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Perspectives in Biology and Medicine 50.2 (2007) 295-307

Do Think Twice
Kramer and Shenk on depression
Erik Parens
The Hastings Center, Garrison, NY 10524.
Peter D. Kramer, Against Depression. New York: Viking, 2005. Pp. 337. $25.95.
Joshua Wolf Shenk, Lincoln's Melancholy: How Depression Challenged a President and Fueled His Greatness. Boston: Houghton Mifflin, 2005. Pp. 327. $25.00.

In their radically different interpretations of depression, both Joshua Wolf Shenk and Peter Kramer invoke William James's distinction between people who are "once-born" and those who are "twice-born." James suggests in The Varieties of Religious Experience (1902) that the once-born are thrown into the world optimistic and happy, natural believers in the world's beauty and goodness. The twice-born come into the world dogged by doubt and discord. They, too, achieve wholeness, but only after struggling mightily with their sense that people are broken and that the world is out of joint.

In Lincoln's Melancholy, Joshua Shenk writes in the spirit of the twice born. He seeks to show that Lincoln's depression was not only a burden but also an integral part of his good life. This puts Shenk squarely in the interpretative tradition that now fills Peter Kramer with disgust. In Against Depression, Kramer is an apostle of the once-born. Against the spirit of gravity, he announces the good news that depression is an illness just like tuberculosis, syphilis, and diabetes. He argues for initiating a new tradition, one that celebrates optimism, lightness, assertiveness, confidence, and resilience. He is Nietzsche's heir, the champion of a new fröhliche Wissenschaft. [End Page 295]

While Kramer and Shenk proceed from importantly different conceptual frameworks, they share the goal of reducing human suffering. Kramer worries first about the suffering entailed by untreated depression. Shenk worries first about the suffering that can result when we become less tolerant of ways of being in the world that currently are devalued. I suggest that we should take on board the insights from both—and beware of the risks associated with each. We should think twice about depression.

On Depression's "Firm Biological Basis"

Kramer acknowledges that his book is a polemic, but believes that depression, "the major scourge of mankind" (p. 152), calls for no less than war. The first prong of his strategy is to show what depression "is," specifically what neuroscience and genetics now teach that it is. The second is to expose and undermine the interpretive tradition that suggests that traits associated with depression are signs of intellectual or spiritual depth. If he succeeds, we will go from thinking of depressive traits as signs of honest engagement with a tragic world to seeing them as obstacles to genuine engagement. We will go from thinking of such traits as an essential part of an authentic self to thinking of them as wholly alien.

Whereas Kramer's 1993 bestseller Listening to Prozac began from a story about low levels of serotonin, his new book begins from a story about damage to various parts of the brain. Beyond describing correlations between depression and abnormalities in the prefrontal cortex, hippocampus, and amygdala, Kramer leans heavily on behavioral genetics to make his case that "depression has a firm biological basis" (p. 148).

Kramer is careful to acknowledge that the heritability estimates for major depression are in the neighborhood of 35 to 40%. That is, if you're trying to understand why some people are depressed and others are not, then genetic differences can help to explain about 35 to 40% of the variance between the two groups. This means that 60 to 65% of the variance can be explained by environmental differences, which would seem to be a problem for a comprehensive "biological" account. But Kramer marshals at least two arguments to reconcile the claim that depression is "biological" and the geneticists' acknowledgement that about 60 to 65% of the observed differences in a population can be explained by environmental differences.

The first argument...


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