Many feel that depression is threatening to become the Number One epidemic. Cultural critics search for explanations. Is it society that pushes us? Are we wimps and cry-babies who can’t take anything anymore? Or is it the cunning pharmaceutical industry that talks us into it? Ethicist Frits de Lange has a different explanation.

Professor Maarten van Buuren remembers the day and the hour he lost what he had always taken to be his ’self’. A routine meeting, early 2000, at the faculty. He is offered coffee, but is unable to look at anyone or say anything. He flees in a panic and barricades himself inside his home for days. It is the start of a deep depression, for which he seeks treatment. He describes the course of the depression in ’Kikker gaat fietsen! Of over het leed dat leven heet’ [Frog goes out cycling! Or about the affliction that is called life]. The renowned literary scholar, translator and essayist must say: ,,I no longer exist, draped in the chair are mortal remains. I am no more. […] I am being erased, demolished, destroyed. All I can hope for is that some medicine or self-medication will restart the machine, so that the world will be mercifully restored to me.”


In a razor-sharp self-analysis Van Buuren then dissects the shaky foundations on which his seemingly robust identity was constructed. A harsh mother, an absent father an a demanding grandfather, a Reformed upbringing, the inability to build lasting relationships – all depressogenic factors that contributed to his breakdown. But he does not want to hold them responsible. The depression is his. The only way to conquer it, is to appropriate it as part of himself. Depression is part of who he is, it is part of his identity. It is the empty space that his ’self’ orbits. The self is not a stable and unchangeable core of his personality, but a house of cards that can collapse at any time.
Not everyone with depressive complaints falls so deep they lose touch with themselves and reality. Depression is an umbrella term for phenomena like sleeplessness, anxiety, fatigue, despondency, dulling of emotions, lack of initiative, indecision, loss of energy and concentration, lack of interest in everyday activities, being tormented by feelings of powerlessness and personal failure, thoughts of death and suicide. Mood disorders that, if they occur over a long period of time and in sufficient density, are labelled ’depression’ in the DSM IV – the current standard for psychiatric diagnostics.
People who recognize these signs in themselves do not always go to see the doctor, let alone a psychiatrist. But the number of people that do is rising at an alarming rate. Depression is well on the way to becoming our Number One disease, writes Trudy Dehue in ’De depressie-epidemie’ [The depression epidemic]. Between 1993 and 1998 the number of depressive disorders increased by 63 percent, and the number of prescriptions for antidepressant by 278 percent. In 63 percent of the cases in 1993 that came to him for the first time with depressive complaints the GP prescribed antidepressants, in 1998 that number had risen to 73 percent. Between 1999 and 2006 the use of antidepressants had again doubled. In 2006 there were approximately 1 million users, 6 percent of the population.
Depression is a serious condition with an enormous disease burden, that prevents people from functioning normally. And yet, an estimated one third of the depressed Dutch do not consult any professional. Its severity is often underestimated, especially in the elderly. They often have so many other ailments. Also, it is very difficult to distinguish between the natural slowing down that is typical of ageing and the depression that results in pathological immobilization. And is growing old not enough to make a person feel gloomy anyway?
Depression as a disease of epidemic proportions. But since when has it been a ’disease’? We call something a disease when we agree that what ails you is socially unacceptable (not ’normal’) and you need to see a doctor about it, according to Dehue. Over the course of the 1980s the symptoms that the DSM merely provides with a name and labels a disorder, developed into a treatable disease for which you visit a doctor. Who in turn sends you to the pharmacist. And so ’depression’ becomes an explanatory model and signs become symptoms, to be combated with medicines that the pharmaceutical industry is eager to bring to market. Dehue outlines the alarming conflict of interests between scientific research, industry, and the health care sector. The ’pharmaceutical-industrial complex’ seems to be more interested in expanding its market than in the mental health of those suffering from depression. And so marketing does not shy away from statements like ’Even babies can be depressed’ and ’You may be without knowing it’.
Antidepressants help and depression is not a figment of the imagination. Ask Maarten van Buuren and he will tell you how seroxat enables him to function on a relatively normal level. ,,It’s a miracle”, he exclaims. Those little white pills in blister pack are his salvation.
A conspiracy theory starring the greedy pharmaceutical-industrial complex does not offer a sufficient explanation for the depression epidemic. You are not kidded into a depression. Not being able to get going and shrivelling up into a little ball of misery without having anything physically wrong with you is not normal. The cultural critique by philosophers like Philip Rieff and Frank Furedi – that we have become wimps and cry-babies in a soft welfare state, unable to cope with life when we experience the slightest setback, running to the doctor all depressed – is also not satisfactory. For depression emerged when the welfare state went into decline. Society is only becoming harsher and is forcing people to become more aggressive. Depression is not an act.
For a better understanding of depression Dehue also points out something else, although she is careful not to imply any immediate causal relationship. In her opinion the emergence of the depression must somehow be connected with the moral dictate of neoliberal culture that requires the individual to take his fate into his own hands. The fact that each individual is personally responsible for making himself into someone who amounts to something in the eyes of others and in his own, may be the ultimate depressogenic factor. Every individual today is expected to be his own business, the manager of his own life. Enterprising, energetic, motivated, flexible, stress-proof, communicative, risk taking – these are no longer the ideal traits for success in small and medium-sized businesses; they are the minimal preconditions for all of us to make it in life.
The cultural ideal of the ’makeable’ individual creates a new divide between winners and losers. The losers are those individuals who succumb to the pressure of becoming themselves. They make up the growing army that appeals to mental health care out of sheer necessity. The mental health services as the shadow economy of the performance culture.
If this hypothesis holds water, depression would appear to be a condition that is an integral part of modern society. An identity disease, lying dormant at the bottom of all of our egos, even if we do not have to visit the psychiatrist for it. It is new and unheard of, and not to be compared with the acedia of the medieval monk, the melancholy of the nineteenth century poet, or the mal de siècle that seduced many into suicide around the previous turn of the century.
Dehue’s analysis deserves to be looked at in more depth to become plausible. A competitive performance-driven society cannot be solely responsible for the depression epidemic. A competition with others may make you tired, it does not make you sick. What makes us sick is primarily the competition with ourselves. For that is a race we can never win. The incessant pressure to improve yourself and depression – there must be some link between the two.
Underlying the liberal flirt with the role model of the entrepreneur, which has been taking root since the early 1990s, is the primal myth of modern culture: the Self that creates itself from Nothingness into a sovereign individual. Friedrich Nietzsche was the first to make an effort and think the myth all the way through. In his philosophy he calls on the individual to grant himself the sovereignty that once belonged to God or the king. That was real autonomy in his opinion: not merely choosing which laws you want to bow to (like Immanuel Kant had still done half-heartedly), but inventing your own rule of life, your own Ten Commandments. Then the law is no longer dictated by God or the state, or even by the humanity in you. Total freedom is: the desire and ability to invent your own values.
This modern primal story imbues the ideal personality with enormous dynamism. Not Reason, but rather the Will becomes dominant. For he who creates himself, is not done with himself. He has become his own transcendence. Self-actualization then becomes continuous self-improvement. You enter into competition with others not because your status depends on their judgement, but to test and go beyond your own boundaries. Self-enhancement is the categorical imperative of this sovereign individual. He must ’work on himself’ incessantly.
Can one ever live like this? Nietzsche’s sovereign man is, like the wise Zarathustra, an Übermensch, an aristocrat of the mind, living in isolation, high up in his ivory tower. But his philosophy has been democratized over the past century, and the sovereign individual is by now a widely shared ideal. Through trial and error we all attempt to constantly reinvent ourselves, and we compel each other to do the same. This changes us as people. In the disciplinary, hierarchical society of less than one hundred years ago your place was predestined and you were what you did. Embedded in institutions like State, School, Church, or Company you played your own role. Now we are living in a society of equals and there is no fixed script. We are all at the same starting line and we must become exceptional persons. We can only distinguish ourselves by energetically developing initiatives. Life was once a destiny, a ’destination’. Now it is a series of choices we use to create our own history. Personal identities are open and unlimited. The ego is a project in no-man’s land, in which we are our own guides, our own horizon.
This also puts a different face on moral authority. The commandment is no longer outside us, it has been internalized. We become our own judges. We no longer lose sleep over being guilty according to some law above us. We do over our inability to meet our own requirements. Bit by bit we have shifted from a culture of guilt to a culture of shame. Not that we feel shame in front of other people; we are ashamed in front of the self we aspire to.
Finding yourself in a depression means you are no longer able to look yourself in the eye. Ultimately the shame is so profound that you would rather erase yourself than look away from yourself. Depression is a form of self-aggression.
Normally we let our self-esteem depend strongly on what we are worth in the eyes of others – fearing their judgement. ’Status anxiety’, British writer Alain de Botton calls it. But even if others do nothing but heap praise upon us, we are still unhappy about ourselves. Even more than in the demanding eyes of others, we exist in our own eternally dissatisfied eyes. And so we adjust our goals all the time, just a little higher, just a little further. If you are happy with yourself you are a loser. ’Surpass yourself,’ is the motto used to entice young people to come to Rotterdam University; you shouldn’t want to settle for less. The fitness centre is a prime example of this culture: a room where you gather with others, but only to enter into the contest with your own body. You do not measure the performance of the person on the next treadmill openly, you cast furtive glances.
Our identity is like an SUV that will only run on the powerful engine of motivation, guzzling large quantities of mental energy along the way. When you become depressed you find out that this complex has broken down. Someone seems to have put sand in there. Sociologist Alain Ehrenberg titled his book about depression ’La fatigue d’être soi’. Depression is the fatigue that prevents you from being you any longer. The modern depression is not characterized by melancholy, but instead by the loss of all power to act. Prozac should therefore not be considered a happiness medicine, but more of an initiative pill. The new generation antidepressants does not aim to help you accept life as it is. They are performance molecules, that will get more out of you than seems to be in there. Depressions today, according to Dehue, can be defined as ’the antonym of enterprise’, the flagrant failure of personal productivity.
Depression is the failure of the will, that is no longer able to muster any desire. It is the pathology of a society where the norm is no longer set by guilt and discipline, but rather by individual responsibility and initiative.
The depressed person is an individual who has no choice but to give up the process of self-creation. An individual en panne, who, tired, inhibited, decelerated, time-less and future-less, no longer knows how to act. Apathetic motionlessness, total asthenia, both mental and physical – this is the essence of depression.
Sigmund Freud would not have known what to make of this modern depression. He happened upon the neurosis, the illness of the uncoped-with relationship with our past. Depression faces the other way. Its problem is not the earlier relationship with a strict Father or smothering Mother, but rather the unbearable future with Ourselves. Due to the pressure of having to reinvent himself again tomorrow, the sovereign individual is in a constant state of war with itself. Self number 1 will have to be succeeded by Self number 2, and this to the umpteenth power. As long as you can generate the energy to keep this tension alive, there will be a distance between who you are and who you think you should be. In a depression this space shrivels up. The self-factory implodes. The sovereign individual must juggle so many selves simultaneously that, out of breath and at his wits’ end, he drops them all at once.
With the depression epidemic the post-war culture of self-realization seems to have reached its second stage: where the sole aim initially was the liberation of the individual from external authorities, he now needs to be liberated from the pressure of his own inner self. In view of its scope and persistence, depression seems to be turning into a keeper, a sombre shadow that will follow modern man as long as his chronic identity crisis lasts. Intervention does seem to be able to temper depression, but it remains kurieren am Symptom, regardless of whether we attack it psychodynamically by talking, biomedically with a molecule, or with a combination of both. The modern individual suffers, not from an ailment but from life. A suffering that has no subject other than itself.
Can you ever be cured of it? In many cases depression seems at most treatable to the extent that you can function ’normally’ again. With an antidepressant Maarten van Buuren is able to load his ’personal settings’ every day like a computer. But depression, he must acknowledge, is an inseparable part of his identity. A weak and vulnerable construction that can collapse at any time. The only remedy is to slow down the self-factory, and settle for a smaller, more modest ego.
’Cured’ would mean that the inner conflict between the real and the desired self at the bottom of the soul is resolved. But antidepressants do not resolve the tension, they only transform and compensate it. The molecule does not restore the subject, but calms his fears without lulling him to sleep, and stimulates his enterprise without catapulting him into euphoria. Depression as a kind of mental diabetes: you can never get rid of it, but with the correct self-care and medication, you can live a full life with it.
Nietzsche called on twentieth century man to take control of his own existence after the death of God. To him ’the death of God’ represented being done with the illusion of a moral world order, in which the meaning of our lives was predestined. The meaning of life is not something to be discovered, it is to be created. Around the empty centre of Nothingness we must heroically construct a robust identity. But in reality the modern ego turns out not to amount to much. It is a house of cards above the abyss.
People with a depression discover first hand what it means to live under these conditions. They do not deserve to be dismissed as patients or losers, on the contrary. They are guides in the nihilistic universe. They are visionaries who, for whatever reason, have fallen through the paperthin ice we all skate on. Albert Camus’ opening remark in ’The myth of Sisyphus’ is that there is but one serious philosophical problem: suicide. Why do we not commit suicide? ,,Deciding whether or not life is worth living, that is to answer the fundamental question of philosophy.” Only after he has found an answer to the absurdity of this question, can the individual enjoy life.
There may be another option. One that requires much more endurance and a radical change in the course of our culture. We will have to turn our backs on the myth of the sovereign individual that forces us to creatively improve and surpass ourselves, and hurls us into depression when we no longer have the energy to do so.
The sovereign individual is his own transcendence, his own hereafter. He is simultaneously himself and the Other of himself. Isn’t that enough to make all of us totally miserable? ,,If you raise the bar too high, it is easy to go under”, said writers’ collective and poster-activist group Loesje (www.loesje.org). Constantly inflating our identity project breeds vulnerable selves, insecure little balls of Dasein that float like balloons above the abysmal Nothing. Who or what will break through this mechanism?
There are two potential paths out of the impasse. First of all there is saying goodbye to the – literally futureless – duty to continue to be your own transcendence. We need real transcendence, a horizon that goes beyond our self.
I borrow the term self-transcendence from Jewish philosopher-psychiatrist Viktor E. Frankl. He survived four concentration camps, and after the war he brought his survival skills to his psychiatric practice. In the camp Frankl had reasons why he could not die: he had to write his book and his wife was waiting for him. To have something or somebody outside yourself to live for – this keeps an individual going, he later concluded. Don’t ask what you can expect from life, ask what life expects of you, became his motto. The more a person loses himself (or: transcends himself) in his dedication to a cause or a person, the more he becomes himself.
„Self-actualization is only possible as a side effect of self-transcendence”, Frankl wrote. ’Responsibleness’ is the core of meaningful human life. We can let others free us from the inner need to always improve ourselves. We don’t even have to think up the master plan that will take us out of the motionlessness; we simply let ourselves be enticed into, involved in the appeal that comes to us from outside. Something or someone else must surely be able to knock us out of our orbit around the black sun? Perhaps we will ultimately find ourselves by losing ourselves.
The second path that might relieve the pressure is self-acceptance. Self-improvement is a pointless dictate. If, however, you can say: this is who I am, this is what I can do, and I can say yes to that, you let out all false air. You no longer have to work on yourself, eternally dissatisfied. Self-acceptance means acknowledgement of individual particularity, acceptance of one’s own finiteness. I am all I have – so let me embrace myself wholeheartedly.
All too often we are not able to and it is up to others who, in their appeal to our shoddy self acknowledge its infinite value. Self-transcendence then drives us to self-acceptance. Another person telling you: ,,I want you. Not your repertoire of possible selves, but you’’, will give you a foothold when you are hovering above Nothingness.
But if you have already fallen in, you can no longer hear this call.

Translation Maggie Oattes

Dr. Frits de Lange is a professor of Ethics at the Protestant Theological University in Kampen, the Netherlands. This article originally appeared in Trouw newspaper on the 7th of february 2009.