a treatment of the therapist.” and leaves it there. A lot of the chapters had this characteristic, which made it difficult to get much out of it.

The subtitle of the book was appealing to me, but it didn’t take long before I realised I was going to be disappointed. A short book, I finished it anyway. I wouldn’t recommend it. What is somewhat comical is that I found it on an article on psychiatric letter, where the author of the article went through several themes in psychiatry and which books to read and which to avoid. The author of the article recommended not reading psychoanalysts (including Freud) or philosophers. But all the themes included a recommendation on a book by Ghaemi. Who wrote the article? Ghaemi. Lol.

[Jonathan · Rating 1 out of 5]

Huge disappointment! Adds little that hasn't been said. Makes frequent confident assertions of very debatable propositions. If you're interested in the subject, skip this one--there's much better stuff out there.

[Andrew Montgomery · Rating 4 out of 5]

I thought this was a pretty good read on depression, and, while most of the ideas weren't new to me, I still found it helpful. In my very unqualified opinion, I agree that depression is over diagnosed and over medicated. I am a big believer that grief should not be medicated or diagnosed, and a healthy grief process can still be one of the hardest things a person ever experiences. Medicating the hard feelings just masks the emotions so that they are never properly processed, and real healing cannot take place. Of course, that does not mean antidepressants don't have a place - they do in cases of major depressive disorder, but that should not be diagnosed when someone experiences a depressive episode after a spouse dies, job loss, etc.

What I found particularly interesting is the idea that depressed people see the world more accurately than the rest of the population. This seems to make sense when contrasting it with someone experiencing a manic episode - they often have extremely ambitious goals, like becoming president, and they do not understand the world in a realistic way. People with depression, on the other hand, understand just how futile and meaningless life can be, especially when one considers one's place in the larger place of the world. I recall the author saying that, if aliens looked down at the world, they would not see significant value in any individual human life, just as we probably don't see significant value in any individual ant. A person with depression may feel this futility. Healthy functioning happens in the balance, when one finds sources of meaning but balances that with realistic expectations of the world. This is easier said than done, and the author even challenges the concept of "healthy," as it can change with culture.

Overall, I enjoyed this book, but I doubt I'd read it again. I'd be interested to hear a psychiatrist's take on it because I just don't have the knowledge of how medications work to really agree or disagree with the arguments in this book concerning that.

[Glenda · Rating 3 out of 5]

Definitely not what I had expected, but an interesting read.

Thought provoking discussion around pharmacology, how "depression" should really be diagnosed (including discussion on the DSM and definitions) and that perhaps much of this categorization has to do with insurance purposes/billing and administrative reasons rather than something particularly beneficial to the patient. (my summation)

I'll agree with another reviewer who said it perhaps best, "This is most definitely not self-help. Philosophical, historical, ethical, yes; like a really long, very interesting New Yorker article."

There's a good discussion on some different psychological approaches, including work from Rollo May, Leston Havens, Karl Jaspers, and Paul Roazen. Again, though provoking and interesting philosophical discussion, beautifully written.

[Carmen · Rating 5 out of 5]

This book was very good. It has a lot of psychology in it - the real thing - not pop psychology. I think Dr. Ghaemi offers a very fresh and valid viewpoint on depression.

[Ingo · Rating 2 out of 5]

A rambling philosophical treatise that felt all over the place. Didn't learn much about depression and didn't care enough about the author's voice to be inspired on philosophy. Not impressed, sorry.

[Holly · Rating 1 out of 5]

What an utter waste of time and money.

Often I dislike a book without feeling any animosity for its author. But this book is so dreadful that my main reaction to it is a visceral loathing for Ghaemi. One reason for the personal dislike Ghaemi arouses is that this book isn't about depression; it's about how much Ghaemi hates postmodernism. I hate it too, but I don't think it holds as much sway over the average person as he does.

A much better book that covers some of the same terrain with far more insight and far less weirdness is Madness Explained: Psychosis and Human Nature by Richard P. Bentall.

[Chris · Rating 4 out of 5]

There are a lot of good insights here, but as a layman I needed to dig through the clinical language to get to them. I found the last chapter particularly poignant.

[Marlene]

The author, Nassir Ghaemi is a psychiatrist associated with Tufts Medical Center. He provides the reader with a history of psychiatry and psychology as part of medecine starting with the approaches to health of Hippocrates and Galen. He spends a lot of verbiage on the philosophies that have brought us to the current trend of treating unhappiness with drugs. Postmodernism is largely to blame for our current state of affairs and existentialism is the answer. (Chap. 6 Postmodernism Debunked). Dr. Ghaemi is neither for or against psychopharmacology but in favor of treatment that works.

Dr. Ghaemi describes and critiques the research and conclusions of many doctors that have been influential during the 19th and 20th centuries. These include: Emil Kraepelin, Philippe Pinel, Victor Frankl, Rollo May, Elvin Semrad, Leston Havens, and others.

I was interested in Dr.Ghaemi's views on making choices, despair, failure and hope.

There are extensive notes and a bibliography.

[Heather · Rating 4 out of 5]

Great book. A bit rushed at points, almost leaving the reader behind without worry (or perhaps with pleasure...). Some excellent profound points made clearly, some important points made much less clearly. He seems to write for himself more than for readers at various times, but when he doesn't the writing is great. Includes a very good review of existential psychology/therapy among other things.

[Phillip · Rating 3 out of 5]

Provides fruitful thoughts. Though I recommend beginning with part two and then returning to the beginning if the book appeals. The author takes a while to get to the place he promises to take the reader described on the inner dust jacket. And when he gets there the ideas are good but brief.

[Olivia Thomas]

Really interesting thought provoking read.