Two Views of Mental Illness

The Noonday Demon. An Atlas of Depression, Andrew Solomon, Scribner (2001) 576 pp, $28.00 hardcoverBrave New Brain, Nancy Andreasen, Oxford University Press (2001) 390 pp, $32.50 hardcoverMany neuroscientists are drawn to this discipline by their curiosity about human thought, emotion, and behavior. Many of us recognize, moreover, that the brain diseases described by the rather outdated term “mental illnesses” are among the cruelest. Not only do they tend to be recurrent or chronic throughout life and to produce serious disability, but also they can affect the very tissue of our self-concept, our experience, and our ability to conduct our lives. In the busy life of a working scientist, this larger context is all too readily forgotten as we struggle with individual experiments or attempt to make sense out of accumulating data at the molecular or cellular levels. It is important, therefore, that we have occasional opportunities to refocus at a larger grain size and recall some of the wonder—and empathy—that initially intrigued and concerned us about the brain and its vulnerabilities. Both books under review here are intended for the general reader, but both would make interesting reading for neuroscientists.Perhaps the most common serious brain disorder in the world is major depression. An estimated ten percent of people will directly experience major depression at some point in their lives severe enough to warrant medical treatment, but the illness has a wider impact because it also affects family members, friends, and coworkers. According to the World Health Organization, major depression is the leading cause of disability in the developed world. Because of its high prevalence and its potent, often devastating, impact on human life, depression has been the topic of many powerful memoirs and other writings. Important works in recent years include William Styron's brief and riveting Darkness Visible (1990) and more recently, Kay Redfield Jamison's anatomy of suicide, Night Falls Fast (1999)—two books that could be read profitably by neuroscientists. I would now add to this list Andrew Solomon's The Noonday Demon. An Atlas of Depression. This is both a memoir, containing courageous and on occasion outrageous descriptions of personal experiences with depression and also an extensive report of conversations with other sufferers. It is also an atlas in some sense, as implied by the subtitle, describing journeys to face depression in places as far from the author's New York as West Africa and Greenland. These travels were made in search of healing in the former case and to better understand the diversity of experiences of depression in the latter. The book is also an “atlas” in a more figurative sense in that it presents a scientific and philosophical history of depression, and a textbook for nonspecialist readers. The “textbook” presents ideas gained from Solomon's extensive reading and his interviews with physicians and scientists (in the spirit of full disclosure, this reviewer was one of the sources). These sections, which dwell on the causes and treatment of depression will be the most familiar, but also in some degree, the least interesting to active neuroscientists, and many will find quibbles here and there with the choice of facts being reported. However, the greater part of the book is a compelling and transporting reminder of the impact of this disease—on the author and on many others with whom he comes in contact. Andrew Solomon is clearly no ordinary person and his experiences, typically described in an arresting literary style, provide us with an insightful and informative framework, both cognitive and emotional, from which to consider the impact of depression on human lives. As one reads Solomon's clear-eyed description of his deliberate—and unsuccessful—attempt to commit suicide by contracting AIDS, one is transported to a world in which the logic of a deadly brain disorder holds sway, a world far from the cool, rational approach to depression which characterizes research on psychiatric disorders in the lab. The reader is left with a remarkably enriched view of the effects of depression on humanity.Figure 1, Figure 2Figure 1View Large Image | View Hi-Res Image | Download PowerPoint SlideFigure 2View Large Image | View Hi-Res Image | Download PowerPoint SlideNancy Andreasen's Brave New Brain is the sort of book that I often have wished for when a colleague or friend from outside neuroscience asks for something good to read on mental illness. We sometimes forget how older, often strange, ideas derived from early this century still color the view of educated nonscientists about mental illness. In addition to its value for the lay reader, Brave New Brain would be a credible introduction to mental illness for neuroscientists working in areas that do not touch directly upon the clinical arena. Andreasen presents a clear overview of the current understandings of mental illness that are emerging from neuroscience and genetics. She does so, however, in a way that does not overstate what we know. This is important because the study of mental illness is difficult, and we have far to travel before our understanding is anywhere near satisfactory. Too often books of this sort exude an inappropriate arrogance about what we know. Brave New Brain begins with a basic introduction to the systems-level study of the brain, to neurotransmitters, genomics and genetics, and to current approaches to investigating mental illness, especially neuroimaging. It then proceeds to a discussion of major mental illnesses including schizophrenia, mood disorders, anxiety disorders, and dementias. Andreasen has written in a logical order, with clarity, and with attention to both more reductionist and more systems level approaches to mental illness. While perforce some simplification must occur in writing such a book, I looked carefully for pet peeves that I have with such overview accounts and came away pleased that Andreasen has dealt with the complexities of the brain and mental disorders quite admirably. Her discussion of “genetic complexity” in the context of schizophrenia is exemplary. With lucidity and precision, she explains that no single gene causes schizophrenia or any other mental illness, but that disorders are thought to arise from complex gene-gene and gene-environment interactions. Similarly, in a thorough review of contemporary brain imaging technologies, she describes straightforwardly the promise—and the current limitations—of these new tools. My highest praise is that I believe this is a book that could inspire a medical student or a graduate student to dedicate a career to better understanding mental illnesses.