Durkheim posited that the higher rate of suicide in Protestantism than in any other Western religious group had something to do with the essence of the religion itself. Protestantism developed in the sixteenth century as a response to the suffocating nature of Catholicism. In Catholicism one must rely on a priest to talk to God. One must go to confession and pour forth one’s venial sins. The religion is full of pageantry. Those who began to oppose it sought something simpler and purer. Most importantly, they wanted a direct, autonomous route to the divine, a God they could access entirely on their own. Eternity would no longer be the business of a priest with his incense and myrrh. Durkheim proposed that the highly individualised nature of Protestantism, the do-it-yourself emphasis, the loss of clergy in whom to confide one’s transgressions, created an ultimate loneliness that made Protestants more vulnerable to ending their own lives. That Americans live in a primarily Protestant country and that their suicide rates are among the highest in the industrial world may not, therefore, be a coincidence.
More than a century after Durkheim wrote Suicide, another sociologist set out on a similar but opposite quest, seeking this time the rates and reasons not for misery but for its antithesis – happiness. Roko Belic was a 34-year-old documentary film-maker when his friend and colleague Tom Shadyac read a New York Times article that reported the United States as only the twenty-third happiest country in the world. Given that the country’s gross domestic product is the highest in the world and their medical hospitals are staffed with unsurpassed experts, Shadyac, a successful film-maker who lived alone in a 1,580-metre-square (17,000-square-foot) mansion in Los Angeles and was himself struggling with depression, thought it interesting that they were, as a country, so unhappy. Shadyac, offering to fund the project, told Belic to go out and find out why and make a film. Thus began Belic’s four-year journey winding around the globe, into and out of fourteen different countries, seeking the source of happiness or, as he put it, ‘the secret of life’s greatest mystery’.
In the course of making his film, Happy, Belic interviewed a beauty queen who had been run over by a lorry and lost her good looks as a result, and who was happy nevertheless. He interviewed a rickshaw driver living in the slums of Kolkata where sludge and sewer waste ran in rivulets through the streets, a man whose hut was made of bamboo sticks and plastic tarps which did not keep out the rain during monsoon season, and who was happy nonetheless. He interviewed a Cajun fisherman in a Louisiana bayou and several centenarians in Okinawa in Japan, the island with the longest-lived residents in the world. What Belic learned was that, in every instance, happiness depended on a strong and supple social fabric, and an interdependence of family and friends. In Denmark, rated the happiest country in the world, Belic found co-housing projects where families lived together, dined together, celebrated and mourned together. Co-housing offered a salve against loneliness and the modern-day pressures on the nuclear family, in which, at least in the United States and in the UK, two working parents are somehow supposed to raise their children while giving forty hours a week to their jobs.
Ann Bolo
Ann Bolo was thirty-five years old, struggling with postnatal depression, living in a suburb of Boston in Massachusetts with her husband and their new baby when she saw Belic’s film on happiness. Her house, a single-storey style flanking a motorway, was beset by the whir and wheeze of cars, audible in every room. It was pervaded by a damp odour as well, and the lawn was studded with giant weeds bearing platter-sized leaves and spiky purple petals. A painter and a social worker, Bolo was taking time off from work – a six-week maternity leave – in order to care for her newborn.
‘Six weeks,’ she said, and shrugged, leaning over and looking at Emily who was swaddled in a bassinet, only the tiny disc of her face visible above the striped baby blankets. ‘If I lived in a European country I’d get six months off,’ Bolo said. ‘If I lived in Denmark I’d have a whole community of caretakers and wouldn’t have to worry about paying for health care’. She also mentioned she wouldn’t have to worry about paying for university – both of which is correct. The Danish government endows every citizen with lifetime health care and free university education. Bolo, when she first spoke with me, had given birth a month earlier, by Caesarean section; her wound still hurt, she reported, and until starting fluoxetine – which for her, unusually, worked within days – she had felt tired and low. In those first two weeks after Emily’s birth, isolated in her small house by the side of a buzzing motorway her only daytime company an infant, Bolo had quickly grown despondent, and then depressed.
‘At first I lost my appetite,’ she said, ‘and when that happened I knew something was wrong, because I love food. But nothing looked good to me.’ Bolo was sitting in a padded gliding chair. As she spoke she pushed the chair back and forth with her feet. ‘After my appetite went, my sleep followed. I still have to get up every few hours to feed the baby, but before, when she was done and back in her crib [cot], I would just lie awake, staring at nothing.’
When her appetite went, in addition to having trouble sleeping Bolo started crying for reasons she could not articulate. ‘The strangest things made me sad’, she said. A crack in the plaster on the wall of the hall. The polished brightness inside their brand-new freezer. The supermarket, where packed chicken pieces floated in fluid, where marbled meat hung off hooks in the butcher section.
‘I didn’t hear voices or see visions,’ Bolo said, ‘but I began to think I was going crazy. The morning was the worst. I’d wake up seized with terror. But it wasn’t tied to anything; it was free-floating, it was everywhere. I’d lie in the bed and think, All I need to do is swing one leg over the edge and put my foot on the floor, but that action seemed insurmountable to me. The smallest things were completely overwhelming. I was scared all the time, even in the shower. I felt like I was moving through jam, or sludge. Then Emily started to seem’ – and here Bolo’s voice dropped, as if in shame – ‘demonic to me. It’s odd how depression can do that, can so alter your perceptions. When I first saw my baby, when they lifted her out of the slit in my stomach and held her up, this pudgy ball with blue eyes, I thought she was adorable. But two weeks later when I looked at her, I thought her eyes seemed possessed and her crying was like nails on a blackboard. It caused my whole self to shrivel up.’
Alarmed, Bolo called the 800 telephone number at the bottom of her health insurance card. She got what most insured citizens in the United States would have gotten in her situation: one fifty-minute session with a psychopharmacologist, whose sole mission is to dole out drugs and to provide monthly fifteen-minute follow-up sessions called ‘med checks’, the purpose of which is to assess the efficacy of the antidepressant prescribed in the initial consultation. Bolo was lucky. Neither she nor her doctor could have predicted just how swiftly she would respond to her initial fluoxetine doses. Within four days, her symptoms began to abate.
Bolo’s brief first encounter with her psychopharmacologist is the norm in the United States, where the still briefer follow-up sessions are also the norm. ‘Most people are under the misconception that an appointment with a psychiatrist will involve counselling, probing questions and digging into the psychological meanings of one’s distress’, wrote psychiatrist Daniel Carlat, of the Tufts University School of Medicine. ‘But the psychiatrist as psychotherapist is an endangered species.’ Carlat goes on to offer this frank observation about what has happened to the profession in that country: ‘Doing psychotherapy doesn’t pay well enough. I can see three or four patients per hour if I focus on medications . . . but only one patient in that time period if I do therapy. The income differential is a powerful incentive to drop therapy from our repertoire of skills, and psychiatrists have generally followed the money.’
Should it be any surprise that when I asked Bolo if she felt listened to, her response was ‘No, not at all’? But she was quick to add, ‘I left with a prescription for twenty milligrams of Prozac and I’ll tell you, just having that prescription in my h
and, just the fact of it being there, gave me some hope and lifted my spirits.’
Here Bolo is alluding to the much-discussed placebo effect that psychiatric medications must outperform in clinical trials in order to be approved by the US Food and Drug Administration (FDA). When fluoxetine, in particular, was tested, it needed to outperform the placebo in six-to-eight-week double-blind trials. (‘Double-blind’, you’ll remember, means that neither the researchers nor the patients know who is swallowing the sugar tablet and who the real deal.) But even in Eli Lilly’s published research, any difference between fluoxetine and earlier antidepressants was inconsequential, and two-thirds of the people in its trials would have fared just as well or better on a placebo.
Pharmaceutical companies, in testing a new antidepressant drug, need only come up with two studies that demonstrate their drug’s efficacy. And when scientists and doctors looked into the unpublished research on approved SSRIs through the Freedom of Information Act, they discovered some pretty unfavourable data. Consider that of the forty-seven trials that were conducted for the country’s six major antidepressants (citalopram, venlafaxine, paroxetine, nefazodone and sertraline, in addition to fluoxetine), the drug beat the placebo only twenty of those times – fewer than half. Second, the FDA does not mandate exactly how much more effective than the placebo the drug must be. In those same forty-seven clinical trials, when measured on the Hamilton Depression Rating Scale, the tool most clinicians use to measure a person’s depression, the average patient improved on the drug only two points better than on the placebo, a difference that Irving Kirsch, a Harvard psychologist and associate director of the Program in Placebo Studies, has called ‘trivial’ and ‘clinically meaningless’.
These lax requirements, in and of themselves, are disturbing. Now add in the fact that the FDA approved fluoxetine after just six to eight weeks of clinical trials. But virtually no one, in actuality, takes these drugs for just six to eight weeks. The vast majority of patients taking fluoxetine – perhaps all of them – use the drug for far longer periods of time. In fact many psychiatrists believe that patients who have had a depressive episode should stay on the drug indefinitely in order to prevent relapses, since each relapse, the theory goes, makes the brain that much more vulnerable to future episodes and thus justifies a lifetime of antidepressant use. But despite the fact that the original six-to-eight-week trials did not, and do not, reflect real life, and despite the millions of people to date who have ingested, and continue to ingest, these drugs for years on end, there have been very few studies on the long-term side effects of serotonin boosters. There have been some long-term studies on the drugs themselves, yes, and some mid-term studies (after a period of months or a couple of years) on patients’ rates of remission and relapse, but not when it comes to the side effects that serotonin boosters produce. Why have so few long-term studies been done? The answer, said Donald Klein, former head of the American Society of Clinical Psychopharmacology, is plain: ‘I think the industry is concerned about the possibility of finding long-term risks.’
Like most depressed patients, Bolo was informed she had a chemical imbalance that a serotonin booster would fix. She was not made aware that there is, in actuality, a paucity of evidence to support the view that depression – or, for that matter, any other psychiatric disorder – is tied to a chemical imbalance in the brain. Instead, the offices of psychopharmacologists in the United States often display laminated posters from the various drug companies showing how SSRIs, by inhibiting the reuptake of serotonin, keep higher levels of this crucial neurotransmitter available in the synaptic cleft, thereby boosting serotonin throughout the brain. ‘I was told,’ said Bolo, when I spoke to her for the second time, six months after the birth of her baby, ‘that I had low serotonin and that my symptoms were classic and would likely respond to a drug. I had some hesitations, but the doctor told me that if I was diabetic I would take insulin, and that there really was no difference.’
Bolo had no way of knowing that the all-pervasive diabetes metaphor which some psychopharmacologists use in order to persuade their patients to take drugs has no merit. Diabetes is a disease for which we absolutely know the cause. We know that in diabetes the pancreas stops producing insulin and that, as a result, blood sugar gets dangerously high. We do not know, in the case of depression, why suffering starts and why it continues, whether it is the result of an excess of the stress hormone cortisol, hereditary gene expression, neurotransmitters run amok, an overly individualistic society, all of these things or none of these things. We do know, however, that it is not the consequence of something as simplistic as low serotonin alone. When it comes to diabetes, a doctor can diagnose or screen for the disease via a patient’s blood or urine, using valid and reliable tests. But we have no such tests for diagnosing depression. We cannot use the fluids of the body to tell us why a patient’s mood has plunged.
Medication is dispensed on the basis of a patient’s report and the degree to which the patient’s symptoms fit with the symptom checklist in the Diagnostic and Statistical Manual of Mental Disorders. The DSM, what some call the bible of psychiatry, was first published in 1952. It’s a book that lists all the psychiatric syndromes decided upon by committee, a list that has been updated seven times over the last half century. To give you a sense of the evolution, the first DSM, in 1952, included 106 diagnoses; in the 2015 edition of the DSM there are more than 300 diagnoses. In every case the committees reaching these decisions are made up of mental health professionals, many of them psychiatrists, deciding in a fairly random manner what the diagnoses will be. For instance, up until 1974, homosexuality still appeared in the DSM as a disorder. In the 2015 edition we have the diagnosis ‘social anxiety disorder’, a diagnosis that did not exist until 1994. The DSM reflects the consensus of the committees that conjure it and is not rooted in real biological phenomena such as tissue samples or blood and urine tests, because to date we have no known physiological substrates for any psychiatric disorder.
Bolo was never told this. She was told, in essence, a lie: that her suffering was the mental equivalent of diabetes and that a drug would make things right. The good news for Bolo, in the short term, was that soon after starting fluoxetine, she was a changed woman. Her appetite was back. She slept soundly between feedings of her infant daughter, whose wail no longer irritated her but rather called forth an urge to comfort, to console.
In the first couple of weeks of her daughter’s life, Bolo had tried joining a new mothers’ group, but at the time the group’s discussions focusing on types of pushchairs and car seats had quickly left her feeling unfulfilled, and she stopped going. ‘The strangest thing,’ she said, ‘is that when I started going again to my new mothers’ group, I actually enjoyed the conversations which before had sounded so stupid and superficial to me.’ She paused, shifted in her chair and studied her pearlescent nails, then sighed the sigh of someone weighted with worry. Outside the window the motorway hummed and hummed as cars shot past in a blur of sun-blasted chrome. ‘In that mothers’ group,’ Bolo continued, ‘it’s like I can hear the conversation on two levels. On one level it’s just a conversation about Graco strollers [pushchairs] versus who knows what, and I contribute and enjoy it. On another level, though, there I am, sort of hovering above it all and wondering what’s gotten into me that I find something so banal suddenly so enjoyable. There have been other things that bothered me too. I have my master’s in social work and have always been bookish. But on Prozac I notice that I read less and shop more. I suddenly have a thing for scarves. Scarves’, Bolo repeated, and stopped to finger a scarf she was wearing, frothy white and dotted with the palest pastilles. She pulled the scarf off over her head and, holding it between thumb and forefinger, dangled it above the floor before letting it fall, which it did, floating slowly to the carpet and collapsing in an impossibly soft heap. ‘So much for that’, she said.
The Little Libido Problem
Eli Lilly’s sales force touted Prozac, their brand name for fl
uoxetine, as a clean medicine designed to provide rapid relief. For Bolo, relief did come relatively swiftly. But while she did not have the dry mouth or blurred vision associated with the older antidepressants, she began to have other side effects. Bolo’s libido disappeared, and she became anorgasmic during the sex she and her husband, Ryan, did have. When one takes a closer look at the literature, it becomes clear that Bolo’s experience is not unusual. In the initial Lilly package insert for fluoxetine, sexual dysfunction is listed as occurring in 2 to 5 per cent of patients, but researchers estimate that it occurs, in actuality, in 60 to 75 per cent of patients and perhaps at an even higher rate. Why the enormous discrepancy? Was Lilly truly unaware that its medication made both men and women sexually dysfunctional? Was its estimate of 2 to 5 per cent made in good faith? Or was the company, having observed the sharp downwards turn in prescriptions of MAOIs resulting from the dietary restrictions imposed on that class of drugs, trying to downplay, or even hide, a very significant problem?
The aforementioned six-to-eight-week period of the clinical trials isn’t the only problem. Adding to that shortcoming is the fact that researchers performing the trials did not ask patients specifically about sexual side effects; it was only when a patient spontaneously complained that the side effect was noted and logged. Sex, by its very nature, exists in a private realm. Many people are naturally hesitant to tell researchers they hardly know that their genitals don’t seem to be working.
The Drugs That Changed Our Minds Page 18
