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Depression: Depression & Related Conditions
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by Andrew Solomon
Scribner, 2001
Review by Christian Perring, Ph.D. on Jul 31st 2001

The Noonday DemonAndrew Solomon's new book has received a great deal of positive press. The website associated with the book has a page listing reviews; many of them have been glowing, and few have had criticisms of the book. The Noonday Demon certainly is an impressive work, but it is worth pointing out that is a curious and obviously imperfect work.

A Noonday Demon is a large book, at 567 pages in total, with 432 pages of main text and another 54 of notes. In twelve chapters, Solomon covers a great deal of ground: Depression, Breakdowns, Treatments, Alternatives, Populations, Addiction, Suicide, History, Poverty, Politics, Evolution, and Hope. In the earlier chapters he includes his own experience of depression, including three severe breakdowns, suicidal behavior, psychoanalysis, psychopharmacology, the help of his father and his friends, and occasional references to his lovers. He describes in detail his mother's struggle with cancer and her planning to kill herself as hope for cure faded. When all hope was extinguished, she called her family around her bedside and took an overdose, saying her final words to her sons and husband, and dying. In the chapter on alternative approaches, he reports his investigations trying out a range of unusual and unorthodox ways to reduce depression. In the later chapters he occasionally refers to his own experience in his comments on the topic at hand. Throughout the book he relates the stories of people he has met or communicated with while he was researching and writing. He also never shies away from giving his own opinions on controversial issues -- he is open minded but basically a defender of mainstream psychiatry. All these features make this book very different from most textbooks, popular psychology books, or personal memoirs of depression. It is both encyclopedic and idiosyncratic, combining elements from different genres. The style of writing is for the most part accessible and relaxed. Occasionally he tends towards the poetic or philosophical. He quotes famous literary sources, letters by well known authors, aphorisms and proverbs -- mostly from high culture, rarely from popular culture. It is a high minded book that can also serve as popular psychology, memoir, and even self-help.

Solomon has done a massive amount of work in putting this book together, talking with some of the top researchers in the relevant scientific fields, reading scientific and historical work, and integrating this information with the personal experience of the people he has met who suffer from depression, as well as his own experience. Ultimately though, this is more a work of reporting and memoir than a scholarly study. Solomon argues for his views, but his arguments are very much his own, and while interesting, are often problematic.

One clear example of how Solomon's work is troubling is in his treatment of medication. He tends to defend the pharmaceutical industry from its critics. He writes, "the ludicrous assertions made in such stridently foolish books as Prozac Backlash cannot be taken for more than pandering to the cheapest fears of an apprehensive audience. I deplore the cynics who keep suffering patients from the essentially benign cures that might give them back their lives." (p. 81). He doesn't say which assertions are the foolish ones, and it's hard to even guess what he might mean. Joseph Glenmullen, the psychiatrist who wrote Prozac Backlash, says that he often prescribes Prozac and thinks that it can be a very helpful medication in the treatment of serious depression. Glenmullen's point is that the side effects of SSRI antidepressants have been underemphasized and that the drug manufacturers have made decisions based on the desire to make profits, at the expense of patient welfare. Glenmullen also suggests that health maintenance organizations and insurance companies put financial pressure on physicians to prescribe medication when it is not the best option. Furthermore, he argues that antidepressants can have withdrawal effects when discontinued which leads to patient dependence on the medication.

Not only does Solomon misrepresent Glenmullen's views, but he also expresses ideas that agree with Glenmullen. He says that he is happy to be dependent on his medications -- he has tried three times to stop taking Zyprexa three times in two years, and has failed every time. (p. 236). Solomon is also ready to acknowledge the power of new medications including their unpleasant side effects, and he explains in some detail how other treatments may be more helpful than, or could be used in combination with, medication. Solomon also gives several stories of incompetence and malpractice by psychiatrists, so thankfully he does not insist that professionals never make mistakes. Ultimately then, it's not at all clear why Solomon has such a strong reaction to Glenmullen's book. It's as if he is confusing Glenmullen with Peter Breggin.

One of the most moving chapters is the one on suicide. He gives the story of his mother's illness and suicide, as well as his own suicidal inclinations. He defends the possibility of rational suicide, and holds up his mother's case as an example of it. He also defends the right to suicide. But his treatment of the ethical issues is crude. He writes, "If I ever attempt suicide, I'd like someone to save me, unless I have reached a point at which I accurately believe that the amount of joy left in my life cannot exceed the amount of sorrow or pain." (p. 247). Obviously the idea that we could find a way to measure amounts of happiness is implausible (a problem that has plagued utilitarianism and economic theory since their inception) but this problem applies to a wide range of proposals. More specific to Solomon's criterion is that is seems to allow too much suicide. One might plausibly think that most lives have more sorrow and pain than joy -- some major religions are based on the fundamental idea that life is full of suffering. In my experience, most people would say that they would find a small amount of joy made life worth living even if they had to put up a large amount of pain.

Solomon sets out some of the arguments that have surrounded the right to suicide, but his discussion is a mixture of anecdote, statistics, and brief summary of other people's ideas, with his own opinions thrown in. He emphasizes that whether or not it is rational, suicide still provokes powerful reactions. Even when it is justifiable, part of us still finds it very hard to accept. Yet Solomon says that the idea that he might be robbed of his ability to kill himself is horrific to him. It's an unusual view: of course there might be circumstances when I'd want to kill myself, but I can't say that it's a freedom that is precious to me. I wonder to what extent Solomon's view is shared by other people. In the end, while it's interesting and powerful, it's a chapter without a sharp focus. There's plenty of food for thought, but it's a stew.

Other chapters also have similar characteristics -- brief accounts of different treatments, the history of the understanding of depression, the relation between addiction and depression, the political dimension of depression, and so on. Most of the information that Solomon gives is familiar to those who have read other books on depression, even if no other books collect the same range of information together. One of the most important and original chapters is on poverty. Solomon charts how poverty and depression are significantly correlated and are mutually reinforcing. He points out that we can reduce the amount that society spends on welfare services if we treat mental health problems, but as the chapter on politics shows, there's little rationality when it comes to public policy concerning depression.

Overall, other books will give more detail about the topics of individual chapters, but no single book for a general audience gives as much information about depression as The Noonday Demon. As with most atlases, it will contain some facts or ideas that are new to most people, but most of them will be familiar. It's well written and thoughtful, and it will be useful and interesting to people who have not already read several other books about depression.

© 2001 Christian Perring. First Serial Rights.

Available in the UK from Amazon.co.uk.