Вы находитесь на странице: 1из 3

Book Forum

Sandra L. Patterson, Editor

The Ethical Brain, by Michael S. Gazzaniga. Washington, and eventually elucidate a cortical basis for such ethical prin-
DC, Dana Press, 2005, 201 pp., $25.00. ciples as the wrongfulness of killing. He makes clear, however,
that he believes there is a limit to what brain research can
“Neuroscience will never find the brain correlate of re- contribute to an appreciation of individual moral responsibil-
sponsibility, because that is something we ascribe to hu- ities, since people’s responsibilities toward each other by def-
mans—to people—not to brains. It is a moral value we inition exist in a social context, rather than in isolated brains.
demand of our fellow, rule-following human beings. Just Gazzaniga concludes his book with a discussion of how hu-
as optometrists can tell us how much vision a person has man empathy originates. He thinks it is likely that “mirror
(20/20 or 20/40 or 20/200) but cannot tell us when some- neurons” give a person the ability to put himself in another’s
one is legally blind or has too little vision to drive a school place and to figure out what the other person would want in a
bus, so psychiatrists and brain scientists might be able to given situation. Gazzaniga sees this neurologically grounded
tell us what someone’s mental state or brain condition is empathy as the basis for certain universal ethical principles.
but cannot tell us (without being arbitrary) when some- He believes that an understanding of those ethical principles
one has too little control to be held responsible. The is- all people carry inside will help people of different religions
sue of responsibility (like the issue of who can drive and belief systems to get along, even when they do not agree
school buses) is a social choice.” (p. 101) about individual ethical issues.
In The Ethical Brain, we thus find echoes of earlier thinking
In The Ethical Brain, Dartmouth cognitive neuroscientist in the field of sociobiology in which attributes such as altru-
Michael S. Gazzaniga explores the evidence for hardwired ism, tool use, and intentional warfare were tied to an explicit
brain functions that contribute to a universal set of human biological origin. It is interesting that these attributes, which
ethical values. Gazzaniga, a member of the President’s Coun- were previously thought to separate our species from all oth-
cil on Bioethics, has had plenty of experience grappling with ers, are also no longer identified as unique to humankind. Just
issues ranging from when a fetus should be accorded the sta- as the observations and implications of sociobiology were
tus of a person to whether parents should in the future be al- criticized by diverse members in our society for widely vary-
lowed to genetically select intelligent children, and he dis- ing theoretical, philosophical, and religious concerns, we an-
cusses those topics and others from a neuroscientist’s ticipate that the ideas laid forth by Gazzaniga will also be met
perspective in this brief book. with a mixed response. Nevertheless, it addresses a field of
importance to psychiatry, the neurosciences, bioethics, and
The book begins with fairly routine discussions of what
our society; it should evoke and provoke more sophisticated
neuroscience contributes to the familiar debates on the moral
thinking in an as yet relatively unexplored domain.
status of embryos and on end-of-life issues. Psychiatrists will
The Ethical Brain is generally clearly written, and it includes
find Gazzaniga’s chapters on “Better Brains Through Genes”
a wealth of references that guide the reader to helpful texts in
and “Shaping the Smart Brain With Drugs” more thought-
neuroscience and sociobiology for further exploration.
provoking in their discussions of the heritability of intelli-
gence and its potential chemical enhancement. He foresees a JOSEPH B. LAYDE, M.D., J.D.
day when gene therapy allows more people to be really smart. LAURA WEISS ROBERTS, M.D., M.A.,
More problematic is Gazzaniga’s assertion that cognitive en- Milwaukee, Wisc.
hancement therapy and drugs are inevitable and his belief
that government should avoid regulating them. In libertarian The Age of Melancholy: “Major Depression” and Its
fashion, Gazzaniga is sanguine that people’s ethical and Social Origins, by Dan G. Blazer. New York, Routledge, 2005,
moral senses will prevent societal dislocation from a flood of 251 pp, $34.95.
newly smart people.
In later chapters, Gazzaniga writes that brain function re- According to the World Health Organization, depression
search is likely to identify with increasing certainty what areas ranks fourth among the 10 leading causes of the global bur-
of the cerebral cortex are most involved in moral reasoning den of disease and is expected to rise to second within the

Am J Psychiatry 163:4, April 2006 ajp.psychiatryonline.org 751


next 20 years. In this slim treatise, Dan G. Blazer, J.P. Gibbons our current age is experiencing the rise of depression as a ma-
Professor of Psychiatry and Behavioral Sciences at Duke Uni- jor illness of our time. Dr. Blazer offers a critical examination
versity Medical Center, looks at the social origins of depres- of various Western intellectual traditions of the past 200 years
sion, and in the process makes an impassioned plea for re- such as enlightenment, modernity, and postmodern predica-
vival of social psychiatry. He believes that coincident with the ment to explain such a trend. In this context, he sketches the
rise of depression in the past few decades, American psychia- shift of psychiatry’s focus from the meaning of an illness to an
try has seen the rise and fall of social psychiatry and its cohort individual to its current emphasis on biological basis of dis-
community psychiatry and the ascendance of biological psy- eases and issues of diagnostic reliability and validity. Dr.
chiatry and its helpmate descriptive psychiatry. However, as Blazer believes that in the process, psychiatry has traded
significant and far reaching as these developments have depth for precision.
been, psychiatry has overlooked the contribution of social Finally, in section IV, “The Revival of Social Psychiatry,” Dr.
factors to the causation of psychiatric illness in general (1), Blazer describes how social psychiatry can undergo a renais-
and depression in particular. An understanding of these soci- sance, supported by a foundation of empirical research and
etal factors will go far in treating and perhaps preventing de- by avoiding the social activism and the excesses of the 1960s.
pression in our age, as well as providing a road map for the re- He examines how a study of depression in the workplace and
vival of social psychiatry. the social ecology of depression can contribute to the launch-
This book has four sections and in section I, titled the “Di- ing of the new social psychiatry as a scientific discipline. He
agnosis of Depression,” the author discusses the birth and further discusses how a study of emotion, such as depression,
growth of major depression as a social phenomenon and as a can demonstrate the crucial link between body and society by
diagnosis. After the Second World War, simultaneous with the examining related concepts of “social zeitgebers” and “allo-
growing popularity of psychoanalysis, depression was seen as static load.” He concludes by cautioning society against ig-
occurring in reaction to the events in one’s life. In response to noring its most fundamental ills and treating itself with a
the backlash against psychoanalysis, depression began to be medical panacea, much like Aldous Huxley’s fictional drug
conceptualized mainly as a medical illness. Now major de- “Soma” was used to placate people in the Brave New World.
pression is treated as a “thing” that happens to people due to This well-researched and well-written text provides an ex-
chemical imbalance much like a stroke that happens due to cellent overview of the rise and fall of social psychiatry, as well
physical factors. as the evolution of depression from a psychological disorder
In section II, titled “Social Psychiatry,” the author reviews to a biomedical illness. In its broad canvas, it captures many
the birth, the growth, and the retreat of social psychiatry. He social and intellectual forces that contributed to this phe-
believes that emotional suffering is a social and personal ex- nomenon. Dr. Blazer adopts a well balanced and scholarly ap-
perience, and the way we communicate our emotions de- proach to the study of a much overlooked topic that evokes
pends on the standards society sets for their expression. So- strong emotions in its adherents. It is remarkable how much
cial psychiatry—the study of our feelings and behaviors is accomplished in these 211 pages in terms of covering the
within the context of society—became a dominant force in history, reviewing the broad social backdrop, and setting out a
the 1950s and 1960s because of the support of the ambitious modest research agenda for social psychiatry. The chapter
social agenda of Presidents Kennedy and Johnson as well as “Things Fall Apart: Society and Depression in the 21st Cen-
because of the work over the preceding half century of sociol- tury,” which addresses modernism and postmodern critique,
ogists such as Emil Durkheim and psychiatrists such as Ado- is especially exhaustive and is a must read for anyone inter-
lph Meyer and Harry Stacks Sullivan. This flowering of social ested in studying larger intellectual developments in society
psychiatry was followed by its very quick retreat, and Blazer and their impact on psychiatric thinking. As much as this re-
provides a detailed account of various factors that contrib- viewer loved reading this book, there were some shortcom-
uted to it. ings that need to be pointed out. Dr. Blazer makes a powerful
In section III, “The Frequency of Depression and the Les- argument that psychiatry has sacrificed its focus on depth in
son From War and Society,” the author reviews two waves of favor of diagnostic and scientific robustness, and a revival of
epidemiological studies, each emblematic of psychiatry’s ex- social psychiatry will correct this deficit. It is not clear how it
isting priorities. The earlier wave, which included the Sterling can be accomplished without discussing the role of the mind,
County study and the Midtown Manhattan study, focused on which was not in the purview of this book. It seems that the
social phenomena such as a community’s degree of disinte- author is aware of this dilemma as per the following state-
gration and the occurrence of psychiatric illness in its wake. ment: “Although the study of the social origins of depression
The second wave consisted of the Epidemiological Catch- might be an interesting intellectual pursuit, how might it
ment Area (ECA) study and the National Comorbidity Survey change the relationship between doctor and patient? …. Does
(NCS) and targeted measurement of the prevalence and dis- therapeutic encouragement to discover ways to better adapt
tribution of specific DSM-III and DSM-III-R disorders; this to the social environment always meet the needs of the pa-
emphasis on phenomenology heralded the birth of descrip- tient?” (p. 15).
tive psychiatry and the reification of such phenomena as de- The next critical issue is whether the present day psychia-
pression. In a similar vein, he demonstrates how our under- trists are any better skilled to practice community psychiatry.
standing of war syndromes went through several iterations While reviewing factors that contributed to the fall of commu-
and war trauma, much like depression, is currently being nity psychiatry, Dr. Blazer points out: “Though concern for
viewed like a medical illness. community prompted community intervention in theory,
The chapter “Things Fall Apart: Society and Depression in community intervention and social activism felt strange to
the 21st Century” presents the core argument of this book: mental health professionals. In addition, psychiatrists and

752 ajp.psychiatryonline.org Am J Psychiatry 163:4, April 2006


other mental health workers had gained their experience Treating and Preventing Adolescent Mental Health
within the doctor-patient framework. Their training did not Disorders: What We Know and What We Don’t Know.
produce the skills needed for community intervention” (p. A Research Agenda for Improving the Mental Health
75). These sentiments still hold true today because the one- of Our Youth, Edited by Dwight L. Evans, Edna B. Foa,
to-one relationship between the psychiatrist and the patient Raquel E. Gur, Herbert Hendin, Charles P. O’Brien, Martin E.P.
continues to be the bedrock of all professional relationships Seligman, and B. Timothy Walsh. New York, Oxford University
regardless of whether one is practicing psychopharmacology Press, 2005, 818 pp, $59.50 (hardcover).
or psychotherapy. Similarly, the author does not provide how
social circumstances now are more conducive to the revival of Adolescence is a transitional but developmentally very im-
social psychiatry than they were in the 1950s and 1960s, when portant period, which is also “noticeably malleable and plas-
American society was awash with funds, high ideals, and tic from a neurobiological, behavioral, and psychological per-
great willingness to countenance social engineering in con- spective” (p. xxv). As pointed out in the introduction to this
trast to the current paucity of resources and attempts to dis- large volume, the prevention and treatment of developmen-
mantle social institutions created in the 1960s. In the last tal, emotional, or behavioral problems in adolescence (de-
chapter, the author’s likening current antidepressant use to fined here broadly as ages 10 to 22) is one of the major public
the use of fictional drug “Soma” seems somewhat overstated health problems facing the United States, since at least one in
in the context of the recent decline in use of antidepressants five adolescents suffers from a current developmental, emo-
secondary to society’s concerns about their efficacy as well as tional, or behavioral problem. There is a high prevalence of
their potential to generate suicidal thoughts. Likewise, as the depressive disorders, anxiety disorders, and substance abuse
rise in use of complementary medicine in our society has among adolescents, and suicide is the third leading cause of
death among youth. It is interesting, and unfortunate, that the
shown, nonpharmacological ways of reducing distress such
prevalence of some of these disorders has been on the rise
as meditation are becoming more popular than taking medi-
over each successive generation. It is also unfortunate, al-
cations to manage ones discomfort.
though we know a lot about adolescence, that there is a lot we
In addition, the author, in his attempt to be conciliatory to
do not know and do not understand about this period of life
the other major schools, continuously soft-pedals his cri- and its role in the development of a host of psychological and
tiques of biological and descriptive psychiatry. This approach behavioral problems. Thus, the editors of this book felt that
perhaps is understandable given his stated aim of positioning there was a need to provide the interested readership with “a
the new social psychiatry as a complement of the other major comprehensive evaluation of what we know, and what we
paradigms and not as their competitor. However, one begins don’t know, about adolescent mental health to create a road
to wonder if the author sees virtue in every major paradigm, map for further scientific study and point the way toward
why propose a revival of social psychiatry at all? In addition, needed changes in social policy” (p. xxv). With the help of The
the attention given in this book to a discussion of social class Annenberg Foundation Trust at Sunnylands’ Adolescent
and its contribution to illness is somewhat sparse (2). Mental Help Initiative they put together a group of leading ex-
The title of the book is somewhat misleading: A reader perts to work on these issues and put together this book.
might be forgiven for thinking that the main focus of the book The experts, grouped into several commissions, focused on
is an “Age of Melancholy,” while in actuality, it is on social psy- six areas: depression, bipolar disorder, schizophrenia, anxiety
chiatry in equal measure. Furthermore, by de-emphasizing disorders, eating disorders, and youth suicide. These six areas
culture in his discussion of factors that contributed to the rise constitute the six major parts of this volume. Each part con-
of depression, Dr. Blazer provides an incomplete argument. sists of four chapters dealing with the definition, treatment,
We currently live in a society felicitously named “Flat World” prevention, and research agenda for each of these areas (with
(3) that is filled by high anxieties caused by the phenomenon the exception of the part on youth suicide, which has five
of globalization and its attendant danger of terrorism. Conse- chapters, two of them focusing on a universal approach to
quently, one wonders whether our age is any more depres- suicide prevention and a targeted approach to suicide pre-
sogenic than those other times in history. In the context of the vention). The remaining two parts of this book discuss the
current war on terrorism, there seems to be more of a perva- positive perspective on youth development and summarize
sive sense of anxiety and apprehension than depression in conclusions, recommendations, and priorities while discuss-
our culture. Curiously, in his broad review of social forces, the ing issues such as stigma, the role of primary care physicians
author does not mention the contribution of the post 9/11 cli- in detecting and treating adolescent mental health problems,
mate to the current age of melancholy. and the role of school mental health professionals in promot-
ing adolescent mental health. As noted in the introduction,
References two major disorders—conduct disorder and attention deficit
1. Cohen CI: Overcoming social amnesia: the role for a social per- hyperactivity disorder—are not covered in this volume, since
spective in psychiatric research and practice. Psychiatr Serv they are rooted in childhood and are well covered in a book
2000; 51:72–78 considered a complementary volume to this book (1).
2. Cohen CI: Social inequality and health: will psychiatry assume It seems to me that the major objectives of this work—to 1)
center stage? Psychiatr Serv 2002; 53:937–939
review and summarize the adolescent literature for the six
3. Friedman TL: The World Is Flat: A Brief History of the Twenty- disorders (including risk factors and preventive measures)
First Century. New York, Farrar, Straus and Giroux, 2005
and positive development; 2) provide an understanding of
NYAPATI RAO, M.D. similarities and differences between adolescents and adults;
Brooklyn, N.Y. 3) provide recommendations for future research; and 4) help

Am J Psychiatry 163:4, April 2006 ajp.psychiatryonline.org 753