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

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

In a post to students enrolled in a course I teach on Death and Loss in Literature and Film, I recently wrote:

“One of my better friends here in Boston is the psychiatrist Nassir Ghaemi, whose books A First-Rate Madness and, even more, On Depression: Drugs, Diagnosis, and Despair in the Modern World are eminently worth reading. Ghaemi is deeply immersed in the existential literature to which many of us are also drawn—Nietzsche, James, Jaspers, etc. He is also very much involved in a clinical understanding, assessment and treatment of the major mental disorders typified by a nuanced reading of the literature that constitutes an enlightened rejoinder to psychiatric convention and routine. He is almost unique in his attention to the ways in which mood disorders, in particular, may color experience and effect character in multifaceted and often astonishing ways.”

Ghaemi’s On Depression: Drugs, Diagnosis, and Despair in the Modern World is a uniquely satisfying book by one of psychiatry’s most forward-leaning representatives. The book is dedicated to two colleagues/mentors, one living and one recently deceased (Nassir is assiduously attentive in both writing and life in honoring the many lofty souls who have contributed to his development as a thinker, clinician, and human being) and begins with these searching lines from Chilean poet Pablo Neruda:

What was man?
In what part of his conversing,
of his laugher and whistling,
in which of his chemical movements
lived the indestructible,
the enduring,
the living?

Following another quote by Beckett (the literary genius who had had the midlife epiphany that he might make a living out of his own considerable despair), we find ourselves reading a chapter entitled “Lives of Quiet Desperation” and immersed in a discussion of Nietzsche’s Thus Spake Zarathustra (“a book for all and none,” according to its itinerant author, about absconded gods, wayward “last men,” and potential ubermenschen) followed, as implied, by tips of the hat to stateside epochal “diagnosticians” Emerson and Thoreau. And from here we are on to a chapter on “The Varieties of Depressive Experience,” with its invocation of the spirit of William James, the genius psychologist and philosopher whose work and story Ghaemi also knows extremely well.

Like James, Ghaemi is interested in personal accounts of depression and despair and given to philosophical speculations on the variegated natures, possibilities, and limits of existence, though these interests commingle here with a scientific sensibility equally indebted to the realms of methodology and hard-nosed facts. And this, I think, is one of the striking things about Nassir’s overall body of work. It is one that argues from the onset for the integration of elements (biology, philosophy, psychology, and the broader humanities) and in books like this one accomplishes precisely this. I should note also Ghaemi’s unusual historical sensibility—his knowledge of, and indebtedness to, both recent and more distant pasts. What other clinician among us seriously considers “the unknown Hippocrates” (whose wise and conservative approach to medicine, we learn, has been oversimplified and, thereby, misconstrued) or Canadian physician William Osler—“the father of medical humanism, the ideal well-bred physician”? “Osler’s Rule,” Ghaemi, informs us, may be stated directly: “Treat diseases, not symptoms.” Just the reverse of how psychiatry tends, presently, to proceed:

“I believe we use medications too much: we practice a symptom-oriented psychopharmacology that belongs in the nineteenth century. We need to be clear about what we need to do: we should prescribe medications primarily for diseases, not symptoms, and not even for all diseases; we should avoid prescribing them by habit, only doing so when proof of benefit exists and far outweighs risks. With that basic philosophy, we can then turn to studies and research and data, leading to a scientific Hippocratic psychopharmacology. Otherwise, in my view, the science and data are twisted by doctors and patients to their own whims, producing that eclectic mish-mash that is contemporary psychiatry. Hippocratic method can permit modern psychiatry to get us closer to that ever-elusive, ancient goal of the school of Cos: to cure sometimes, to heal often, and to console always.”

Ghaemi is an astute researcher, diagnostician, and thinker. He is not a poet (though he has, I believe, translated poetry into English from both Farsi and Spanish) but, rather, a man with a feeling for the complexity and, also, nuance that illumines the less determined sides of life—“the vague and inarticulate,” as James so beautifully puts it. Such attributes are reflective of an inquiring and very broad mind—one that takes into its orbit large swathes of experience that we may rightly think of as profoundly human in its purview and reach. The opening quotes by Neruda and Beckett constitute a frontispiece of sorts. The book itself is a meditation on depression and despair (and, to a lesser extent, their manic and hyperthymic counterpoints) in four parts—“Entrance,” ”Pretenders,” “Guides,” and “Exit.” Think of it as a compositional suite, reflective of a feeling for form that, among other things, subtly informs Nassir’s themes and sensibilities. It is also what makes him one of the more brilliant psychiatrists I know and, likewise, someone who may be subject to misapprehension by his more orthodox colleagues and avoidance by almost all of ours. It is, perhaps, more than coincidental that in his consideration of Rollo May (along with existentialist-leaning Boston luminaries like Elvin Semrad, Leston Havens, and Paul Roazen and exemplary perennials like Victor Frankl and Karl Jaspers), we encounter these words out of Whitman: “This is no book;/Who touches this, touches a man;/(Is it night? Are we here alone?)” James and Jaspers pointed wisely and doggedly to the broadest approaches to scientific inquiry while clearly having their most inward respective hearts given to other realms of experience and inquiry. Ghaemi seems to pick up where they leave off, adroitly straddling a fence between biology and human understanding gleaned from complementary sources that have been the lifeblood of humanistic and depth psychology from the very start.

It is time, it seems to me, for Ghaemi’s work (simpatico with, and in some ways an extension of, our own) to be embraced by discerning humanistic psychologists most deserving of this descriptor. Nowhere among the best of our coteries do we find evidence of an endemic eschewal of biology that tends to compromise humanistic psychology’s imprimatur and hamper its overall advance:

“It is not at all incongruent for the existential psychotherapist to be a biological psychiatrist too; indeed, the philosopher and psychiatrist Karl Jaspers was exactly such a biological existentialist, someone who recognized and appreciated biology and science, as well as the limits of such science, and the freedom of existence beyond such biological limits. Rollo May also repeatedly stated that existential psychology is completely consistent with science, not opposed to it.”

I should point out that May (who also gracefully honored important mentors like H. S. Sullivan and Frieda Fromm-Reichmann throughout his life) was a man whose visionary insights into anxiety, self, love and will, power and innocence, freedom and destiny, wonder, and the place of myth in a world gone wrong often preceded the world’s by years and even decades. He possessed an artist’s intuition and was himself restlessly imaginative in life, loves, and work. “The authentic prophet,” he wrote, “experiences the anxiety that comes with his freedom to see into the future, to see beyond the usual limits in which other people see.” May knew such things from hard-won personal experience. I am suggesting that Ghaemi, too, is a herald of a finer psychiatric attunement that deserves, also, to have its day.

Originally published in my HUMANITAS column in the Society for Humanistic Psychology Newsletter:

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