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Psychiatrist Peter Kramer isn't happy with how depression is perceived in society, and he's doing many things about it

PROVIDENCE -- He does not look like one who would lead a cavalry charge. Seated in a wing chair in his Federal-style home on College Hill, with its elegant furnishings and muted colors, Peter D. Kramer, 56, is the very image of a mild-mannered psychiatrist.

He is leading a charge, however, not on horseback but armed with his new book, ''Against Depression." His adversary is the sentimental and romantic defense of depression, and society's failure to face what he sees as an obvious fact -- that depression is a disease, with no redeeming qualities, like diabetes or cancer. It is, he writes, ''the most devastating disease known to mankind," with an estimated ''workplace cost" in America of more than $40 billion.

Kramer, professor of psychiatry at Brown University, distinguishes depression from transitory moodiness. True depression usually includes symptoms such as sleeplessness, eating problems, intractable sadness and feelings of worthlessness, paralysis of the will, and often suicidality. Almost everyone experiences sadness, self-doubt, or melancholy sometimes, but the nondepressed person has what Kramer calls ''resilience" -- he or she can get back on an even keel without damage.

Kramer's 1993 bestseller, ''Listening to Prozac," explored the ethical questions surrounding a drug that many of his patients said made them feel ''better than well," like different people. Should society give, or withhold, drugs that seem to change their personalities? The book did not toss out psychotherapy or anoint Prozac as a magic bullet for depression, but some reviewers took it that way.

Since then he has published a novel, ''Spectacular Happiness," and a nonfiction exploration of the psychological tangles of love relationships, ''Should You Leave?" Starting with its title, this book is Kramer's most polemical, filled with exasperation at the idea that depression has positive value in artistic achievement or depth of character -- what he calls ''heroic melancholy." He was repeatedly asked, during public appearances for ''Listening to Prozac": ''What if van Gogh had taken Prozac?" -- as if the positive benefits of mental illness in an artist might justify its terrors. After years of immersion in the depression of his patients, he has no patience with those ideas.

''I find it a puzzle," he said. ''We should say, 'This is ridiculous.' Why is asking, ''Is depression a disease?' different from asking 'Is cancer a disease?' He was ''seething," ''outraged," at a professional meeting when a psychiatrist outlined his decision to let a patient fester in depression as a way of getting him to confront his underlying narcissism. Kramer said, ''What was ghastly about that presentation is how it could have been made any time in the last hundred years. Doesn't anybody see that this is awful?"

Kramer says the excuse-making and toleration largely comes from ''people who have not suffered major depression. But even in those who have," he said, ''there is worry that [without it] one would not be driven enough or would not struggle enough. But we don't make that argument about other diseases."

In his book, he does not promote any one solution or therapy, since the malady's origins are still not well understood. He acknowledges that available treatments have limitations. And he himself uses traditional psychotherapy, and sometimes prescribes medications. But he does describe recent research that points to real physiological damage from depression, such as heart, vascular, and brain damage, as well as family, social, and economic devastation, which he says puts it in the same league as diabetes or heart disease.

Kramer's career interests are literary, artistic, and cultural as much as medical; he is also host of a public radio program, ''The Infinite Mind." ''I really think of myself as a writer first," he said. ''If I could afford it or convince myself, after this next book I'm committed to [a short biography of Sigmund Freud], I would write fiction. I have in my head a series of connected short stories or novellas."

Kramer is youthful-looking -- like a 30-year-old in a salt-and-pepper wig -- and speaks in a resonant voice and with a pensive manner. He was born in New York to German-Jewish immigrants who barely escaped the Holocaust, was educated at Harvard College and Harvard Medical School, and eventually settled in Providence. He and his wife have three children. His father was a pharmacist and his mother a school psychologist, and he said, ''between a pharmacist father and a psychologist mother, psychiatry sort of split the difference."

''When I went into psychiatry," he said, ''it was a story-listening, story-analysis profession. There was no notion of medication at all, no notion that medical school was anything except something to get through in order to get to the psychoanalytic part of psychiatry." His friend Kenneth Kendler, director of the Virginia Institute for Psychiatric and Behavioral Genetics, recalls him from their psychiatric residency at Yale. ''Peter was and remains an earnest individual," said Kendler. ''He stood out in our residency program. He was well-educated and literary, always trying to connect the issues of psychiatry with the broader context of society and the humanities."

Not everybody agrees with Kramer's thesis, and resistance doesn't come only from romanticizers or people who know nothing about depression. Joseph Glenmullen, a clinical instructor in psychiatry at Harvard Medical School whose book, ''Prozac Backlash," strongly criticized overreliance on antidepression drugs, disagrees with it strongly.

''Depression is not established as a disease," Glenmullen said. ''If you look at the diagnostic and statistical manual, it is called 'major depressive disorder.' It is certainly psychological as well as biological. It should not be romanticized, but nor should it be reduced to biology and plumbing. The biological model inevitably leads to a principal reliance on drug treatment. For diabetes, you wouldn't prescribe exercise -- you need your insulin."

However depression is technically defined, resistance to the disease model seems to have elements that are other than professional. As with alcoholism, many people feel that once you call it a disease, you are exempting the individual sufferer from broader responsibility, or taking away his own capacity to master or transcend it. Kendler said, ''My main research is in genetics. You can talk to people about the genetics of disease, but when you bring up alcoholism, they will say, 'How dare you give another excuse for my uncle to say he's not responsible for his drinking.' "

Some point out that denying the biological component tends to lead back to traditional moral opprobrium. ''Depression is a real affront to the work ethic," said Sharon O'Brien, a professor of literature and American studies at Dickinson College. O'Brien's recent book, ''The Family Silver," is about depression in her Boston family and herself, and its ambiguous situation in society's eyes.

''People get angry at those who suffer from serious depression," O'Brien said. ''They think it's a failure of the will. They see a person with no surface wounds, sitting glazed in front of a TV, and they get furious." She adds that the various uses of the word work against the seriously ill: ''The adjective 'depressed' also means to have a low mood. We say, 'I'm feeling sort of depressed today.' But this is not the same vocabulary; it's a major illness. We don't say, 'I'm feeling a little diabetic today.' "

''The whole argument needs to be more nuanced," said Lauren Slater, a Somerville psychotherapist whose 1999 book, ''Prozac Diary," concerned her own struggles with mental illness and medication. ''Some people will say, 'I have a chemical imbalance,' and others will say, 'I suffer from depression and wrote my best novel with it' -- it becomes very polarized."

Slater insists there is nothing wrong in finding, or trying to find, positive meaning in one's depression, especially when it resists treatment. ''Otherwise you'd just kill yourself," she said. Even so, like Kramer, she is impatient with the depression/creativity myth. ''Would Kierkegaard be Kierkegaard if he had not been a mess?" she asked. ''Probably not, but what a terrible price to pay, whatever he wrote." If the famously dolorous Danish philosopher had not suffered what some today believe was deep depression, Slater says, ''he might have written something else that was great, maybe 'Laughter and Joy' instead of 'Fear and Trembling.' "

David Mehegan can be reached at mehegan@globe.com.

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