Against Depression

by Peter D. Kramer

"Deeply felt... [Kramer's] book is a polemic against a society that accepts depression as a fact of life." —O, The Oprah Magazine

A profound look at depression by the author of The New York Times Bestseller, Listening to Prozac

In his landmark bestseller Listening to Prozac , Peter Kramer revolutionized the way we think about antidepressants and the culture in which they are so widely used. Now Kramer offers a frank and unflinching look at the condition those medications depression. Definitively refuting our notions of "heroic melancholy," he walks readers through groundbreaking new research—studies that confirm depression's status as a devastating disease and suggest pathways toward resilience. Thought-provoking and enlightening, Against Depression provides a bold revision of our understanding of mood disorder and promises hope to the millions who suffer from it.

Genres: Psychology, Nonfiction, Mental Health, Mental Illness, Science, Self Help, Health

353 pages, Paperback

First published January 1, 2005

About the author

Peter D. Kramer is the author of eight books, including Ordinarily Well, Against Depression, Should You Leave?, the novels Spectacular Happiness and Death of the Great Man, and the international bestseller Listening to Prozac. Dr. Kramer hosted the nationally syndicated public radio program The Infinite Mind and has appeared on the major broadcast news and talk shows, including Today, Good Morning America, The Oprah Winfrey Show, Charlie Rose, and Fresh Air. His essays, op-eds, and book reviews have appeared in the New York Times, Wall Street Journal, Washington Post, and elsewhere. For nearly forty years, Dr. Kramer taught and practiced psychiatry in Providence, Rhode Island, where he isEmeritus Professor of Psychiatry and Human Behavior at Brown University. He now writes full time.

Reviews

[S̶e̶a̶n̶ · Rating 3 out of 5]

The emptiness, paralysis, and terror of depression have only a modest connection to the sadness of everyday life.

I have conflicted feelings toward this book. On the one hand, Kramer is one of the more prominent contemporary psychiatrists writing for a lay audience who support the biomedical model of research and treatment of mental ‘illness’—a model which in general I oppose. Kramer believes depression is a disease and as such it deserves all the attendant research and medical attention relegated to any other disease, with the ultimate goal of eradication. Part of this means that, while in fairness he admits they are imperfect, he also rarely misses a chance to put in a plug for antidepressants, even if he’s doing it in his lucid, restrained manner. On the other hand, Kramer’s writing on depression is not without its elegance in certain passages and I did sometimes find myself falling under the sway of his literate prose (he also lists Gabriel Josipovici as a favorite writer, for which I grudgingly must give him points). It is clear that Kramer has a fairly good grasp on what it means to live with depression. He is, after all, a psychiatrist with many years’ experience of treating depressed patients. He does not rely exclusively on antidepressants in his practice and acknowledges their shortcomings and inappropriateness in certain circumstances. At times his empathy shows through his clinical veneer, although he is often just as quickly back on his psychiatrist’s pedantic pedestal.

Kramer’s various arguments for the biomedical approach to viewing depression also do occasionally make sense. One of the problems with the book, though, is that he employs too many of these arguments. It’s like he’s trying to use everything he can think of to convince the reader, even briefly veering off into memoir in an attempt to prove by relating his personal experience that he understands alienated states. This multipronged approach he uses ends up diluting his argument instead of strengthening it. There are other problems with the book, such as the somewhat condescending tone he uses when discussing his patients, and in particular, women patients. There’s more than a whiff of patriarchal arrogance to these passages that I found both distasteful and detrimental to his points.

I wish I had more time to properly engage with this book and with Kramer’s arguments, but frankly it’s getting dark and I’d rather go take a walk in the woods right now. He makes some valid points and I don’t disagree with him across the board. His arguments and points are also very well cited, with the supporting research properly documented and annotated in the endnotes. I just think he could have made a better impression in this book if (a) he wasn’t so condescending; (b) he wasn’t sexist in that way that men of his generation often are; and (c) he had streamlined his approach (e.g., not talked so much about art and melancholy).

[Kristen · Rating 5 out of 5]

I read this several years ago, after recovering from a serious episode of depression. Peter Kramer addresses the sort of twisted love affair that western culture has with depression. He writes to combat the idea that melancholy and depression somehow make one heroic and interesting. My favorite part of this book is that he attacks the myth that famous artists would not have been or would not be the great artists they are without the mental torment and dark valleys of depression. Instead, he suggests that depression is a debilitating illness, one that limits its sufferers capacity. Depression is not a virtue, Kramer says, but an illness. He argues that without depression the tormented souls we idolize could have even been greater. Yes, Van Gogh was amazing. But what could he have been? And what would society be without mental illness be? I hugely appreciated Kramer's bravery in writing against such a hugely mistakenly romanticized view of depression. Against Depression is very thought-provoking, smart, and compassionate.

[John · Rating 2 out of 5]

The author certainly knows about depression, but in this book his prose style and frequent tangents slow the reader down and are little more that detractors and fillers. You wonder if he is writing for himself: has he fallen in love with his writing style so that as many sentences as possible can be sretched out beyound usefulness. His message gets lost in these elongated thoughts, elaborate case histories that are overdrwwn as if he intends a shore story. See,for example case of the women who could not get her laundry done.

His effors at style are overwrought and interfert with a clean message that is easibly followed.

The CD is not any better option and should not be played while driving -- you could drive into a ditch.

[Jesse · Rating 5 out of 5]

Against Depression may be the most significant book I've read on the topic of depression, combining new scientific research with cultural and social criticism. The book chronicles new developments in the science of the brain, highlighting the lack of resilience in certain parts of the brain in the depressed.

Using this physical description of depression, Kramer argues persuasively that depression should be considering a disease in the same literal sense as other physical illnesses such as cancer.

Assuming that depression is, in fact, a disease, Kramer wonders why the culture still romanticizes depression in a way that it doesn't for other diseases. In particular he addresses the supposed role of depression in art. He argues that difference, not depression in particular is valuable to writing and art. He believes that certain aspects of both the artistic and the depressive temperament, such as feelings of alienation from society, can still be valuable to art, as long as the feeling of alienation is not simply a product of a depressive illness. Kramer's longstanding interest in literature and the arts was particularly engrossing to this reader.

He argues that depression is one of the most pressing health concerns confronting the world, with major depression being more debilitating than many other, more obviously "physical" illnesses, and often striking much earlier in life. Particularly noteworthy is that Major Depression is a progressive illness in the same sense as cancer; if not treated properly early on, recurrences tend to be more frequent and more severe. Non-treatment can eventually lead to permanent debilitation.

Kramer covers all of this ground in a sparkling prose style that raises Against Depression above other purely academic tracts on the topic. The book includes a wealth of information while being extremely readable and engaging at the same time.

[Emily · Rating 4 out of 5]

in natalie angier's review for the new york times, she says, "Forget the persistent myth of depression as a source of artistry, soulfulness and rebellion. Depression doesn't fan creative flames. It is photophobic and anhedonic and would rather just drool in the dark." this is so important for artists to know: if you're depressed, it's an illness. if you treat your illness, you will not lose your artistry. you may in fact gain a greater capacity for creating the art that lies within you.

[C · Rating 5 out of 5]

Probably my giant intellectual crush on Kramer is clouding my views on this book -- which, if I'm being honest, meanders too much and is about 75 pages too long. But I don't care. Take all five of my stars.

In a series of section (What It Is To Us, What It Is, What It Will Be) Kramer argues that our current understanding of depression is colored by our past love affair with melancholy. It probably would have been helpful to read Listening to Prozac before Against Depression, as this book seems to pick up where the other one left off. Kramer smashes together clinical vignettes, modern genetics research, and a historical survey of depression to make his argument. While a lot of the material was familiar to me, I found that he framed it in a new way. I also preferred this depression "survey" to Andrew Solomon's; Kramer is much more objective and clear-headed in his arguments, having experienced depression mostly by abiding with his patients. That being said, the brief personal section on Kramer's own alienation was one of the book's strong points. The cherry on top for me was that Kramer and Kenneth Kendler (a brilliant, brilliant psychiatrist and researcher at my hospital) went to residency together and Kramer spends a whole chapter supporting his argument with Kendler's research. Which isn't just because their pals -- it's because Kendler has published basically everything that matters on the genetics of depression and schizophrenia. Also some nice shout outs to Carl Elliott and Kay Jamison (and he works with Christine Montross at Brown! Swoon-city).

Overall: a v. interesting (if not perfectly tidied) read by someone I deeply respect. Informative for physicians, patients, philosophers, and the curious among us.

[Kirsten · Rating 5 out of 5]

This is a magnificent book, definitely required reading for those who have suffered from major depression or anyone who has ever been close to a depressive. Kramer (the author of the also-excellent Listening to Prozac) makes it clear from the start that he believes that depression is an insidious disease that does not deserve the romanticization that has long surrounded it. He compares depression and the culture of melancholy to the way people used to romanticize tuberculosis, which used to be seen as a romantic disease that indicated refinement and tragic beauty. He offers up a lot of evidence to back up his beliefs, both from his own practice and from scientific studies that illustrate the physical effects (and possible causes) of depression. Even so, he is not unsympathetic to the impulses that lead us to romanticize depression and feel uncomfortable about the idea of eradicating it completely, and this book never edges into polemic. Reading it is sort of like having a series of dinner table talks with a very intelligent friend.

[Frrobins · Rating 1 out of 5]

I found this book in a library giveaway without knowing much about it. Ironically I thought it would be arguing that depression didn’t exist when it turned out to be a strong argument that it does, an exploration of why some people may believe that the benefits of depression are worth its miseries (such as the rather debunked idea that depression makes people creative) but how the author believes it needs to be treated with medication.

This book is divided into three sections. I quickly picked up on how the author was throwing spaghetti on the wall in a pretentious manner, using a lot of flowering language to say very little of substance. I’ve come to conclude when I see this writing style that someone’s arguments are not as rock solid as they would like and feel that they try to overwhelm the audience with their intellectual prowess to divert them from the fact that they really aren’t saying anything substantial. During the second part this changed, and he started going through studies and things became more concrete and substantive, so I hung on during the second part and the second part was worth my time and gave me things to think about. During the third it was back top throwing spaghetti on the wall and I gave up.

I work in mental health doing talk therapy, something that Kramer doesn’t put much stock in. One challenging question in mental health is the question of when a natural reaction to sadness or depression due to life events becomes pathological. This is something that Kramer does throw against the wall without answering. He acknowledges that someone suffering the loss of a loved one will be sad and that there is a difference between healthy grief and pathological grief but does not define that difference. Overall he seemed to argue strongly that suffering is wrong and unjustified and brought in evidence of physical symptoms that accompany depression to prove his case.

And I have no doubt that mental illness produces physical symptoms. We can’t separate our minds from our bodies, and I don’t believe that we have souls or that our minds and body are separate. But that also means that a stressful and harmful environment will affect our mental and physical health and I strongly believe that when we are in a toxic environment we need to change our environment so it is healthier rather than medicate ourselves to tolerate a bad environment. Kramer never even touches this reality.

A hard truth of life is that no one is going to be able to live a life without suffering, and that some people are more resilient in the face of suffering than others, something he does acknowledge but once again he does not define the difference between healthy coping and pathological. And some things that he uses as physical evidence of depression, like inflammation, also occur with people who do not have depression. I have several autoimmune disorders that are caused by inflammation and I don’t have depression. Further, Kramer acknowledges that a lot of the data on what causes depression and how to treat it is confusing and contradictory but then he quickly drops it and moves onto something else without explaining how his argument was on firmer empirical grounds than others.

This was published in 2005 and since then some people who work in mental health, myself included, are concerned about how people are more focused on their mental health diagnosis, as though knowing their diagnosis is what they need to get the right treatment, and less on focusing on whether certain behaviors or ways of thinking are helping or hurting them as well as how the criteria for some disorders have been expanded to include people who are not going through clinical levels of distress. This is not to minimize their struggles. Life is hard! But pathologizing people unnecessarily won’t help and will hurt. I feel that arguments like Kramer’s have contributed to some of this and frankly it makes me angry because I see real harm result.

For instance one thing I do is help people who are in abusive relationships leave. People who are in an abusive relationship are often depressed and anxious, walking on eggshells to appease someone who is tearing them apart mentally and while beating them physically. They will often talk about their anxiety medications not working properly because they still feel anxiety while living with their abuser, but I will say that they are living with someone who beat them badly enough to leave them hospitalized, of course they are going to be anxious! That anxiety they are trying to medicate away is trying to help them. So is the depression. It is not normal or healthy to be happy with someone who verbally berates you before beating you. In this case depression is a sign to get out. It would be pathological to not be depressed and anxious in such a situation!

Medication may reduce that person’s inflammation or increase their serotonin, but it won’t fix the fact that they are living in an unhealthy environment, and I strongly believe that this is not something we should fix. Whether or not medication helps them to keep it together as they leave and go through the challenging emotional recovery work is hard to say because of the placebo effect, which some studies suggest is very strong with mental health medications. But I do know that getting to a healthier environment and grieving and rebuilding a sense of self is integral to recovery, but they don’t make a pill for it.

And like many in my field I have noticed that some people come in, capable of insight, flexibility in thinking and being able to make changes while others come in with more rigid ways of thinking, who have a harder time challenging cognitive distortions and unhelpful patterns and more difficulties with insight. In fact I would say the big difference between someone who is capable of recovering and one who gets stuck is how cognitively flexible they are, something that some evidence backs up. I’ve yet to see a medication that improves someone’s cognitive flexibility though.

I’m not anti-medication for the record. There are people who do not respond to therapy and who experience depression when everything in their life is going well. One benefit of talk therapy is the exploration that occurs into what is contributing to someone’s feelings of depression. And while many people are not in abusive environments it is eye opening how often it can be tied to things in their environment or ways of thinking that need to change. But sometimes it can’t. I believe medication is worth a try after that exploration has happened and the client has shown no benefit or improvement. But I feel that medications are often used as a first resort rather than a fourth resort.

Which is what gets lost in all the spaghetti tossing in this book. Of course we need to treat people experiencing clinical levels of depression in a way that honors the pain of what they are experiencing with compassion. But where is the line between someone experiencing a normal reaction to adverse life circumstances and someone experiencing a clinical level of distress unrelated to life circumstances? With medication, how do we determine who will and who won’t benefit and how do we ensure that we aren’t medicating people to tolerate abusive environments (battered women rarely admit they are being abused in a screening)? And most importantly in both cases, are our methods to help effective?

Kramer left a beautiful mess of spaghetti on the wall in the hopes of hiding that he never really addresses these questions.

[Sian Jones · Rating 5 out of 5]

Dr. Kramer presents the latest medical research into the progressive, systemic disease that is depression. He debunks the misplaced morality and flawed personality theory that colors any discussion of the disease in this culture. He even tries to figure out why we talk about depression, a physiological condition, as an individual spiritual failure. He tackles all of Western cultural history to account for how we got where we are, and poses suggestions for what the world would be if we treated depression the way we do high blood pressure or other chronic diseases.

It's safe to say that this book is one of the most important I've read, as the beloved Eddie Izzard would say, in the history of ever. If you've been anywhere near me in the four months that I took my time savouring this book, you've heard me talk about it. I've probably tried to cajole you into reading it pretty much every time you talked to me. This review is unabashedly an attempt to cajole some more. I will put this book IN YOUR HANDS myself if I have to.

What it comes down to is this: Kramer puts into words what I cannot about the very things going on in my own feral mind. If you suffer from depression, this book helps you see yourself more clearly. If you love someone who suffers from depression, this book helps you to see them more clearly than they could present themselves.

[Kate Wyer · Rating 5 out of 5]

This book is essential reading for anyone who has/is experiencing depression, or who has a loved one who is. It documents the way our culture romanticizes the illness, and opened my own eyes to how I think about my own tendencies. It also details the real, physical damage the disease does on the heart, the brain, the nervous system as a whole, and the stress response. Please do not tolerate depression, or think that is it part of your personality. Seek treatment. Your body, your memory, and your future quality of life depend on getting help, in whatever modality works for you. Art therapy, combined with methylfolate (I have the MTFHR mutation), have been slowly returning me to a less isolated, less sick individual.

[Flat · Rating 2 out of 5]

According to Kramer, tuberculosis was once romanticized because it made its sufferers delicate and pale; today we link depression with creative genius and are reluctant to treat it. That's a fascinating analogy, but depression is not an infectious disease, no matter how much Kramer wants to believe it is.

[Erin Smith · Rating 3 out of 5]

Another counseling course book. He makes a decent argument against the overuse of medication for depression and how many people often do not continue therapy with the medication, which should go hand in hand. A good read for anyone battling depression.

[Eva · Rating 3 out of 5]

A good book, but what I really love is his Listening to Prozac.

My Kindle highlights:



I used a test question: We say that depression is a disease. Does that mean that we want to eradicate it as we have eradicated smallpox, so that no human being need ever suffer depression again? In posing this challenge, I tried to make it clear that mere sadness was not at issue. Take major depression, however you define it. Are you content to be rid of that condition? It did not matter whether I was addressing physicians or pharmacology researchers or relatives of patients gravely affected by mental illness—all proponents of the “medical model of depression.” Invariably, the response was hedged. Just what do we mean by depression? What level of severity? Are we speaking about changing human nature? I took those protective worries as expressions of what depression is to us. Asked whether we are content to eradicate arthritis, no one says, well, the end-stage deformation, yes, but let’s hang on to tennis elbow, housemaid’s knee, and the early stages of rheumatoid disease. Multiple sclerosis, high blood pressure, acne, schizophrenia, psoriasis, bulimia, malaria—there is no other disease we consider preserving. But eradicating depression calls out the caveats. - location 334


She wanted to know why, in our discussions, I had granted an impostor—the depression—such standing. I had been negotiating with an occupying government, of Margaret’s mind, while the legitimate ruler was in exile. - location 569


epileptologist - location 810


Eagerness—the anticipation of pleasure—requires an intact prefrontal cortex. - location 1017


Studies had shown decreased blood flow and decreased energy utilization in the prefrontal cortex of patients in the midst of depressive episodes, - location 1019


hippocampi (from the the Latin for seahorse, the name refers to the structure’s curved shape in cross section) - location 1085


“Depression Duration but Not Age Predicts Hippocampal Volume Loss in Medically Healthy Women with Recurrent Major Depression.” - location 1104


Betty’s is a considerate opening. No disheartening history of anguish. She sets about her task as a short story writer might, with homely detail, complete with appeal to the senses—shape, color, time. - location 1181


Cancer of an internal organ can present as a skin rash. - location 1286


Eva was battered regularly, from the inside. - location 1756


adrenals, small glands that sit atop the kidneys (therefore ad-renal). - location 2004


branchlike dendrites grow (the process is called arborization), - location 2053


Major depression turns out to have a heritability of 35 or 40 percent. - location 2155


In research on monkeys, seemingly modest challenges to pregnant mothers result in decreased hippocampal size and impaired neurogenesis in their young, accompanied by behaviors that look like anxiety and depression. - location 2186


When depression is the outcome under study, the effect of overarching, seemingly uniform environments is always, always mediated by the perceiving mind and the predisposed brain. - location 2298


Interviewing the twins and their family members, researchers stumbled across an unexpected result: in the twins’ childhood, the fathers were more protective toward the daughter who would later go on to develop a mood disorder. These were not abusive fathers—the main body of research examined that issue. Rather, they seemed to be fathers who had sensed emotional need in one daughter, and not in her identical twin sister. - location 2308


In Listening to Prozac, I discussed the hypothesis that depression ensues when the culture fails to reward people who are passive, unassertive, and averse to risk. That theory is compatible with the view that depression is partly heritable. The genes for the disfavored temperamental traits lead to unsuccessful behaviors that in time elicit a discouraging environment—fewer friends, less living space, and the rest. Those with genes for (or early experience conducive to) traits that are punished socially create a worse-than-average set of experiences for themselves. And then a further interactive effect comes into play. - location 2336


The results showed that “independent events” do trigger depression. But “dependent events”—where the depressive had a role in her own bad luck—had a yet stronger effect. A person may pick a fight with a supervisor and then find herself demoted at work—and become depressed as a result. Often what looks like an external event causing depression is an intermediate step in a complex interaction. The behavior of the depressive creates an environment rich in potential stressors. Overall, between half and two thirds of the association between stressful events and depression is causal—the stress giving rise to the depression. At least a third of the causation runs the other way, and the proportion rises for later episodes of depression. The more often you’ve been depressed, the more you tend to contribute to your own misery. This result does not arise from acute depression—the stressful event almost always precedes a new episode. It is the ongoing, between-episodes aspects of the disease that lead depressives to complicate their own lives. - location 2376


losing a parent (by death, divorce, or separation before age seventeen) has no discernible effect on depression if the child then enters a protected environment, with a supportive family, and if the child manages to stay in school. - location 2421


Kindling includes an early, inapparent phase. Here, stress affects the brain without causing an episode of depression, but each event nonetheless increases vulnerability. These hidden events and responses are the kindling that precedes an open blaze. - location 2469


Patients who experienced caused depressions went on to experience uncaused episodes, and vice versa. - location 2495


Some are born more vulnerable, some are made vulnerable by early experience. Further stressful life events lead both sorts of depressives along the same slope. A short distance down, the brain is less sturdy in the face of a variety of insults. - location 2531


Because public health dollars are scarce, statisticians have worked to quantify the harm diseases cause. Their findings have surprised even the researchers who devised the major studies: Depression is the most devastating disease known to humankind. - location 2548


Among the chronic diseases of midlife, depression was (by 1990) already the most burdensome, and not by a small margin. Major depression accounted for almost 20 percent of all disability-adjusted life years lost for women in developed countries—more than three times the burden imposed by the next most impairing illness. - location 2579


But after controlling for those variables, depression still accounted independently for a 24 percent increase in deaths—from such causes as heart attack and pneumonia. This increase put depression at the level of high blood pressure, smoking, stroke, and congestive heart failure as a risk factor for death in the elderly. - location 2644


The operational definition of depression gained its initial standing from its correspondence to clinicians’ impression of “caseness.” The criteria picked out patients whom psychiatrists considered ill. Most people who qualified were well within the boundary; they had been profoundly incapacitated repeatedly, for months at a time. If you ask either patients or doctors to rate symptoms and role impairment from very mild to very severe, you find that most patients who meet the minimum criteria for depression are at the severe end of the range. Most depression, operationally defined, is severe illness. - location 2698


early depression is both disease and risk factor. If you are depressed for two weeks, the odds are that you will continue to meet criteria for at least four months, and more likely nine months or a year. Most people who meet the minimal criteria will then suffer recurrences of the full syndrome or experience symptoms on an ongoing basis. Actually, the two-week episode “predicts” the past as well. It predicts that investigators will discover that you have a family history of depression, and a genetic predisposition (judging from the state of your identical twin), and memories of a difficult childhood. It predicts that you will look vulnerable in a variety of ways, that you have a broad syndrome, extending beyond the five recent symptoms and beyond the recent episode. - location 2727


When they did recover, the vast majority of patients experienced subsequent episodes: 40 percent at two years, 60 percent at five years, 75 percent at ten years, and 87 percent at fifteen years. With each recurrence, the time to recovery lengthened and the time to the next recurrence shortened. After a second episode, the two-year recurrence rate was 75 percent. After a fifth episode, the six-month recurrence rate was 30 percent. With each recurrence, about 10 percent of patients remained depressed continuously for five years. - location 2741


In the 1980s, only 3 percent of those depressed for six months had received even one full-dose, four-week trial of antidepressants. - location 2745


In terms of how psychiatrists treat depression, the main effect of the research findings was to emphasize the importance of complete remission—the elimination of all symptoms—as a goal. In the heyday of psychoanalysis, therapists had been content to end an episode of depression—if they considered that task important at all. Therapy had more fundamental aims. Character change was the gold standard. Without character change, a person is not yet master of his demons, and so a remnant of melancholy is only natural. Quite mainstream theories held that certain depressed patients were not depressed enough—their moderate depression arose from a failure to understand how deep their moral crisis ran. But even pragmatic psychotherapists were content to see a patient rise from frank depression to low-level pessimism and self-doubt. Pharmacologists had similar standards. A patient who, on medication, halved his burden of symptoms was said to have responded to treatment. Generally, such patients no longer met the episode-based definition for major depression. Technically, they had recovered, so long as they now had, say, three symptoms rather than five. But in the past decade, it became clear that patients with residual symptoms suffer recurrences sooner and more often than patients who become fully “themselves again.” The findings of the NIMH study were particularly stark. The researchers looked at subjects whose depression had remitted to the point that they had only one or two mild symptoms. Even that seemingly trivial degree of depression left subjects at risk. Patients with minimal residual symptoms were 30 percent more likely to relapse into major depression than patients who, on recovery, were symptom-free. Patients with residual symptoms relapsed to an episode of major depression three times as fast as patients with no residual symptoms. And for patients with one or two residual symptoms, additional symptoms began to accumulate almost immediately; these patients—unlike patients with a symptom-free recovery—slid back toward depression as soon as the prior episode was declared over. These findings caught the diagnostic experts flat-footed. In 1991, some years into the NIMH study, a consensus group had proposed a definition of recovery from depression that allowed for the persistence of a moderate degree of symptomatology. That definition was wrong. Even modest disruptions of sleep and appetite, for example, signal a substantial increased likelihood of future episodes and all they imply in terms of harm. By the late 1990s, it had become clear that symptom-free recovery is the goal in the treatment of depression. - location 2750


The research identified symptom clusters that form a halo around depression. Psychiatrists gave these syndromes names like dysthymia (which refers to low mood of long duration), minor depression (like major, but with fewer symptoms), and recurrent brief depression (repeated episodes of full intensity, none of which lasts two weeks). - location 2807


But most dysthymia looks like the behavioral, lived-out representation of the stuck switch—relentless stress, constant fragility, battering and bruising from without and within. - location 2861


faute de mieux, - location 2880


Krishnan’s group gave a “trail-making” test to elderly subjects half of whom did, and half of whom did not, suffer vascular depression—and none of whom showed signs of dementia. The test is like a child’s dot-to-dot game. The goal is to connect in sequence (1 to A to 2 to B, and so on) a series of numbered and lettered circles scattered on a page. This task is not one that depressed patients do well. Even worse than the initial error rate is depressives’ response to correction. In the test, if a subject makes an error, the administrator gently points out the problem and suggests how to proceed. After correction, virtually no control subjects make a subsequent (“perseverative”) error. But depressed patients do—many more than controls even when the baseline error rate is taken into account. Some depressives have catastrophic reactions; after a correction, they go on to connect dot to dot in random fashion, as if they had lost all hope of succeeding at the task. Krishnan repeated the test one and two years after the initial administration. Even as they aged, the nondepressed elderly got better and better at the initial puzzle. The depressed patients did not improve, and their perseverative error rate continued to worsen. These problems persisted whether or not the patients remained depressed—indeed, the errors did not correlate with the active level of depression but seemed to signal an ongoing problem in responses to mild challenges. (“Processing information with a negative valence” is what the postcorrection portion of the trail-making exercise is said to test.) Krishnan was then able to use functional brain imaging—the kind that follows energy utilization in different parts of the brain. When test administrators suggested corrections, the subjects’ orbitofrontal cortices lit up. - location 2939


It is true that the adaptive state for human beings involves a degree of unrealistic optimism. In gambling experiments, where subjects are asked to evaluate the odds of winning at a given level of risk, the nondepressed tend to give optimistic estimates, even in the face of mounting losses. The depressed are more accurate—well, what else would they be? But in these same trials, depressives continue to make bad bets. Even when depressives perceive accurately, they lack the motivation to heed their own judgment and alter their behavior. - location 2953


And then the viruses lie dormant in the nerve cell, until the organism is stressed—at which point they leap into action. That’s why you get a cold sore just when everything else in your life is going wrong. How do viruses know when to turn on? They monitor your stress hormone levels. - location 3259


Losing someone you care about can trigger depression; that part is universal. But “caring about” covers more territory for women. A wider network of attachments entails more losses. A portion of the difference in rates of depression can be attributed to differences in social investments. Studies suggest that it is not only major losses that matter; because of their multiple attachments, women also suffer more minor, daily stress than men. Within the genders, too—comparing men with men, or women with women—those individuals who care more broadly are more prone to depression. - location 4162


(At selective colleges, by the time of graduation about a quarter of students will have been prescribed an antidepressant at the on-campus clinic; this figure omits those who receive medications from a doctor at home.) - location 4227


I was a European born in America. In its acquisitiveness and superficiality, in its apparent blindness to life’s dangers, my native land was foreign to me. And yet I was estranged from Europe, as hostile—the site of the Holocaust. - location 4391


I was a Jew, but I had never been to temple, except to attend other children’s bar mitzvahs. I did not believe in God. Perhaps atheism should appear as a separate item on this list. I felt distant from believers and belief. If an omnipotent spirit existed, he had a lot to answer for. - location 4393

[Abhi V · Rating 5 out of 5]

I feel like Kramer is one of the most underrated writers in English (it's a nice idea that there are gems out there, waiting to be discovered, the world is big and unknown and therefore could be good after all), ... anyway he is knowledgeable, convincing, humane, insightful, concise, original. Also funny that he so well defends views that in other circumstances I find it fashionable to criticize (the biological model of depression in this book, and its corollary, the "no redeeming value" attitude towards it; elsewhere, antidepressants (duh!)). Despite the crazies and the hacks who defend those views: they're also correct....

Like Putnam said of Chomsky: that part of his genius is that he deals with perennial, even basic or foundational questions; there is something 'definitive' about his treatment of these topics, something willing to be partially banal, and good enough that there is no reliance on an insecure specialization....

His writing about the relationship between the charm of the sensitive, neurotic depressive (early on) and then his extension of that to an investigation of the nature of literary subjectivity: the contrast between polymath authors of the Middle Ages and Renaissance to the contemporary (literary, in a different sense than above) interiorized, neurotic, modern: wow! You remember that history is short and full of contingencies, and are returned to the simple fact that some people are good at living, and those good-natured (in William James' terminology, "the once-born," as contrasted with the "twice born"): perhaps the sedentary and interior life of a scholar does not make you happy? There is an easy dullness to people who are happy in life (often), in athletes... and might their inarticulacy be the result of never seeking a vocabulary for the pain of their interior life, if it's there? Or not engaging in the (always-losing) battle of talking back to one's interior ("biting," as Kenzie would say)?

His suggestion that art really might have a whole different set of emotional ranges.... I am going to do a much closer review of this book at a later time.

[Muriel Unseth · Rating 5 out of 5]

"Many of us... spend much of our lives fending off depression, in those we care about, but also in ourselves. There are chances we do not take; they would be favorable and prudent gambles, if only we could bear for them to fail. That strategy has ancient roots, in the Greek practice of ataraxia-- muted feeling, limited attachment-- as a prophylactic against the horrors of loss. How much freer we would be to live life, knowing ourselves to be reliably resilient. Not fearing depression, we might love more generously. Indirectly, the mind and brain may translate immunity from depression into a bodily awareness that carries a message of cognitive therapy or transactional analysis-- I'm okay, solid enough to risk what we say that people should risk: openness and commitment and intimacy."

[Ana Isabel Lage Ferreira · Rating 4 out of 5]

How seeing depression as a "proper" disease can actually help all the ones who succumb to it and also the ones with whom they interact.
Depression is not nostalgia, is not a character trait and is not an artistic disposition. It's a disease that combines body and mind and this is why it's so hard to fight it.
With research and validated evidences Kramer opens new avenues to understand, treat and .... maybe one day erradicate depression.
Not advisable if you're expecting lay language.

[Leez · Rating 2 out of 5]

The author wrote a lot of interesting stories based on his experieces as a psychiatric. However, he used a lot of difficult and scientific term without explaining the meaning. It's hard to understand for common people especially for non native english speaker.

[Carlin Nasiatka · Rating 2 out of 5]

If you’re looking for a very textbook like read, this is well reaserched

[Samantha · Rating 3 out of 5]

I listened to the audio version of this book and had a hard time concentrating on it. Certain voices are just harder to focus on for me. I plan to try the text version.

[A Ter · Rating 3 out of 5]

Flashes of profound brilliance, but you really have to sift through a lot to find it... often in the weeds.

[Marie Rimer · Rating 5 out of 5]

Best explanation of depression ever.

[Lori · Rating 4 out of 5]

As I started reading this book, I also began to read and learn more about mood disorders in general. As a result, I felt that Kramer's use of "mood disorder" to refer to depression specifically was inappropriate. Mood disorders cover a wide range of mental illnesses. Different mental illnesses affect different areas of the brain and are treated using different medications and methodologies. (He touches on this in the prologue, but decides to use mood disorder as a synonym for depression, which is misleading.)

With that being said, this is one of the best books I have read about depression. Kramer covers a wide range of topics concerning depression: what it is, how it effects people, how it effects society and the struggles involved in eradicating it. For people who don't understand depression, its a great resource to gain knowledge about it. For those who suffer from depression, it gives more understanding about why it is so difficult to treat and provides some hope.

I think it is hard for those who lead a "normal" life without depression to really understand and accept it. As Kramer notes, "Depression is so debilitating. ... You lose the capacity for action altogether. Death seems preferable to effort." For most people, feeling that low is incomprehensible.

[Lydia · Rating 5 out of 5]

This book is a must-read for anyone with depression or anyone who knows someone with depression (read: everyone).

Some people, when the idea of curing depression is brought up, object, saying that if Van Gogh, an assumed depressive, had had access to antidepressants, wouldn't his art be less rich? Therefore, some even go as far to say that Van Gogh shouldn't be cured because it would take away from the world of art. Kramer discusses this problem with subtlety and nuance, but also absolute clarity: by no means should we refuse to cure someone for the sake of art.

The main message of the book is that depression is a disease and must be treated as such. Kramer discusses how our culture has for two thousand years elevated "heroic melancholy" as a more refined sort of existence. And he cuts that idea to shreds.

A holistic discussion of science, art, medicine, and culture, Against Depression is well-researched, well-written, and the author is certainly well-read. It completely corrects your approach to depression and your understanding of what it is to us, what it is, and what it will be.

[Jen · Rating 4 out of 5]

This book contains the view of depression that I've been waiting to find--one that juxtaposes science with mythology and the reality of illness with the idealization of melancholy. Kramer starts with a central question that people always ask him at his presentations, "what if antidepressants had been available to Vincent Van Gogh?" and explores the assumptions behind this question from every angle. I expected the scientific detail but was pleasantly surprised by how deeply this book also delves into literary and art history. The author's first and final argument that depression is a destructive disease that needs to be eradicated is one that I can agree with; the discomfort that this argument might cause makes for interesting subject matter.

[Lucas · Rating 4 out of 5]

This book convinced me that the opposite of depression is not happiness or complacency. The opposite of depression is resilience.


On the other hand, it takes him too damn long to say that. The first half or so of the book largely consists of him whining about various professional slights and conflicts arising out of the reception of his successful other book, "Listening to Prozac." When you set out to write a polemic against something as widespread as depression, it does no one any good to veer into self-indulgent pity parties about how someone once asked you an ignorant or impertinent question at a conference.

Still, it promises a lot, taking on such a huge target, and it ultimately does fulfill its promise, just not in the most efficient way possible.

[Andrew · Rating 4 out of 5]

Kramer examines research into depression. In a reasonably readable (if not exactly exciting) manner he looks at studies that support the assessment of clinical depression as an actual, treatable disease. Associated as he is with anti-depressants because of his more famous work Listening to Prozac, it is perhaps unsurprising that he comes down on the side of treating the malady as a disease rather than as he describes it, simply heroic melancholy.

[Yuna · Rating 4 out of 5]

Kramer argues that depression is a medical pathology, similar to other illnesses and diseases that have physiological roots and symptoms. I think he's convinced me; at least, he's made me realize more of the pros of depression medication. Although extremely interesting and thought-provoking, parts of this book felt repetitive, especially the multiple sections devoted to dissecting and challenging the romantic idea that depression leads to self-awareness or that genius is often found among the melancholics.

[Lynn Weber · Rating 4 out of 5]

The first few and first last chapters of this book are amazing. There's so much that I relate to, and so much about societal attitudes toward depression. It covers questions like the perennial "What if Prozac had been around in Van Gogh's day?" and "Why do we think that sorrow = depth?" But I give it four stars rather than five because the bulky middle of the book is very technical. It gets into the medical research done on depression, which is interesting to read but probably not for everyone.

[Erica Freeman · Rating 3 out of 5]

Sort of still reading this...part of me loves it because the science makes a lot of sense, and it's reassuring to see someone taking depression as seriously as it should be taken.

On the other hand, I've felt a lot of self-doubt in relation to this book...I'll say more in private if anyone's interested.

[John McElhenney · Rating 5 out of 5]

Picking up where he left off in listening to Prozac, Kramer now turns to the subject of depression and our romantic notions of the empassioned and depressed artist. If you could cure depression once and for all, would you. Would Van Gogh been better off without his mania and depression. He might have kept his ear, but would he have painted Starry Night?