Academic Medicine:
Commentary

Commentary

Metzl, Jonathan M. MD, PhD; Howell, Joel D. MD, PhD

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Dr. Metzl is assistant professor, Departments of Psychiatry and Women's Studies, and director, Program in Culture, Health, and Medicine, and Dr. Howell is Victor Vaughan Professor of the History of Medicine, both at the University of Michigan, Ann Arbor.

In Albrecht Dürer's allegorical engraving Melencolia I (1514), a large figure sits bent in deep contemplation, surrounded by a saw, a plane, a molding curve, the nozzle of a bellows, a grindstone, a hammer, and other implements of manufacture. These items are joined by their collective dormancy. Instead of being used for construction, the artisan's tools lie idly at the figure's feet, as motionless as his sleeping guard dog. Meanwhile, the figure stares intently into the horizon.

Why do these tools lie unused? Dürer suggests two answers. On the one hand, the image implies that the melancholic figure refuses to pick up the tools because he is lazy. Dürer's depiction of the seated figure references the widespread notion that melancholics were possessed of the vice of sloth—often similarly shown in idle repose. Far from being a disease in the modern sense, melancholy was assumed in the 1500s to be a temperament resulting from imbalanced bodily fluids, or humors. Melancholics were believed to suffer from a buildup of black bile, causing apathy, dullness, and a “swarthy” complexion. When connected to moral theology, this belief usually resulted in casting melancholy in a negative light.

On the other hand, the figure may ignore the tools because he is deep in thought. In this reading, melancholy's lack of corporeal productivity belies a burst of creative mental energy. Through the figure's reflective pose (later emulated by Rodin's thinker), noble wings, and gleaming eyes, Dürer lauds melancholy as an inspired state in the tradition of Plato's divine frenzy of artistic production, or Aristotle's notion of the excellent soul of madness. Dürer thus suggests that instead of requiring treatment with the then-standard therapies of syrups or blood letting, this condition is requisite for the production of ideas, theories, and indeed art itself. Melencolia stands as testament to the richness of this notion of melancholy: if, as has been suggested, the seated figure is autobiographical of the artist, then the engraving is itself reflective of Dürer's introspective musings.

These assumptions about Melencolia presuppose paradigms that were likely as recognizable to viewers in the sixteenth century as they are unfamiliar to viewers today. Yet the notion of melancholy as a tension between sloth and creativity continues to inform our own, historically specific notions of depression. A present-day correlate is seen in the ways depressive illness is often described as an inability to work. American Journal of Psychiatry (AJP) studies cite sick days and decreased “productivity” as markers of depression in “employed populations.”1 Meanwhile, Prozac advertisements tout the drug's ability to restore “productive days,” and Peter Kramer's Listening to Prozac describes case studies of patients such as “Tess” and “Juila” who take Prozac and become confident in their business jobs.2 These and other instances assume that a return to gainful employment is indicative of successfully treated disease.

However, as Melencolia reminds us, it is myopic to define both depression and productivity in such limited terms. At the most basic level, depression encompasses a variety of possible symptoms—including weight loss, sleep disturbances, and suicidality—in addition to impaired motor or intellectual activity. Similarly, productivity can have meanings well beyond job-related activities or products that are measured, counted, or sold. Such narrow focus often excludes the contemplation and introspection required for creativity and indeed for mental health. In this sense, speaking of depression and other chronic illnesses solely in terms of lost work hours works to efface awareness of a deeper form of loss—the loss of self. More broadly, metonymically employing lack of job-related productivity for depression fails to acknowledge quiet reflection, speculation, uncertainty, and other less quantifiable forms of production that are nonetheless vital to the process of innovation.

This reading of Melencolia is in no way meant to overlook the agonizing ways in which depressed patients can misinterpret decreased job performance as reflective of their own diminished worth. Yet Melencolia asks us to think about how time spent not working, as defined in the AJP and elsewhere, is a condition with both positive and negative valences. Interrupted labor is at once a symptom of illness and a process vital to creativity, identity, selfhood, and other conditions that may or may not be appropriately treated with Prozac. By extension, narrow definitions of productive work are both vital for success in one economy and inimical to artistic expression in another.

Realizing productivity's various meanings requires a different relationship to time than is afforded by quick prescriptions, brief office visits, and other markers of our own efficiency as clinicians. Yet only by briefly stepping back and considering each patient's complex and often conflicting meanings of productivity—what we might think of as their melancholy of depression—can we begin to see the multiplicity of functions, values, and indeed outcomes that people attribute to their depressed states.

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REFERENCES

1. Druss B, et al. Depressive symptoms, satisfaction with health care, and 2-year work outcomes in an employed population. Am J Psychiatry. 2001;158:731–4.

2. Kramer P. Listening to Prozac. New York: Penguin, 1994.

© 2003 Association of American Medical Colleges

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