Book Forum
Sandra L. Patterson, Editor
The Ethical Brain, by Michael S. Gazzaniga. Washington,
DC, Dana Press, 2005, 201 pp., $25.00.
“Neuroscience will never find the brain correlate of re-
sponsibility, because that is something we ascribe to hu-
mans—to people—not to brains. It is a moral value we
demand of our fellow, rule-following human beings. Just
as optometrists can tell us how much vision a person has
(20/20 or 20/40 or 20/200) but cannot tell us when some-
one is legally blind or has too little vision to drive a school
bus, so psychiatrists and brain scientists might be able to
tell us what someone’s mental state or brain condition is
but cannot tell us (without being arbitrary) when some-
one has too little control to be held responsible. The is-
sue of responsibility (like the issue of who can drive
school buses) is a social choice.” (p. 101)
In The Ethical Brain, Dartmouth cognitive neuroscientist
Michael S. Gazzaniga explores the evidence for hardwired
brain functions that contribute to a universal set of human
ethical values. Gazzaniga, a member of the President’s Coun-
cil on Bioethics, has had plenty of experience grappling with
issues ranging from when a fetus should be accorded the sta-
tus of a person to whether parents should in the future be al-
lowed to genetically select intelligent children, and he dis-
cusses those topics and others from a neuroscientist’s
perspective in this brief book.
The book begins with fairly routine discussions of what
neuroscience contributes to the familiar debates on the moral
status of embryos and on end-of-life issues. Psychiatrists will
find Gazzaniga’s chapters on “Better Brains Through Genes”
and “Shaping the Smart Brain With Drugs” more thought-
provoking in their discussions of the heritability of intelli-
gence and its potential chemical enhancement. He foresees a
day when gene therapy allows more people to be really smart.
More problematic is Gazzaniga’s assertion that cognitive en-
hancement therapy and drugs are inevitable and his belief
that government should avoid regulating them. In libertarian
fashion, Gazzaniga is sanguine that people’s ethical and
moral senses will prevent societal dislocation from a flood of
newly smart people.
In later chapters, Gazzaniga writes that brain function re-
search is likely to identify with increasing certainty what areas
of the cerebral cortex are most involved in moral reasoning
Am J Psychiatry 163:4, April 2006
and eventually elucidate a cortical basis for such ethical prin-
ciples as the wrongfulness of killing. He makes clear, however,
that he believes there is a limit to what brain research can
contribute to an appreciation of individual moral responsibil-
ities, since people’s responsibilities toward each other by def-
inition exist in a social context, rather than in isolated brains.
Gazzaniga concludes his book with a discussion of how hu-
man empathy originates. He thinks it is likely that “mirror
neurons” give a person the ability to put himself in another’s
place and to figure out what the other person would want in a
given situation. Gazzaniga sees this neurologically grounded
empathy as the basis for certain universal ethical principles.
He believes that an understanding of those ethical principles
all people carry inside will help people of different religions
and belief systems to get along, even when they do not agree
about individual ethical issues.
In The Ethical Brain, we thus find echoes of earlier thinking
in the field of sociobiology in which attributes such as altru-
ism, tool use, and intentional warfare were tied to an explicit
biological origin. It is interesting that these attributes, which
were previously thought to separate our species from all oth-
ers, are also no longer identified as unique to humankind. Just
as the observations and implications of sociobiology were
criticized by diverse members in our society for widely vary-
ing theoretical, philosophical, and religious concerns, we an-
ticipate that the ideas laid forth by Gazzaniga will also be met
with a mixed response. Nevertheless, it addresses a field of
importance to psychiatry, the neurosciences, bioethics, and
our society; it should evoke and provoke more sophisticated
thinking in an as yet relatively unexplored domain.
The Ethical Brain is generally clearly written, and it includes
a wealth of references that guide the reader to helpful texts in
neuroscience and sociobiology for further exploration.
JOSEPH B. LAYDE, M.D., J.D.
LAURA WEISS ROBERTS, M.D., M.A.,
Milwaukee, Wisc.
The Age of Melancholy: “Major Depression” and Its
Social Origins, by Dan G. Blazer. New York, Routledge, 2005,
251 pp, $34.95.
According to the World Health Organization, depression
ranks fourth among the 10 leading causes of the global bur-
den of disease and is expected to rise to second within the
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next 20 years. In this slim treatise, Dan G. Blazer, J.P. Gibbons
Professor of Psychiatry and Behavioral Sciences at Duke Uni-
versity Medical Center, looks at the social origins of depres-
sion, and in the process makes an impassioned plea for re-
vival of social psychiatry. He believes that coincident with the
rise of depression in the past few decades, American psychia-
try has seen the rise and fall of social psychiatry and its cohort
community psychiatry and the ascendance of biological psy-
chiatry and its helpmate descriptive psychiatry. However, as
significant and far reaching as these developments have
been, psychiatry has overlooked the contribution of social
factors to the causation of psychiatric illness in general (1),
and depression in particular. An understanding of these soci-
etal factors will go far in treating and perhaps preventing de-
pression in our age, as well as providing a road map for the re-
vival of social psychiatry.
This book has four sections and in section I, titled the “Di-
agnosis of Depression,” the author discusses the birth and
growth of major depression as a social phenomenon and as a
diagnosis. After the Second World War, simultaneous with the
growing popularity of psychoanalysis, depression was seen as
occurring in reaction to the events in one’s life. In response to
the backlash against psychoanalysis, depression began to be
conceptualized mainly as a medical illness. Now major de-
pression is treated as a “thing” that happens to people due to
chemical imbalance much like a stroke that happens due to
physical factors.
In section II, titled “Social Psychiatry,” the author reviews
the birth, the growth, and the retreat of social psychiatry. He
believes that emotional suffering is a social and personal ex-
perience, and the way we communicate our emotions de-
pends on the standards society sets for their expression. So-
cial psychiatry—the study of our feelings and behaviors
within the context of society—became a dominant force in
the 1950s and 1960s because of the support of the ambitious
social agenda of Presidents Kennedy and Johnson as well as
because of the work over the preceding half century of sociol-
ogists such as Emil Durkheim and psychiatrists such as Ado-
lph Meyer and Harry Stacks Sullivan. This flowering of social
psychiatry was followed by its very quick retreat, and Blazer
provides a detailed account of various factors that contrib-
uted to it.
In section III, “The Frequency of Depression and the Les-
son From War and Society,” the author reviews two waves of
epidemiological studies, each emblematic of psychiatry’s ex-
isting priorities. The earlier wave, which included the Sterling
County study and the Midtown Manhattan study, focused on
social phenomena such as a community’s degree of disinte-
gration and the occurrence of psychiatric illness in its wake.
The second wave consisted of the Epidemiological Catch-
ment Area (ECA) study and the National Comorbidity Survey
(NCS) and targeted measurement of the prevalence and dis-
tribution of specific DSM-III and DSM-III-R disorders; this
emphasis on phenomenology heralded the birth of descrip-
tive psychiatry and the reification of such phenomena as de-
pression. In a similar vein, he demonstrates how our under-
standing of war syndromes went through several iterations
and war trauma, much like depression, is currently being
viewed like a medical illness.
The chapter “Things Fall Apart: Society and Depression in
the 21st Century” presents the core argument of this book:
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our current age is experiencing the rise of depression as a ma-
jor illness of our time. Dr. Blazer offers a critical examination
of various Western intellectual traditions of the past 200 years
such as enlightenment, modernity, and postmodern predica-
ment to explain such a trend. In this context, he sketches the
shift of psychiatry’s focus from the meaning of an illness to an
individual to its current emphasis on biological basis of dis-
eases and issues of diagnostic reliability and validity. Dr.
Blazer believes that in the process, psychiatry has traded
depth for precision.
Finally, in section IV, “The Revival of Social Psychiatry,” Dr.
Blazer describes how social psychiatry can undergo a renais-
sance, supported by a foundation of empirical research and
by avoiding the social activism and the excesses of the 1960s.
He examines how a study of depression in the workplace and
the social ecology of depression can contribute to the launch-
ing of the new social psychiatry as a scientific discipline. He
further discusses how a study of emotion, such as depression,
can demonstrate the crucial link between body and society by
examining related concepts of “social zeitgebers” and “allo-
static load.” He concludes by cautioning society against ig-
noring its most fundamental ills and treating itself with a
medical panacea, much like Aldous Huxley’s fictional drug
“Soma” was used to placate people in the Brave New World.
This well-researched and well-written text provides an ex-
cellent overview of the rise and fall of social psychiatry, as well
as the evolution of depression from a psychological disorder
to a biomedical illness. In its broad canvas, it captures many
social and intellectual forces that contributed to this phe-
nomenon. Dr. Blazer adopts a well balanced and scholarly ap-
proach to the study of a much overlooked topic that evokes
strong emotions in its adherents. It is remarkable how much
is accomplished in these 211 pages in terms of covering the
history, reviewing the broad social backdrop, and setting out a
modest research agenda for social psychiatry. The chapter
“Things Fall Apart: Society and Depression in the 21st Cen-
tury,” which addresses modernism and postmodern critique,
is especially exhaustive and is a must read for anyone inter-
ested in studying larger intellectual developments in society
and their impact on psychiatric thinking. As much as this re-
viewer loved reading this book, there were some shortcom-
ings that need to be pointed out. Dr. Blazer makes a powerful
argument that psychiatry has sacrificed its focus on depth in
favor of diagnostic and scientific robustness, and a revival of
social psychiatry will correct this deficit. It is not clear how it
can be accomplished without discussing the role of the mind,
which was not in the purview of this book. It seems that the
author is aware of this dilemma as per the following state-
ment: “Although the study of the social origins of depression
might be an interesting intellectual pursuit, how might it
change the relationship between doctor and patient? …. Does
therapeutic encouragement to discover ways to better adapt
to the social environment always meet the needs of the pa-
tient?” (p. 15).
The next critical issue is whether the present day psychia-
trists are any better skilled to practice community psychiatry.
While reviewing factors that contributed to the fall of commu-
nity psychiatry, Dr. Blazer points out: “Though concern for
community prompted community intervention in theory,
community intervention and social activism felt strange to
mental health professionals. In addition, psychiatrists and
Am J Psychiatry 163:4, April 2006

other mental health workers had gained their experience
within the doctor-patient framework. Their training did not
produce the skills needed for community intervention” (p.
75). These sentiments still hold true today because the one-
to-one relationship between the psychiatrist and the patient
continues to be the bedrock of all professional relationships
regardless of whether one is practicing psychopharmacology
or psychotherapy. Similarly, the author does not provide how
social circumstances now are more conducive to the revival of
social psychiatry than they were in the 1950s and 1960s, when
American society was awash with funds, high ideals, and
great willingness to countenance social engineering in con-
trast to the current paucity of resources and attempts to dis-
mantle social institutions created in the 1960s. In the last
chapter, the author’s likening current antidepressant use to
the use of fictional drug “Soma” seems somewhat overstated
in the context of the recent decline in use of antidepressants
secondary to society’s concerns about their efficacy as well as
their potential to generate suicidal thoughts. Likewise, as the
rise in use of complementary medicine in our society has
shown, nonpharmacological ways of reducing distress such
as meditation are becoming more popular than taking medi-
cations to manage ones discomfort.
In addition, the author, in his attempt to be conciliatory to
the other major schools, continuously soft-pedals his cri-
tiques of biological and descriptive psychiatry. This approach
perhaps is understandable given his stated aim of positioning
the new social psychiatry as a complement of the other major
paradigms and not as their competitor. However, one begins
to wonder if the author sees virtue in every major paradigm,
why propose a revival of social psychiatry at all? In addition,
the attention given in this book to a discussion of social class
and its contribution to illness is somewhat sparse (2).
The title of the book is somewhat misleading: A reader
might be forgiven for thinking that the main focus of the book
is an “Age of Melancholy,” while in actuality, it is on social psy-
chiatry in equal measure. Furthermore, by de-emphasizing
culture in his discussion of factors that contributed to the rise
of depression, Dr. Blazer provides an incomplete argument.
We currently live in a society felicitously named “Flat World”
(3) that is filled by high anxieties caused by the phenomenon
of globalization and its attendant danger of terrorism. Conse-
quently, one wonders whether our age is any more depres-
sogenic than those other times in history. In the context of the
current war on terrorism, there seems to be more of a perva-
sive sense of anxiety and apprehension than depression in
our culture. Curiously, in his broad review of social forces, the
author does not mention the contribution of the post 9/11 cli-
mate to the current age of melancholy.
References
1. Cohen CI: Overcoming social amnesia: the role for a social per-
spective in psychiatric research and practice. Psychiatr Serv
2000; 51:72–78
2. Cohen CI: Social inequality and health: will psychiatry assume
center stage? Psychiatr Serv 2002; 53:937–939
3. Friedman TL: The World Is Flat: A Brief History of the Twenty-
First Century. New York, Farrar, Straus and Giroux, 2005
NYAPATI RAO, M.D.
Brooklyn, N.Y.
Am J Psychiatry 163:4, April 2006
BOOK FORUM
Treating and Preventing Adolescent Mental Health
Disorders: What We Know and What We Don’t Know.
A Research Agenda for Improving the Mental Health
of Our Youth, Edited by Dwight L. Evans, Edna B. Foa,
Raquel E. Gur, Herbert Hendin, Charles P. O’Brien, Martin E.P.
Seligman, and B. Timothy Walsh. New York, Oxford University
Press, 2005, 818 pp, $59.50 (hardcover).
Adolescence is a transitional but developmentally very im-
portant period, which is also “noticeably malleable and plas-
tic from a neurobiological, behavioral, and psychological per-
spective” (p. xxv). As pointed out in the introduction to this
large volume, the prevention and treatment of developmen-
tal, emotional, or behavioral problems in adolescence (de-
fined here broadly as ages 10 to 22) is one of the major public
health problems facing the United States, since at least one in
five adolescents suffers from a current developmental, emo-
tional, or behavioral problem. There is a high prevalence of
depressive disorders, anxiety disorders, and substance abuse
among adolescents, and suicide is the third leading cause of
death among youth. It is interesting, and unfortunate, that the
prevalence of some of these disorders has been on the rise
over each successive generation. It is also unfortunate, al-
though we know a lot about adolescence, that there is a lot we
do not know and do not understand about this period of life
and its role in the development of a host of psychological and
behavioral problems. Thus, the editors of this book felt that
there was a need to provide the interested readership with “a
comprehensive evaluation of what we know, and what we
don’t know, about adolescent mental health to create a road
map for further scientific study and point the way toward
needed changes in social policy” (p. xxv). With the help of The
Annenberg Foundation Trust at Sunnylands’ Adolescent
Mental Help Initiative they put together a group of leading ex-
perts to work on these issues and put together this book.
The experts, grouped into several commissions, focused on
six areas: depression, bipolar disorder, schizophrenia, anxiety
disorders, eating disorders, and youth suicide. These six areas
constitute the six major parts of this volume. Each part con-
sists of four chapters dealing with the definition, treatment,
prevention, and research agenda for each of these areas (with
the exception of the part on youth suicide, which has five
chapters, two of them focusing on a universal approach to
suicide prevention and a targeted approach to suicide pre-
vention). The remaining two parts of this book discuss the
positive perspective on youth development and summarize
conclusions, recommendations, and priorities while discuss-
ing issues such as stigma, the role of primary care physicians
in detecting and treating adolescent mental health problems,
and the role of school mental health professionals in promot-
ing adolescent mental health. As noted in the introduction,
two major disorders—conduct disorder and attention deficit
hyperactivity disorder—are not covered in this volume, since
they are rooted in childhood and are well covered in a book
considered a complementary volume to this book (1).
It seems to me that the major objectives of this work—to 1)
review and summarize the adolescent literature for the six
disorders (including risk factors and preventive measures)
and positive development; 2) provide an understanding of
similarities and differences between adolescents and adults;
3) provide recommendations for future research; and 4) help
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