The Noonday Demon
Page 3
Illness of the mind is real illness. It can have severe effects on the body. People who show up at the offices of their doctors complaining about stomach cramps are frequently told, “Why, there’s nothing wrong with you except that you’re depressed!” Depression, if it is sufficiently severe to cause stomach cramps, is actually a really bad thing to have wrong with you, and it requires treatment. If you show up complaining that your breathing is troubled, no one says to you, “Why, there’s nothing wrong with you except that you have emphysema!” To the person who is experiencing them, psychosomatic complaints are as real as the stomach cramps of someone with food poisoning. They exist in the unconscious brain, and often enough the brain is sending inappropriate messages to the stomach, so they exist there as well. The diagnosis—whether something is rotten in your stomach or your appendix or your brain—matters in determining treatment and is not trivial. As organs go, the brain is quite an important one, and its malfunctions should be addressed accordingly.
Chemistry is often called on to heal the rift between body and soul. The relief people express when a doctor says their depression is “chemical” is predicated on a belief that there is an integral self that exists across time, and on a fictional divide between the fully occasioned sorrow and the utterly random one. The word chemical seems to assuage the feelings of responsibility people have for the stressed-out discontent of not liking their jobs, worrying about getting old, failing at love, hating their families. There is a pleasant freedom from guilt that has been attached to chemical. If your brain is predisposed to depression, you need not blame yourself for it. Well, blame yourself or evolution, but remember that blame itself can be understood as a chemical process, and that happiness, too, is chemical. Chemistry and biology are not matters that impinge on the “real” self; depression cannot be separated from the person it affects. Treatment does not alleviate a disruption of identity, bringing you back to some kind of normality; it readjusts a multifarious identity, changing in some small degree who you are.
Anyone who has taken high school science classes knows that human beings are made of chemicals and that the study of those chemicals and the structures in which they are configured is called biology. Everything that happens in the brain has chemical manifestations and sources. If you close your eyes and think hard about polar bears, that has a chemical effect on your brain. If you stick to a policy of opposing tax breaks for capital gains, that has a chemical effect on your brain. When you remember some episode from your past, you do so through the complex chemistry of memory. Childhood trauma and subsequent difficulty can alter brain chemistry. Thousands of chemical reactions are involved in deciding to read this book, picking it up with your hands, looking at the shapes of the letters on the page, extracting meaning from those shapes, and having intellectual and emotional responses to what they convey. If time lets you cycle out of a depression and feel better, the chemical changes are no less particular and complex than the ones that are brought about by taking antidepressants. The external determines the internal as much as the internal invents the external. What is so unattractive is the idea that in addition to all other lines being blurred, the boundaries of what makes us ourselves are blurry. There is no essential self that lies pure as a vein of gold under the chaos of experience and chemistry. Anything can be changed, and we must understand the human organism as a sequence of selves that succumb to or choose one another. And yet the language of science, used in training doctors and, increasingly, in nonacademic writing and conversation, is strangely perverse.
The cumulative results of the brain’s chemical effects are not well understood. In the 1989 edition of the standard Comprehensive Textbook of Psychiatry, for example, one finds this helpful formula: a depression score is equivalent to the level of 3-methoxy-4-hydroxyphenylglycol (a compound found in the urine of all people and not apparently affected by depression); minus the level of 3-methoxy-4-hydroxymandelic acid; plus the level of norepinephrine; minus the level of normetanephrine plus the level of metanepherine, the sum of those divided by the level of 3-methoxy-4-hydroxymandelic acid; plus an unspecified conversion variable; or, as CTP puts it: “D-type score = C1 (MHPG) - C2 (VMA) + C3 (NE) - C4 (NMN + MN)/VMA + C0.” The score should come out between one for unipolar and zero for bipolar patients, so if you come up with something else—you’re doing it wrong. How much insight can such formulae offer? How can they possibly apply to something as nebulous as mood? To what extent specific experience has conduced to a particular depression is hard to determine; nor can we explain through what chemistry a person comes to respond to external circumstance with depression; nor can we work out what makes someone essentially depressive.
Although depression is described by the popular press and the pharmaceutical industry as though it were a single-effect illness such as diabetes, it is not. Indeed, it is strikingly dissimilar to diabetes. Diabetics produce insufficient insulin, and diabetes is treated by increasing and stabilizing insulin in the bloodstream. Depression is not the consequence of a reduced level of anything we can now measure. Raising levels of serotonin in the brain triggers a process that eventually helps many depressed people to feel better, but that is not because they have abnormally low levels of serotonin. Furthermore, serotonin does not have immediate salutary effects. You could pump a gallon of serotonin into the brain of a depressed person and it would not in the instant make him feel one iota better, though a long-term sustained raise in serotonin level has some effects that ameliorate depressive symptoms. “I’m depressed but it’s just chemical” is a sentence equivalent to “I’m murderous but it’s just chemical” or “I’m intelligent but it’s just chemical.” Everything about a person is just chemical if one wants to think in those terms. “You can say it’s ‘just chemistry,’ ” says Maggie Robbins, who suffers from manic-depressive illness. “I say there’s nothing ‘just’ about chemistry.” The sun shines brightly and that’s just chemical too, and it’s chemical that rocks are hard, and that the sea is salt, and that certain springtime afternoons carry in their gentle breezes a quality of nostalgia that stirs the heart to longings and imaginings kept dormant by the snows of a long winter. “This serotonin thing,” says David McDowell of Columbia University, “is part of modern neuromythology.” It’s a potent set of stories.
Internal and external reality exist on a continuum. What happens and how you understand it to have happened and how you respond to its happening are usually linked, but no one is predictive of the others. If reality itself is often a relative thing, and the self is in a state of permanent flux, the passage from slight mood to extreme mood is a glissando. Illness, then, is an extreme state of emotion, and one might reasonably describe emotion as a mild form of illness. If we all felt up and great (but not delusionally manic) all the time, we could get more done and might have a happier time on earth, but that idea is creepy and terrifying (though, of course, if we felt up and great all the time we might forget all about creepiness and terror).
Influenza is straightforward: one day you do not have the responsible virus in your system, and another day you do. HIV passes from one person to another in a definable isolated split second. Depression? It’s like trying to come up with clinical parameters for hunger, which affects us all several times a day, but which in its extreme version is a tragedy that kills its victims. Some people need more food than others; some can function under circumstances of dire malnutrition; some grow weak rapidly and collapse in the streets. Similarly, depression hits different people in different ways: some are predisposed to resist or battle through it, while others are helpless in its grip. Willfulness and pride may allow one person to get through a depression that would fell another whose personality is more gentle and acquiescent.
Depression interacts with personality. Some people are brave in the face of depression (during it and afterward) and some are weak. Since personality too has a random edge and a bewildering chemistry, one can write everything off to genetics, but that is too easy. “There is no suc
h thing as a mood gene,” says Steven Hyman, director of the National Institute of Mental Health. “It’s just shorthand for very complex gene-environment interactions.” If everyone has the capacity for some measure of depression under some circumstances, everyone also has the capacity to fight depression to some degree under some circumstances. Often, the fight takes the form of seeking out the treatments that will be most effective in the battle. It involves finding help while you are still strong enough to do so. It involves making the most of the life you have between your most severe episodes. Some horrendously symptom-ridden people are able to achieve real success in life; and some people are utterly destroyed by the mildest forms of the illness.
Working through a mild depression without medications has certain advantages. It gives you the sense that you can correct your own chemical imbalances through the exercise of your own chemical will. Learning to walk across hot coals is also a triumph of the brain over what appears to be the inevitable physical chemistry of pain, and it is a thrilling way to discover the sheer power of mind. Getting through a depression “on your own” allows you to avoid the social discomfort associated with psychiatric medications. It suggests that we are accepting ourselves as we were made, reconstructing ourselves only with our own interior mechanics and without help from the outside. Returning from distress by gradual degrees gives sense to affliction itself.
Interior mechanics, however, are difficult to commission and are frequently inadequate. Depression frequently destroys the power of mind over mood. Sometimes the complex chemistry of sorrow kicks in because you’ve lost someone you love, and the chemistry of loss and love may lead to the chemistry of depression. The chemistry of falling in love can kick in for obvious external reasons, or along lines that the heart can never tell the mind. If we wanted to treat this madness of emotion, we could perhaps do so. It is mad for adolescents to rage at parents who have done their best, but it is a conventional madness, uniform enough so that we tolerate it relatively unquestioningly. Sometimes the same chemistry kicks in for external reasons that are not sufficient, by mainstream standards, to explain the despair: someone bumps into you in a crowded bus and you want to cry, or you read about world overpopulation and find your own life intolerable. Everyone has on occasion felt disproportionate emotion over a small matter or has felt emotions whose origin is obscure or that may have no origin at all. Sometimes the chemistry kicks in for no apparent external reason at all. Most people have had moments of inexplicable despair, often in the middle of the night or in the early morning before the alarm clock sounds. If such feelings last ten minutes, they’re a strange, quick mood. If they last ten hours, they’re a disturbing febrility, and if they last ten years, they’re a crippling illness.
It is too often the quality of happiness that you feel at every moment its fragility, while depression seems when you are in it to be a state that will never pass. Even if you accept that moods change, that whatever you feel today will be different tomorrow, you cannot relax into happiness as you can into sadness. For me, sadness always has been and still is a more powerful feeling; and if that is not a universal experience, perhaps it is the base from which depression grows. I hated being depressed, but it was also in depression that I learned my own acreage, the full extent of my soul. When I am happy, I feel slightly distracted by happiness, as though it fails to use some part of my mind and brain that wants the exercise. Depression is something to do. My grasp tightens and becomes acute in moments of loss: I can see the beauty of glass objects fully at the moment when they slip from my hand toward the floor. “We find pleasure much less pleasurable, pain much more painful than we had anticipated,” Schopenhauer wrote. “We require at all times a certain quantity of care or sorrow or want, as a ship requires ballast, to keep on a straight course.”
There is a Russian expression: if you wake up feeling no pain, you know you’re dead. While life is not only about pain, the experience of pain, which is particular in its intensity, is one of the surest signs of the life force. Schopenhauer said, “Imagine this race transported to a Utopia where everything grows of its own accord and turkeys fly around ready-roasted, where lovers find one another without any delay and keep one another without any difficulty: in such a place some men would die of boredom or hang themselves, some would fight and kill one another, and thus they would create for themselves more suffering than nature inflicts on them as it is . . . the polar opposite of suffering [is] boredom.” I believe that pain needs to be transformed but not forgotten; gainsaid but not obliterated.
I am persuaded that some of the broadest figures for depression are based in reality. Though it is a mistake to confuse numbers with truth, these figures tell an alarming story. According to recent research, about 3 percent of Americans—some 19 million—suffer from chronic depression. More than 2 million of those are children. Manic-depressive illness, often called bipolar illness because the mood of its victims varies from mania to depression, afflicts about 2.3 million and is the second-leading killer of young women, the third of young men. Depression as described in DSM-IV is the leading cause of disability in the United States and abroad for persons over the age of five. Worldwide, including the developing world, depression accounts for more of the disease burden, as calculated by premature death plus healthy life-years lost to disability, than anything else but heart disease. Depression claims more years than war, cancer, and AIDS put together. Other illnesses, from alcoholism to heart disease, mask depression when it causes them; if one takes that into consideration, depression may be the biggest killer on earth.
Treatments for depression are proliferating now, but only half of Americans who have had major depression have ever sought help of any kind—even from a clergyman or a counselor. About 95 percent of that 50 percent go to primary-care physicians, who often don’t know much about psychiatric complaints. An American adult with depression would have his illness recognized only about 40 percent of the time. Nonetheless, about 28 million Americans—one in every ten—are now on SSRIs (selective serotonin reuptake inhibitors—the class of drugs to which Prozac belongs), and a substantial number are on other medications. Less than half of those whose illness is recognized will get appropriate treatment. As definitions of depression have broadened to include more and more of the general population, it has become increasingly difficult to calculate an exact mortality figure. The statistic traditionally given is that 15 percent of depressed people will eventually commit suicide; this figure still holds for those with extreme illness. Recent studies that include milder depression show that 2 to 4 percent of depressives will die by their own hand as a direct consequence of the illness. This is still a staggering figure. Twenty years ago, about 1.5 percent of the population had depression that required treatment; now it’s 5 percent; and as many as 10 percent of all Americans now living can expect to have a major depressive episode during their life. About 50 percent will experience some symptoms of depression. Clinical problems have increased; treatments have increased vastly more. Diagnosis is on the up, but that does not explain the scale of this problem. Incidents of depression are increasing across the developed world, particularly in children. Depression is occurring in younger people, making its first appearance when its victims are about twenty-six, ten years younger than a generation ago; bipolar disorder, or manic-depressive illness, sets in even earlier. Things are getting worse.
There are few conditions at once as undertreated and as overtreated as depression. People who become totally dysfunctional are ultimately hospitalized and are likely to receive treatment, though sometimes their depression is confused with the physical ailments through which it is experienced. A world of people, however, are just barely holding on and continue, despite the great revolutions in psychiatric and psychopharmaceutical treatments, to suffer abject misery. More than half of those who do seek help—another 25 percent of the depressed population—receive no treatment. About half of those who do receive treatment—13 percent or so of the depressed population—receiv
e unsuitable treatment, often tranquilizers or immaterial psychotherapies. Of those who are left, half—some 6 percent of the depressed population—receive inadequate dosage for an inadequate length of time. So that leaves about 6 percent of the total depressed population who are getting adequate treatment. But many of these ultimately go off their medications, usually because of side effects. “It’s between 1 and 2 percent who get really optimal treatment,” says John Greden, director of the Mental Health Research Institute at the University of Michigan, “for an illness that can usually be well-controlled with relatively inexpensive medications that have few serious side effects.” Meanwhile, at the other end of the spectrum, people who suppose that bliss is their birthright pop cavalcades of pills in a futile bid to alleviate those mild discomforts that texture every life.
It has been fairly well established that the advent of the supermodel has damaged women’s images of themselves by setting unrealistic expectations. The psychological supermodel of the twenty-first century is even more dangerous than the physical one. People are constantly examining their own minds and rejecting their own moods. “It’s the Lourdes phenomenon,” says William Potter, who ran the psychopharmacological division of the National Institute of Mental Health (NIMH) through the seventies and eighties, when the new drugs were being developed. “When you expose very large numbers of people to what they perceive and have reason to believe is positive, you get reports of miracles—and also, of course, of tragedy.” Prozac is so easily tolerated that almost anyone can take it, and almost anyone does. It’s been used on people with slight complaints who would not have been game for the discomforts of the older antidepressants, the monoamine oxidase inhibitors (MAOIs) or tricyclics. Even if you’re not depressed, it might push back the edges of your sadness, and wouldn’t that be nicer than living with pain?