Living Crazy

THe Lancet review.

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Find attached a book review that was accepted for the American Journal of Psychiatry residents’ edition.  Most of it will be familiar from the mini-talk you invited me to do last November.  Sorry I couldn’t do more justice to your wonderful book, but I figure one of my roles is to get psychiatrists to read things they need to but wouldn’t ordinarily.  

 

See you soon,

Helena

 

Book Review

 

Bipolar Disorder as Culture Bound Syndrome: 

A Review of Anthropologist Emily Martin’s

Bipolar Expeditions: Mania and Depression

in American Culture

 

By Helena Hansen, MD, PhD, PGY4

NYU Medical Center Department of Psychiatry

 

Contact Information:

 

Helena Hansen MD, PhD, PGY4

Phone: (212) 562-2240

Email: helena [dot] hansen [at] nyumc [dot] org

If Kay Jamison,who argued that bipolar disorder fosters creativity by retrospectivelydiagnosing famous artists and authors in history, helped to usher an era inwhich mania is valorized, Emily Martin might be the anti-Kay Jamison.  Both Martin and Jamison write from thevantage point of their own diagnoses, but that is where the parallel ends.  Rather than asking how bipolar disorderfosters creation, as Jamison does, Martin issues a sharp critique by asking howbipolar disorder itself is works as a concept in popular culture, and what usesthe increasingly widespread concept has in contemporary American society.

Emily Martin is anaward winning medical anthropologist of renown among social science andhumanities scholars.  With thepublication of Bipolar Expeditions: Maniaand Depression in American Culture (Princeton University Press, 2007), sheturns from her previous subjects of inquiry (women’s physiology, immunology) tothe problem of bipolar disorder, applying her formidable skill to unearth howthe details of clinical practice reflect popular culture. 

An ethnographythat interweaves her self-reflection with interviews and observations ofbipolar support group members, clinicians treating bipolar disorder, andpharmaceutical marketing professionals, Martin’s book does not recognizeboundaries.  Like a psychoticperson, it breaks down the distinction of self and other; it does not respectprivate property.  And privateproperty is precisely what the book takes on.

In BipolarExpeditions, Emily Martin uses herself to challenge the idea that living withthe diagnosis of manic depression is an intimate, personal affair.  She cannot keep her own diagnosiswithin the confines of her psychiatrist’s office; at every turn she shows howher experience affects her students, her colleagues, her written and spokenwords.  She wrestles out loud withstanding “in a doubled position” as a person who uses psychopharmacology andtherapy, but also questions their historical and cultural significance.  As a member of the support groups aboutwhich she writes, she offers her story in order to replace “secrecy and fear”around the stigma of mental illness with “collective responsibility.”  At the same time she avoids glamorizingthe diagnosis as a famous anthropologist coming out as bipolar.  She points out that the bipolarcreativity portrayed in the media is one that furthers the status quo ratherthan challenging it.  Moreover, shedocuments how the creative potential of the people in her study is hinderedrather than helped by bipolarity. 

Emily Martinshatters common sense distinctions of public and private, individual andcommunal.  In the process, shemakes sense of what may seem counter-intuitive on the surface: the consciousself-presentation and sociality of people living with the diagnosis of manicdepression.  As Emily Martin putsit, even a “mad” manic can be social.

Manic people, shepoints out, are conformist: they engage; they gravitate to others; as producersthey are “tightly bound to social conventions” and “innovative…in terms themarket can value” (Martin 2007: 259). They are disruptive because they are social to excess: in their pursuitsand seduction they invade, they irritate. Depressed people withdraw, but as they descend it is impossible to do sowithout others noticing.  As theyget so depressed that they are not able to carry on everyday life, it becomesobvious to all, and all are moved in some way.  In both mania and depression, disrupted social rhythms callattention to the sufferer; they bring about a lack of privacy.  Mania and depression are enactedthrough social relations, like those in the support groups that Martindescribes.

It is an ironythat something as private as mania and depression have such a social impact andare experienced through social connections.  The “privacy” of the psychotherapeutic cultural model thatAmericans have for dealing with relational problems is unique: traveling greatdistances to consult in a sound-proofed room with someone we choose because heor she does not know anyone we know, and can guarantee confidentiality.  Consider how different the model isfrom the majority of non-European societies, where relational problems aremediated collectively in the community. Perhaps psychiatrists help to sustain a myth of privacy (of industry,property, individual psyches).  Yeteach of us brings our personal history to the present, and this history iscreated by our experience of other peoples’ emotions and realities. In thatsense, no act of consumer choice, foreclosure, plant construction, orpharmaceutical advertisement can be private.

Martin exposes asecond irony of manic depression. American media have propagated the idea that the mood of the economy, inparticular the stock market, reflects the mood of individual consumers andinvestors as it cycles between extreme optimism and risk taking on the onehand, pessimism and withdrawal on the other.  But the media have not shed light on the ways that theeconomy itself creates individuals with mood disorders.  Using examples ranging from magazineads that portray Ted Turner’s bipolarity in order to boost his image withstockholders, to stockbroker training programs that teach new traders to “behypomanic,” Martin argues that bipolarity is symbolically cultivated as aheroic property.  In the newmillennium, bipolarity has become a way of seeing the world, a way of makingsense of individuals, making sense of markets, and a way of demonstrating one’svalue. 

Martin’s argumentabout bipolarity builds on a literature historically linking psychiatricdiagnoses to the ethos of their time. A version of this history, reproduced by people as varied as David Healy(2006), Nikolas Rose (2007), and Jonathan Metzl (2003), is that post WWIIpsychiatry offered the metaphor of anxiety disorder and the panacea ofbenzodiazepines to a generation obsessed with insecurities about the cold war,changing gender and race relations. In the 80’s, with the introduction of Prozac, an aggressively marketedselective antidepressant free of the side effects of earlier antidepressants,the psychiatric metaphor shifted from anxiety to depression. The Prozacgeneration of baby boomers confronted the decline of American colonialism, andhit the limits of economic expansion. At the same time, physicians’ diagnosticpatterns shifted just as dramatically from anxiety to depression, with aneight-fold increase in antidepressant prescriptions written between 1990-2000(Rose 2007). 

Emily Martindescribes the third wave: the bipolar generation.  Thrust into broadband speed by the internet, and hardened bybooms and busts, from dot coms to the war on Iraq, this generation’s economy demandsimprovisation, risk taking, and perpetual motion.   Martin astute observation goes beyond metaphor.  Like the Indian theater she references,one can create the “conditions that excite a mood” rather than locating moodsin individuals.  In other words,mental illness may not necessarily come from deep within; it may beoverdetermined by the setting that directs its performance. 

The shift to thepsychiatric metaphor of bipolarity in the market has been accompanied by anexpansion of the diagnosis and treatment of bipolar disorder in actualclinics.  A standing joke in mydepartment involves attendings in whose care every patient ends up diagnosedwith bipolar disorder.  Variationson the diagnosis of bipolar disorder are proliferating, which new categoriessuch as “pseudounipolar depression” in those with no manic or hypomanicepisodes, but reporting irritability with depression, and often familyhistories of bipolar disorder, who are thus prescribed mood stabilizers.

In addition, thediagnosis of Bipolar II, which does not require patients to meet full criteriafor a manic episode, is leading young psychiatrists to rediagnose many peoplewho have long been diagnosed with depression.  Psychiatrists cite studies indicating that a number ofpatients mistakenly diagnosed with depression were actually sent into a manicepisode as a result of taking antidepressants without mood stabilizers.  It is striking that currently, patientson the inpatient service in my hospital are rarely discharged on an antidepressantalone.  These days, most leave withsome form of mood stabilizer or antipsychotic.  Among prescribers, there is a mania about the risk ofcausing mania with antidepressants. As a result, doctors prescribe bipolar medications.  Does the fact that Lamictal was onpatent until this year have anything to do with this?  What about the fact that second generation antipsychoticssuch as Seroquel and Zyprexa, whose patents both expire in 2011, are FDAapproved and promoted for use in bipolar disorder?

Products createconsumers, and new diagnoses create patients.  The market literally has turned bipolar, with Seroquel(making $2.76 billion/year), Lamictal (at 0.8 billion pounds/year) and Zyprexa(at $2 billion/year) named the top three profitmakers for pharmaceuticalcompanies by 2006. (health.dailynewscentral.com 2006, Glaxo SmithKline Annual Review2006).  Martin calls forpsychiatrists’ vigilance regarding the social effects of diagnosis, writing“The authority behind the act of naming means that the person will be treatedas if he or she had the condition; this is the sense in which the act ofdiagnosis is performative” (Martin 2007:148).

If we attempt totake Emily Martin’s social analysis to its logical conclusion, what does allthis mean?  Her book gives us someclues.  Bipolarity serves certainpurposes of the market.  Bipolardisorder is sold to Americans as a problem of self-regulation, of impulsivedecisions in an era of too much choice. The irony is that the marketing industry within popular media is soadvanced, as a technology of social manipulation, that bipolarity is ever morepredetermined.

 

Works Cited:

Healy, David. Let Them Eat Prozac: The Unhealthy Relationship Between thePharmaceutical Industry and Depression. NYU Press, New York 2004.

Jamison, Kay Redfield (1989):  “Mood Disorders and Patterns of Creativity in BritishWriters and Artists. ”  Psychiatry52(2):125-134.

Emily Martin. Bipolar Expeditions: Mania and Depression in American Culture PrincetonUniversity Press, Princeton 2007.

Glaxo SmithKline Annual Review March 30 2006.  Electronic document www.flixotidecopd.co.uk/investors/reps05/annual_review_2005/business_operating_review.htm). 

health.dailynewscentral Feb 3, 2006.  Electronic documentwww.health.dailynewscentral.com.

Metzl, Jonathan. Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs. DukeUniversity Press, Durham 2003.

Rose, Nikolas. The Politics of Life Itself: Biomedicine, Power and Subjectivity in theTwenty-First Century.  PrincetonUniversity Press, Princeton 2007.

  

Dear Dr. Martin,

Thank you so much for such an enlightening and important interview.  I was a pleasure to speak with you.

I have posted the audio file a the following sites

Psychjourney Podcast
http://psychjourney.libsyn.com/index.php?post_year=2009&post_month=02
Psychjourney Podcast Blog

I have sent you and your publisher a copy of the audio file of the interview through Send This File.  You can download the audio file to your computer and then upload the interview to your website and blog.  I request that when you post the interview you include a link to Psychjourney www.psychjourneypodcast.com   Thank you.

The length of the interview is 44 minutes, 4 seconds.

Best,

Deborah

Deborah Harper
President, Psychjourney
(408) 365-8933
(408) 613-2532

 

Dear Prof. Martin

 

I thought you might be interested to know of my review of your excellent book, just posted on this online website.  The anonymous colleague in the review is Sander Gilman at Emory, who I presume you know.  Perhaps we can communicate on our joint activities in the future. You might be interested in my book The Concepts of Psychiatry

 

http://metapsychology.mentalhelp.net/poc/view_doc.php?type=book&id=4440&cn=158

 

Regards

 

Nassir Ghaemi

 

S. Nassir Ghaemi MD MPH
Director, Mood Disorders Program
Tufts Medical Center, Dept of Psychiatry
800 Washington Street, #1007
Boston, MA 02111
Phone:  617-636-5735
Fax:  617-636-4852
Email: nghaemi [at] tuftsmedicalcenter [dot] org

Research assistant:   Elizabeth Whitham (ewhitham [at] tuftsmedicalcenter [dot] org) 617-636-3025
Author website:  www.nassirghaemi.com
Blog:  www.mindbrainworld.com

 

Craig writes:

It’s available in hardback or paperback, signed or unsigned.  General release through bookstores and online giants like Amazon will not occur until March 1.

For unsigned books, here’s the link for ordering:

http://www.cyberwizardproductions.com/diminuendo/light.html

For signed books, here’s the link:

http://cechaffin.com/light.html

The hardback runs 156 pp., the paperback, 161.  Both are fine editions, perfect bound, and the hardback will last for years to come.  They also make great gifts for your friends!

It’s my first volume in eleven years and Kathleen and I spent hours whittling down my production to what we considered the best, as I’ve published an average of 50 poems a year for the last eleven years.  I’ve pasted in two short poems below as examples, although they cannot represent the work entire.

Self-promotion is not my forte, but I believe in this book.  I believe it will appeal to poets and non-poets alike, as I have striven to make my poetry accessible in an age where people have actually come to fear poetry as unintelligible.

Should you find it in your heart to purchase a copy, I will, of course, be grateful—but happier at the pleasure and inspiration you might receive from the words of your fellow traveler.

Thine in Truth and Art,

C. E.(Craig Erick) Chaffin

Details

Forget the overdue book,
the music clubs whose disks you never returned,
the extra cellphone charges
for missing the free minute zone,
the soft nagging of dereliction.
Were you ever any different?
Capitalism depends on forgetfulness.
Who can keep up? A friend told me,
"You must get a credit card
that earns free air miles." As if!

There are people who worry
about the insurance on their jewelry,
pick up dry cleaning on time
and organize their shoe racks.
Do you really have the energy?
To manage every detail
you must attend to every wrinkle.
You may miss the pearly trout
beneath the willow bank,
the luna moth drying
green wings with purple piping
on the white clapboard.

The Game of Life

As an infant you discover your body.
As a toddler you explore things
and try to master your body.
In kindergarten you make friends,
in elementary school, circles of friends.
In middle school you discover sex.
In high school self-absorption makes you
what you think your peers think of you.

At twenty ambition nudges you,
by twenty-five you are working hard.
At thirty you have worked hard enough
to see what your parents did to you.
By thirty-five you should have forgiven your parents.
At forty who you are should be obvious.
By then you should have built
a cottage from your broken illusions
else start from the beginning.

I live in an area of California where the philosophy of "thought creates" is quite popular. This notion has been one feature of "New Age" thinking that works well for those with normal brains. Unfortunately for the manic-depressive this notion creates but another layer of guilt to apply to previous varnishes. "You become what you imagine." Hmmm... why would anyone want to imagine themselves thrown in jail, as I have been more than once when manic? Why would anyone want to be curled up in a fetal position, unable to speak? The idea that "thought creates" blames the victim and falsely exalts those free of a mood disorder, which by strict criteria might include 90% of the population.

The mistake of ascribing volition to mood is fairly pervasive. In a world of well-balanced folks with normal brain chemistry this might fly; in the real world it is a crock.

Presently I am suffering from a depression of nearly two years' duration, a new personal record. Being depressed is the last thing I want, truly. I didn't create it, wish it, will it, plan it, hope for it, unconsciously crave it, no-it happened to me. It is not my fault that bipolar genes run deep on both sides of my family-both my maternal and paternal grandmothers were hospitalized for it and my father died of it. Not the best of odds.

One of my doctors once told me that bipolar illness continues on, even in the well-medicated subject who is not experiencing current symptoms. It's the background pattern, always present, of a long-term mood disorder. And ultimately the demon will out, no matter how well treated.

Another type of person I've encountered is one who has been "cured" of manic-depression. I met some like this in Alcoholics Anonymous (a group I attended for support when depressed). "If you want to be really clean and sober you will get off that lithium," so I was advised, which advice is even contrary to their "Big Book." What is in fact true is that the person who so advised me was either misdiagnosed or has another episode to look forward to, no matter what kind of spiritual path they pursue.

If you look at the research, both current and historical, there have always been manic-depressives, and they make up 1% of the population across the board, across borders and ethnic distinctions. The word "lunatic" is in fact derived from the behavior of bipolars, back when their extreme mood changes were attributed to cycles of the moon.

The point of my first post? This is a real illness. If twins are separated at birth and raised in different environments and one twin develops the disease, there is a 75% chance that the other twin will, too.

Once one has a valid diagnosis it is fools' gold to pursue alternative treatments recommended by those who don't understand the disease. What undermines this certainty among the affected is first, a desire not to believe one has the disease, and second, the tendency of the disease to allow long periods of normal mood, or "euthymia," between episodes. If one is lucky enough to enter alternative treatment (or no treatment at all) during a period when the illness is quiescent, well, that's dumb luck but it proves nothing. It's also bad luck because it is false, as the wolf will soon be at the door again, either fattened by mania or starved by depression.

The disease is real. The disease is treatable. And for a bipolar I, the standard by which all other mood disorders are measured, the disease becomes the central fact of one's life--more important than marriage, religion, career, you name it. Because none of the things just named are possible for the bipolar if sick. If I am clinically depressed, for example, church can be quite toxic, as all I hear is judgment, not forgiveness.

There is an old debate over whether thought precedes "affect" (the expression of feeling) or whether affect precedes thought. For manic-depressive illness, at least, affect precedes thought. In other words, I am not sad because something sad happens; my mind seeks out sad things and thoughts because I am intrinsically sad for no good reason. (And when it comes to a bipolar depression, "sad" doesn't cover it--it's much worse than that; it's like having your eyeballs painted black and your heart torn out and deflated like a cheap balloon and stomped upon by a band of gypsies.)

It's not that we bipolars can't experience normal emotions. Things can make us sad or happy, just as in other people. It's just that too often our illness dictates how we feel without regard to circumstance.

In my days as a doctor one simple question I developed for diagnosing depression was to ask the patient if he would feel any different if he won the lottery. A clinically depressed person can't imagine feeling better, so the thought of the prize is of no help. A circumstantially depressed person, or someone with a minor case of the blues, is cheered by the idea.

For the bipolar, no amount of good news will make one feel better in a depressed state, just as no amount of bad news will make one feel bad in a manic state (what patients call "feeling bulletproof").

The point of my first missive, here, again? Bipolar disease is real. Untreated, a bipolar I (like myself, the classic and worst case) has a 30% lifetime chance of dying from the disease untreated, whether by accidents due to poor manic judgment or suicide due to depression. (I knew one patient whose father died racing trains in his car.)

 

p.s. Emily Martin graciously invited me to contribute here. I also have my own blog at http://www.cechaffin.blogspot.com where I struggle with the disease and sometimes speak of other matters, especially literature.

A couple of recent radio talk show conversations with Emily Martin on the cultural context of bipolar disorder, with audio files:

WILL Radio Urbana- Champaign, Illinois

Focus 580
David Inge
Interviews with newsmakers and experts on international affairs and daily life
http://www.will.uiuc.edu/am/focus/archives/07/070910.htm

WYPR Radio Baltimore, Md

The Marc Steiner Show

The Marc Steiner Show is WYPR’s flagship daily public affairs talk program. Marc’s program has graced Baltimore’s airwaves since 1993, and it has earned a well-deserved reputation as the city’s premier radio forum for discussion and debate of national and international political and cultural issues. Above all, The Marc Steiner Show prides itself on providing a venue for intelligent conversation about local issues crucial to the livelihood and well being of the citizens of Baltimore and Maryland.

feed: www.publicbroadcasting.net/wypr/.jukebox?action=viewPodcast&podcastId=58…
http://themarcsteinershow.wordpress.com

In writing Bipolar Expeditions, I thought of the book like a house with many windows through which readers could look at moods, mood disorders, and bipolar disorder in particular. Pg 99 of the book opens one of those windows, beginning a chapter that explores how psychiatrists learn to diagnose bipolar disorder in "affective disorder rounds." Rounds is a teaching setting in which a patient who has been admitted to the hospital with mood problems is "presented" to a group of medical students. In that chapter, we see how fuzzy the lines between different mood disorders are and how difficult it is for psychiatrists and medical students to decide among alternative possibilities. We also see how patients contest the doctors’ efforts to extract information from them, which they anticipate will be used to diagnose them in ways they might not appreciate.

By looking through the other windows in the book, the reader will be able to trace the processes by which a psychiatric diagnosis, like the mood disorders in evidence at Rounds, has emerged into a wide territory beyond psychiatry.

Anyone, from a reader of a teen magazine to a high powered CEO, might regularly chart their moods to determine whether they have a “mood disorder.” Workers undergo training in how to be "manic" so that they can recreate “manic” states – high energy, no sleep, innovative thoughts — later in the workplace. Hollywood actors show up at their psychiatrists’ offices with their agents in tow, the agents’ job being to make sure that any drugs the doctors prescribe will not take the edge off the actors’ “mania.”

Both depression and mania have become fascinating cultural symbols in schools, the workplace and the market place. The low end of the mood spectrum (depression) signifies failure and unproductivity; the high end (mania) signifies creativity and productivity. Bipolar Expeditions argues that mania and depression have a cultural life outside the confines of diagnosis, that the experiences of people living with bipolar disorder belong fully to the human condition, and that even the most so-called rational everyday practices are intertwined with irrational ones.

What is behind the recent explosion in the diagnosis of bipolar disorder among American children? There is much to wonder about, as we know from Time magazine’s 2002 cover, “Young and Bipolar;” and from the recent 60 Minutes segment, “What killed Rebecca Riley?” Four year old Rebecca is said to have died from an overdose of psychiatric medications given to her for her bipolar disorder. The New York Times had already reported last month that the number of American children and adolescents treated for bipolar disorder increased 40-fold from 1994 to 2003. Behind these statistics lie powerful cultural changes in how Americans regard their moods.
One force behind the statistical increase is that bipolar disorder is in the process of redefinition from being simply a disability to being an asset. In many books and Internet sites there are lists of famous, creative, and influential people whose diaries, letters, and other writings indicate their bipolar disorder played a role in the enormously creative contributions they made to society. Larger than life figures like Robin Williams and Ted Turner are frequently described as “bipolar.” The other end of the spectrum of mood disorders, major depression, carries a different load of associations. If mania comes to seem more and more necessary for productivity in the competitive, sped-up global economy, depression signals the opposite: the person seems slow, quiet, inattentive, withdrawn, in short, unable to be productive. Some states have instituted depression screening for people still on the welfare rolls, assuming that these people are likely still on welfare because they are depressed. Of course, they may well be depressed! And medications the state provides may indeed help them become more productive. What interests me as an anthropologist is that cultural values very specific to our society are carried along with these diagnoses.
The notion is that as depression withers away altogether, the wild mania of the manic depressive can be tamed or optimized, the better to enable individuals to succeed and economies to grow. Key agents in this picture are the growing numbers of psychopharmaceutical drugs. They are what allow contemporary doctors to give a patient a diagnosis of mood disorder and treat it, rather than (as in earlier historical periods) lay the patient’s problems at the feet of her temperament or character. This transformation has certain benefits, not least that drugs can be effective and patients can feel less personally responsible for their condition. But as these conditions are rendered treatable, they are also become conditions that are greatly more susceptible to whatever cultural ideals are in play. It becomes thinkable to manage and adjust moods and motivations in directions that are apparently necessary for survival in the fierce economy of the present and that can be harnessed as an asset in the workplace. At a meeting of the American Psychiatric Association, I met a young doctor who practiced in a well-known hospital near Hollywood. When he heard about my research, he became quite interested and offered me this experience.
Where I work, we get a lot of Hollywood comedians coming in. They are manic depressives. There are two important things about this: first, they do not want their condition publicized, and second, their managers always get involved in the details of their treatment. The managers want the mania treated just so. They do not want it floridly out of control, but they also absolutely do not want it damped down too much.
He felt he was being called upon to optimize his patients’ moods (for particular professions and for the particular kinds of creativity each requires) through proper management of their drugs. His comment made me realize that drugs I was taking were being optimized for my profession, too: not so much lithium that my hands shook when I wrote on the blackboard; not so much Lexapro that my mind slowed down and stopped generating ideas during a class; not so little Focalin that my attention wandered constantly and I couldn’t write articles and books; not so little Lamictal that I got depressed and became unproductive altogether. A little like the Hollywood comedians, I was in the fortunate position of being able to afford expensive, expert advice about all this and working in a profession I valued. I began to feel uneasy about the prospect of extending the optimization of psychotropic drugs to suit other kinds of employment. What would happen if optimizing states of mind were extended, through health insurance, say, or perhaps as a condition of employment, to people who work in physically demanding jobs, for long hours, low pay, and little hope of advancement? To people who work in retail jobs demanding continuous emotional work (make the customer smile!), for long hours, low pay, and little hope of advancement? Or to soldiers on combat duty? What are the costs of extending the use of powerful psychotropic drugs to treat children whose behavior causes problems at home or school? It is essential to remember that the need for treatment (real as it may be in some cases) cannot be separated from a cultural environment in which some moods now seem to point to success and others to failure.

Clinical depression | Something in the way he moves | Economist.com - Depressed people move in a mathematically different way from other people

The Economist.com article on Newsvine reports that mathematicians have modeled the slower movements of people who are depressed. 

It isn’t news that movements slow down during depression, but it is interesting that the author jumps immediately to this account of why movement slows down: "a mental disorder which isolates people from human society …which must surely have its origins in some malfunction of the nerve cells." Of course we need nerve cells or we wouldn’t be people. But do nerve cells determine that sad feelings go along with slow movement? Wouldn’t another, more interesting place to look be the meaning of speediness and slowness in the post-industrial societies of today? In our cultural milieu, fast means success, energy, productivity, vitality and slow means failure, fatigue, and lack of progress. Can’t we imagine another kind of society in which different values would be attached to these opposites? In a society that valued calm, reflection, removal, and stillness highly, would depression still be experienced as isolating and miserable? When I taught at Princeton, my colleague, another anthropologist, Gananath Obeyesekere, who is from Sri Lanka, would sometimes notice that my movements were slowed and my expressions downcast. He would then mention that in Buddhist thought, ceasing to care about the things of the world, removal from worldly engagement, are marks of enlightenment. I might not have felt less depressed, but I had gained a new window to think about the experience.