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Nassir Ghaemi's on Depression 142 BOOK REVIEWS haps, has mastered Lacanian concepts clearly!) and he has the ability to psychoanalytic express himself in a way that will make sense to an English-speaking tolerate ambiva audience without diluting Lacan's ideas. I can highly recommend this pacity to hate tl fascinating and clinically useful book. tal achievement and a prominen Gerald P. Perman, M .D. The book is I 2424 Pennsylvania Ave., N.W. Chapter 1 GhaE Suite 100 modernist and] Washington, DC 20037 ation. In Chapf gpperman @gm ail.com ence, recognizu of human life, , understand de] mental triggers, as he essentiall· the same. By P' of the genetics ( On Depression: Drugs, Diagnosis and Despair in the Modern World, by wrong." Nassir Ghaemi, M.D., Johns Hopkins University Press, Baltimore, MD, This bold ass 2013, 232 pp., $24.95. presents or otlu than genes goe. plain the simp] It was the title of this book that made me want to read and review it sion, the odds for the journal. Psychiatry is learning fascinating things about depres­ erably less thar sion, about the limitations of our knowledge, and about the contribu­ evant to this frl tions of genes and environment to depression. I hoped to learn how an it was publishe erudite and thoughtful psychiatrist might put it all together. Indeed, tion Study reSE Ghaemi does a creditable job of making his case for how to understand the Psychiatric these issues, but he omits important recent information that undercuts find any genes his position, and rarely misses an opportunity to take a swipe at, mis­ Polymorphism understand, or misrepresent Freud and psychoanalysis. From my work of tens of thous in organized psychiatry I am familiar with such swipes at psychoanal­ for other disea ysis from those often untrained in it, though I am pleased that such ease . Genome swipes seem to be fading in light of emerging evidence of the efficacy environmental of psychoanalytic treatments, but not so from Ghaemi. ized in causing Despite his swipes at psychoanalysis, Ghaemi extols the virtues of to the heuristic some psychoanalytic concepts without recognizing them. An example 21st century by of this is in a late chapter on Leston Havens, surely a gifted clinician or alleles for the s "guide" as Ghaemi calls him, to whom Ghaemi properly assigns credit of depression 1 for emphasizing in his work with patients the importance of being able the least risk ( to hold simultaneously two conflicting ideas. Ghaemi fails to recog­ sity. These fine nize that here Havens is speaking a basic developmental notion from by environmei BOOK REVIEWS 143 !) and hehas the ability to psychoanalytic object relations theory. Achi evement of the capacity to eto an English-sp eaking tolerate ambivalence is a psychoanalytic notion with origins in the ca­ highly recommend thi s pac ity to hate the one we also need and love-a central developmen­ tal achievement, an essential part of achieving the depressive position, and a prominent clinical issue in our patients. The book is divid ed into four parts. Part I is called "Entrance." In Chapter 1 Ghaemi shows a sure hand, offering a concise overview of mod ernist and postmodernist persp ectives on our lives of quiet desper­ ation. In Chapter 2 Ghaemi takes on the varieties of depressive experi­ ence, recognizing helpfully that sadness, suffering, and grief are part of human life, and not the same as depression as illness. In seeking to understand depression as illness, sometimes with apparent env iron­ mental triggers, Ghaemi lays out his own pe rsp ective, quoting Aristotle as he essentially makes the case that correlation and causation are not the same . By page 19 he reaches the conclusion that "A prime feature of the genetics of depression, rarely emphasized, is that it proves Freud in the Modern World, by wrong ." ityPress, Baltimore, MD, This bold assertion is a non sequitur that does not fit the data Ghae mi presents or other data sug gesting that, althoug h clearly heritable, more than genes goes into the cau sation of dep ression . How else can we ex­ pla in the simp le fact that if one of a set of identical twins has dep res­ ant toread and review it sion, the odds that the second twin will have depression are consid­ . g things about depres­ erably less than 100%? Ghaemi's omission of interesting learning rel­ , and about the contribu­ evant to this from one recent mol ecular genetic study ma y be because .Ihoped to learn how an it was published after his book went to press. Genome Wide Associa­ t it all together. Ind eed, tion Study researchers (Major Depressive Disorder Working Gro up of efor how to understand the Psychiatric GWAS Consortium, 2013) have reported their failure to ormation that undercuts find any genes or even nucleotides (so called SNPs or Single Nucleotide to take a swipe at, mis­ Polymorphisms ) associated with major depressive disorder in studies eanalysis.From my work of tens of thousands of people, samples large enoug h to find such SNPs ch swipes at psychoanal­ for other diseases like some canc ers, typ e 2 diabetes, and Crohn's dis­ I am pleased that such ease. Genome Wide Association Study researchers ackn owledge that evidence of the efficacy environme ntal factors ma y be far more important than previou sly real­ Ghaemi. ized in causing dep ression. Ho we ver, Ghaemi also omits any reference mi extols the virtues of to the heuristic implications of one of the most cited studies of the early 'zing them. An examp le 21st century by Caspi (Caspi et al., 2003), in which homozygous "short" relya gifted clinician or alleles for the serotonin transporter promoter gene confer increased risk iproperly assigns credit of depression to those with early ad versity, like abuse, but also confe r importance of being able the least risk of dep ression to those without histories of early ad ver­ , Ghaemi fails to recog­ sity. These findings have led to intense interest in epigenetics, or gene elopmental notion from by env ironme nt interaction, and have led some mol ecul ar geneticists 144 BOOK REVIEWS (Belsky et al., 2009) to question the entire premise of genetic "vulner­ resent psycho ability" (a premise Gh aemi adheres to) in favor of the concept of genetic for example, ( "plasticity," in which the same genetic makeup (e.g., Caspi's sero tonin based on the tra nsporter promoter gene short alleles) may confer an increased risk does Ghaemi of dep ression in the presence of early environme ntal adversity, but a Part IV, en decreased risk of depression with an early beneficial env ironme nt. analysis, this It sho uld be noted that short alleles do not account for a large amount our confusion of the variance in who becom es depressed . This is not "the gene" for from continu de pression by any means. Studies like those of Casp i and Belsky are im­ Anna Freud 2 portant for their heuristic value . They highlight assump tions we have about what c made that may be false, like Ghaemi's that dep ression is demonstra­ reade r is no II bly and principally the result of gene tic vulnerability. As I have arg ued ysis, when eil in this journal in the past (Plakun, 2012), if emerging genetic research when he is ql demonstrates that the environme nt is far mo re important than we had "the three ba realized in the causation and treatment of mental disord ers like depres­ 168). If Freud sion, then psychoanalysis and Freud, far from being proven wrong, zling . Ghaen may be esse ntial to psychiatry if it is going to make sense of env iron­ related to Gl mental factors in com plex, textured, and sophisticated ways. mediocre "[u Now this is very complex material, and Ghaemi is entitled to his uttere d by a: opinion about how all this should best be understood , but he is not yea rs, thougl entitled to his own facts. And I qu estion why he would present such efforts to unc conclusions to his read ers while omitting such heuristically important he is focused molecul ar gene tic research. In many r, Part II is entitled "Pretenders." In Ch apter 6 Ghaemi makes an ef­ analysis, bu: fort to debunk postmod ernism, and with it, what he sees as its link to it, for exam] psychiatry in the form of the biopsychosocial model, which he explains pharmacolo) as a notion that all answers are right so any thing goes. Here Ghaemi his criticism shows his preference for simple explanations over complex ones, even standing ala if things are complex and not simple, which is wha t the emerging sci­ I would 1001 ence seems to be revealing. His certainty and his categorical "this is mend Ghae right and that is wrong" stance, in which he rep eatedly sets up false what those dichotomies, did not persuade this reader to give up entirely on the bio­ up against it psychosocial model , postmod ern perspectives, or even the DSM, which he sees as a postmod ern instrument. I will give him credit for ma king me think, thou gh . REFERENC In Part III, entitled "Guides," Ghaemi speaks about mentors and col­ leagues who have helped shap e his point of view. These include Vic­ Belsky,J.,[onz tor Frankl, Rollo May, Elvin Semrad, Leston Havens, Paul Roazen, and Vulnert Karl Jaspers. These moving, often quite personal accounts of how these Caspi, A., SUI thinkers influenced him, were the best part of the book.
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