Authors: Andrew Solomon
The extravagance made me very uncomfortable. It did, however, seem to rev everyone up. Cheerleading squads at halftime have seldom provoked more enthusiasm from spectators. By the time this burlesque was done, the crowd was all set to punch misery in the nose. After the opening ceremonies came a serious plea to the humanity of the sales force. The room dimmed for a short film made specifically for the occasion, which showed people who had actually taken the product during Phase III studies. These real people had emerged from terrible suffering; some had found in this product relief from refractory depression that had disabled them for half a lifetime. The images were in Vaseline focus that went with the other aspects of the launch, but they were real, and I saw representatives deeply moved by the horror people had authentically endured. The sense of mission with which people left the outsize auditorium was heartfelt. Over the next few days, the contradictory tenor of the launch was sustained; the salesmen’s aggression and empathy were encouraged in tandem. At the end, however, everyone was showered with products: I came home with a T-shirt, a polo shirt, a windbreaker, a notepad, a baseball cap, an airplane carry-on, twenty pens, and a range of other goods that had the product’s logo displayed as boldly as a Gucci label.
David Healey, former secretary of the British Association for Psychopharmacology, has questioned the approval process for depression
treatments. In his view, the industry has used the term
selective serotonin reuptake inhibitors
(SSRIs) to suggest a false simplicity of function. Healey writes, “Drugs that block serotonin reuptake may be antidepressant, as may compounds that selectively block catecholamine reuptake. Indeed, there is a strong suggestion that in severe cases of depression, some of the older compounds that act on multiple systems may be more effective than the newer compounds. ECT is almost certainly the treatment that is least specific to a particular neurotransmitter system, but it is believed by many clinicians to be the fastest and most effective of current treatments. What this suggests about depression is not that it is a disorder of one neurotransmitter or a particular receptor, but rather that in depressive disorders a number of physiological systems are compromised or shut down or desynchronized in some way.” This suggests that the very traits that many pharmaceutical companies advertise for their drugs are in fact not particularly useful to consumers of those drugs. Based on a bacterial model of illness, the federal system of regulation that was put in place in the 1960s supposes that every illness has a specific antidote and that every antidote works on a specific illness. Unquestionably, current rhetoric, on the part of the FDA, the U.S. Congress, pharmaceutical companies, and the general public, reflects the notions that depression invades a person and proper treatment can expel it. Does the category “antidepressant,” which presupposes the illness “depression,” make sense?
If depression is an illness that affects as much as 25 percent of the people in the world, can it in fact be an illness? Is it something that supersedes the “real” personality of people afflicted with it? I could have done this book in double time if I could function on four hours of sleep a night. I am significantly disabled by my need for sleep. I could not be secretary of state, because that job requires more activity than can be packed into fifteen-hour days. One of the reasons I chose to become a writer is that I can regulate my schedule, and anyone with whom I have worked knows that I do not do morning meetings except under duress. I have occasionally taken an over-the-counter drug—it’s called coffee—to help me get by on less sleep than I would need without it. It’s an imperfect drug; it’s quite effective for short-term treatment of my disorder, but taken over the long term as a substitute for sleep, it brings on anxiety, nausea, dizziness, and reduced efficiency. Because of this, it does not work well enough for me to be able to take up a schedule like that of the secretary of state. It seems likely that if the World Health Organization were to do a study and figure out how many useful man-hours are lost each year to people who require more than six hours of sleep per night, the toll taken by sleepiness would quite possibly be even greater than that taken by depression.
I have met people who need to sleep fourteen hours every night, and they, like people with major depression, face difficulties functioning in the social and professional world of our times. They suffer a terrific disadvantage. What is the edge of disease? And who, if a better drug than caffeine comes along, would be classed as ill? Would we invent an ideal of the secretary of state’s sleep schedule and start recommending medication to everyone who sleeps more than four hours a night? Would it be bad to do that? What would happen to people who refused drug therapy and slept their natural hours? They would be unable to keep up; the rapid pace of modern life would be much more rapid if most people could now avail themselves of this hypothetical medication.
“During the 1970s,” writes Healey, “the major psychiatric disorders became defined as disorders of single neurotransmitter systems and their receptors. The evidence to support any of these proposals was never there, but this language powerfully supported psychiatry’s transition from a discipline that understood itself in dimensional terms to one that concerned itself with categorical ones.” Indeed, this is perhaps the most alarming thing about current wisdom on depression: it dismisses the idea of a continuum and posits that a patient either has or doesn’t have depression, is or is not depressed, as though to be a little bit depressed were the same as being a little bit pregnant. The categorical models are appealing. In an era in which we are increasingly alienated from our feelings, we might be comforted by the idea that a doctor could take a blood test or a brain scan and tell us whether we had depression and what kind we had. But depression is an emotion that exists in all people, fluctuating in and out of control; depression the illness is an excess of something common, not the introduction of something exotic. It is different from one person to the next. What makes people depressed? You might as well ask what makes people content.
A doctor may help facilitate dosage choices, but it may someday be as easy to put oneself on one of the SSRIs as it is to go on antioxidant vitamins, whose long-term benefits are obvious, and whose side effects are minimal, nonlethal, and easily controlled. These SSRIs help mental health, which is fragile; they keep the mind fit. Taking the wrong dosages or taking the drugs inconsistently will prevent them from functioning as they should, but as Healey points out, people take nonprescription drugs with reasonable care. We do not usually overdose on them. We undertake trial and error on ourselves in figuring out how much to take (which is more or less what prescribing doctors do with the SSRIs). The SSRIs are not fatal or dangerous even in extreme overdose. Healey believes that the glamorization of drugs through their prescription status is particularly striking with the antidepressants, which have relatively few side
effects and which are used to treat a disease that for the moment exists only in the patient’s explanation of it, a disease that cannot be tested in any medical terms other than the patient’s self-reports. There is no way to determine whether an antidepressant drug is necessary or not except by asking the patient—and that asking is most frequently done by GPs who have no more information about the pills than does a well-read layman.
My drug regimen is now elaborately and specifically balanced, and I would not have had the expertise to get through my last breakdown without the close consultation of a capable expert. But many of the people I know who are on Prozac simply went to a doctor and requested it. They had already performed a self-diagnosis, and the doctor saw no reason to doubt their insight into their own mind. Taking Prozac unnecessarily doesn’t appear to have any particular effect, and those for whom it is unhelpful probably stop taking it. Why shouldn’t people be free to make these decisions entirely on their own?
Many of the people I have interviewed take antidepressants for “mild depression,” and they lead happier and better lives because of it. I’d do the same. Perhaps what they want to change is really personality, as Peter Kramer suggested in
Listening to Prozac.
The news that depression is a chemical or biological problem is a public relations stunt; we could, at least in theory, find the brain chemistry for violence and monkey around with that if we were so inclined. The notion that all depression is invasive illness rests either on a vast expansion of the word
illness
to include all kinds of qualities (from sleepiness to obnoxiousness to stupidity) or on a convenient modern fiction. Severe depression, nonetheless, is a devastating condition that is now treatable, and it must be treated as vigorously as possible, for the sake of a just society in which people live rich, healthy lives. It should be covered by insurers, protected by acts of Congress, addressed by great researchers as a matter of the utmost importance. There is an apparent paradox here that points to existential questions about what constitutes the person and what constitute his afflictions. Our rights to life and liberty are comparatively straightforward; our right to the pursuit of happiness becomes more puzzling every day.
An older friend of mine once said to me that sex had been destroyed by its public existence. When she was young, she said, she and her first lovers discovered a new thing with only their roughest instincts to guide them. They had no specific expectations of one another, no standards. “You have read so many articles about who should have how many orgasms when and how,” she said to me. “You have been told what to do and in which positions and how to feel. You have been told the right way and the wrong way of everything. What chance of discovery do you have now?”
Dysfunction of the brain too was once a private affair, the history recounted in this volume notwithstanding. One came to it with no expectations, and how things went wrong was largely individual. How those around you dealt with it was also individual. Now we enter into psychic pain within guidelines. We thrive on artificial categorizations and reductive formulae. When depression tumbled out of the collective closet, it became an externally ordered sequence. That is where politics meets depression. This book itself is helplessly enmeshed in the politics of the disease. If you read these pages closely, you can learn how to be depressed: what to feel, what to think, what to do. Nonetheless, the individuality of every person’s struggle is unbreachable. Depression, like sex, retains an unquenchable aura of mystery. It is new every time.
A
great deal has been said about the who and what and when and where of depression. Evolutionists have turned their attention to the why. The interest in the why begins with the historical: evolutionary biology explains how things came to be the way they are. Why would such an obviously unpleasant and essentially unproductive condition occur in so large a part of the population? What advantages could it ever have served? Could it be simply a defect in humanity? Why was it not selected out a long time ago? Why do particular symptoms tend to cluster? What is the relation between the social and the biological evolution of the disorder? It is impossible to answer without looking at the questions that precede the matter of depression. Why, in evolutionary terms, do we have moods at all? Why indeed do we have emotions? What exactly caused nature to select for despair and frustration and irritability, and to select for, relatively speaking, so little joy? To look at the evolutionary questions about depression is to look at what it means to be human.
It is evident that mood disorders are not simple, singular, discrete conditions. Michael McGuire and Alfonso Troisi, in their book
Darwinian Psychiatry,
point out that depression “can occur with and without known precipitants, can sometimes run in families and sometimes not, can show different concordance rates among monozygotic twins, can sometimes last a lifetime and at other times remit spontaneously.” Further, depression is obviously the common outcome of many causes; “some persons with depression grow up and live in adverse social environments while others do not; some come from families in which depression is common while others do not; and significant individual differences in depression-causing physiological systems (e.g., norepinephrine, serotonin) have been reported. What is more, some respond to one type of antidepressant medication but not to another; some do not respond to
any type of medication but do respond to electroconvulsive treatment; and some do not respond to any known intervention.”
The suggestion is that what we call depression seems to be a peculiar assortment of conditions for which there are no evident boundaries. It is as though we had a condition called “cough” that included some cough that responds to antibiotics (tuberculosis) and some cough that responds to changes in humidity (emphysema) and some that responds to psychological treatments (cough may be a neurotic behavior) and some that requires chemotherapy (lung cancer) and some that appears to be intractable. Some cough is fatal if untreated and some is chronic and some is temporary and some is seasonal. Some goes away on its own. Some is related to viral infection. What is cough? We have decided to define cough as a symptom of various illnesses rather than as an illness of its own, though we can also look at what might be called the consequent symptoms of cough itself: sore throat, poor sleep, difficulty with speech, irritating tickly feelings, troubled breathing, and so on. Depression is not a rational disease category; like cough, it is a symptom with symptoms. If we didn’t know about the range of illnesses that cause coughs, we would have no basis for understanding the “refractory cough” and we would come up with all kinds of explanations for why some cough seems to resist treatment. We do not at this time have a clear system for sorting out the different types of depression and their different implications. It is unlikely that such an illness has a single explanation. If it occurs for a whole catalog of reasons, one must use multiple systems for examining it. There is something inherently sloppy about the current modes, which take a pinch of psychoanalytic thinking and a little bit of biology and a few external circumstances and throw them together into a crazy salad. We need to disentangle depression and grief and personality and illness before we can make real sense of depressed mental states.