Scientists working on the Brain Molecule Anatomy Project (BMAP) are trying to figure out what genes are involved in brain development and function. They also seek to know when those genes are active. Genetic manipulation will be greatly facilitated by the BMAP. “I’m placing my bets,” Steven Hyman of the NIMH says. “One is on genes. I think once we have a few genes that are involved in mood regulation or in illness, all of a sudden we’ll say, well, what pathway are these in? Might this pathway tell us about what happens in the brain? Therapeutic targets? When in development are these genes on? Where are they in the brain? What’s the difference in brain function between this version that creates vulnerability to illness and that version that doesn’t? What are the genes that build this part of the brain when? Let’s imagine that we find out that one particular subnucleus of the amygdala is critically involved in the control of negative affect, which is highly likely. What if we have before us every gene that is ever on in that structure through development? Well, then we have a tool kit for investigation. There is no such thing as a mood gene. It’s just shorthand. Every gene that is involved in an illness probably has many other functions in the body or in the brain. The brain is a distributed processor.”
If the human genome is made up of about thirty thousand genes—and that number seems to keep increasing as we discover more and more of them—and if each one has about ten important common varieties, that gives us 1030,000 candidates for human genetic vulnerability to all illnesses. How far is it from identifying some genes to trying to figure out what happens to those genes in different combinations at different stages in the face of different kinds of environmental stimuli? We need brute force of numbers to check out all the combinatorial possibilities. Then we need to see how they play out under various external circumstances. Rapid as our computers are, this knowledge is still an eternity away. Among all diseases, depression must ride near the top of the list for being overdetermined: I am no geneticist, but I would bet that there are at the very least a few hundred genes that may conduce to the development of depressive disorders. How such genes trigger depression would depend on how they interact with external stimuli and with one another. I would guess that most of those genes also serve useful functions, and that simply knocking them out would have significant deleterious effects. Genetic information may help us to control certain kinds of depression, but the chances of eliminating depression through genetic manipulation any time soon are, I believe, thinner than thin ice.
CHAPTER V
Populations
No two people have the same depression. Like snowflakes, depressions are always unique, each based on the same essential principles but each boasting an irreproducibly complex shape. Nonetheless, professionals love to group depressions: bipolar versus unipolar; acute versus mild; trauma-based versus endogenous; brief versus protracted—the list can be and has been drawn out endlessly, a process that has had disappointingly limited utility in diagnosis and treatment. There is something to be learned from the particular qualities of gender-specific depression and age-specific depression, as well as from the cultural determinants of the complaint. These raise a fundamental question: Are the distinctive qualities of such depressions determined by biological differences between men and women, between the very young and the very old, between Asians and Europeans, between gay or straight people, or are they determined by sociological differences, by patterns of expectation we impose on people according to the population they represent? The answer is that in every case, both are true. The monolithic problem of depression cannot be addressed with a monolithic response; depressions are contextual and must be interpreted within the contexts in which they occur.
For reasons variously attributed to chemistry and external conditions, about twice as many women as men seem to suffer depression. The distinction does not exist among depressed children but sets in during puberty. Women suffer several characteristic forms of depression—postpartum depression, premenstrual depression, and menopausal depression—as well as all the forms of depression that afflict men. Fluctuating rates of estrogen and progesterone clearly have mood effects, especially as they interact with the hypothalamic and pituitary hormone systems, but these are not predictable or consistent mood effects. Sudden lowering of estrogen levels will cause depressive symptoms, and high levels of estrogen promote a sense of well-being. Prior to menstruation, some women experience physical discomfort and some, because of bloating, perceive themselves to be less attractive; each of these experiences triggers low mood. Women who are pregnant or who have just given birth, though they are less likely than any others to kill themselves, are more likely than any others to suffer depression. Severe postpartum depression hits about one in ten procreative women. These new mothers tend to be weepy and are often anxious, irritable, and uninterested in their newborn children—perhaps in part because birthing drains estrogen reserves, which take some time to restore. The symptoms ordinarily abate within weeks. A milder version of the syndrome probably occurs in about a third of new mothers. Giving birth is a difficult, exhausting experience, and some of what now gets classed as postpartum depression is really the mild collapse that follows any extraordinary expenditure of effort. Women are likely to experience lower levels of depression around menopause, which strongly suggests a hormonal factor in women’s depression—the period of most acute female depression is the childbearing years. It has been proposed that alterations in hormone levels might affect neurotransmitters, but no mechanism for such action has been located. More striking than the popular but vague focus on hormones is that men actually synthesize serotonin about 50 percent more rapidly than women do, which may well give men greater resilience. Women’s slower replenishment of serotonin reserves may leave them prone to lagging depression.
Biology alone does not account for the high rate of women’s depression. There are some biological differences between men’s and women’s depression; there are evident social differences between men’s and women’s positions of strength and power. Part of the reason women become depressed more often than men is that they are more frequently disenfranchised. Strikingly, the chances of postpartum depression in women under severe stress are particularly high; and women whose husbands take significant responsibility for the basics of child care have low levels of the baby blues. Feminists working on depression tend to prefer sociological to biological theories; they dislike the implication that women’s bodies are somehow weaker than men’s. Susan Nolen-Hoeksema, one of America’s leading writers on women and depression, says, “It is dangerous to imply through the choice of the label that an aspect of women’s reproductive biology is central to psychiatric illness.” This kind of thinking has given much sociological work on women’s depression a political agenda. Although it is an admirable agenda, its expression is not always true to experience, biology, or statistics. In fact, many theoretical approaches to women’s depression exacerbate the troubles of those they seek to help. The overlap of some feminist theory’s manipulation of scientific reality to achieve political goals, and most medical theory’s insensitivity to social reality, has tied up the matter of gender and depression in a Gordian knot.
A recent study showed that on American college campuses, the rates of male and female depression are the same. Some pessimistic feminists have suggested that women who are prone to depression don’t make it to college. Other more optimistic feminists have suggested that women are more entirely equal to men in college than in almost any other social context. I would throw into the mix the notion that men who are at college are probably more open to acknowledging their illness than are less educated or older men. The rate of female-to-male depression does not appear to vary in Western societies; it stays consistent overall at two to one. The world is dominated by men, and that makes things rough for women. Women are less well able physically to defend themselves. They are more likely to be poor. They are more likely to be the victims of abuse. They are less likely to be educated. They are more likely to suffer reg
ular humiliations. They are more likely to lose social position through the visible signs of aging. They are likely to be subordinate to their husbands. Some feminists say that women develop depression because they do not have enough independent spheres in which to assert themselves and must rely on the triumphs of the home for all their feelings of self-worth. Others say that successful women have too many independent spheres in which to assert themselves and are always torn between their work and their home. That each of these situations is stressful is consistent with the finding that married housewives and working married women suffer from about the same rate of depression—which is much higher than that suffered by working married men. It is interesting to note that, across cultures, women have higher rates of not only depression but also panic disorders and eating disorders, while men have higher incidence of autism, attention deficit hyperactivity disorder, and alcoholism.
The English psychologist George Brown is one of the reigning experts on the sociological side of psychology. He has proposed that women’s depression is linked to their concern for their children, a theory that has been borne out by other academics. If one discounts depression triggered by anxiety about offspring, the rate of depression for men and women appears to equalize; and in couples in which gender roles are less rigidly defined, rates of men’s and women’s depression tend to be closer—“Gender differences in rates of depression are, to a considerable extent, a consequence of role differences,” Brown concludes. Myrna Weissman at Columbia has proposed that it makes evolutionary sense for women to be particularly acutely sensitive to loss since this would motivate them through childbearing and childrearing.
It is also the case that many women who are depressed suffered significant abuse as children. Little girls are far more likely to be sexually abused than are little boys, and victims of abuse are far more likely to be depressed than are others. Such women are also likely to suffer from anorexia, an illness that in recent years has been linked to depression. Malnutrition causes many symptoms of depression, so it may be that the depressive symptoms of anorexic women are the consequence of other symptoms; but many women who have experienced anorexia describe symptoms that persist even after they have achieved normal weight. Once more, it would appear that social constructs are implicated in causing both the painful obsession with self-control that is manifest in anorexia and the feelings of helplessness that characterize depression. Self-loathing may cause people to want to make themselves as small as possible until they nearly disappear. Certain key questions may be critical to diagnosis of a separate depressive complaint. It is often useful to ask anorexics whether they sleep badly even when they are not thinking about food or eating.
Mental illness has for a long time been defined by men. In 1905, Sigmund Freud maintained that his patient Dora was suffering hysteria when she rebuffed the unwelcome advances of a man three times her age. This kind of misprision is less common today than it was even fifty years ago. Nonetheless, women are often seen as depressed when they fail to show the vitality that their husbands expect or demand, and which the women have learned to expect or demand of themselves. This principle is, however, tricky: it is also argued that men undertreat women’s depression because withdrawal is mistaken for feminine passivity. Women attempting to conform to ideals of femininity may act depressed out of conformism; or they may become depressed as a consequence of being unable to live within a stultifying definition of femininity. Women who complain of postpartum depression may in some instances be expressing only their shock and disappointment at failing to feel some kind of superemotion that the movies and popular TV have described as the essence of new motherhood. Told too often that maternal love is organic (which they take to mean effortless), they become depressed by the ambivalence that often accompanies infant care.
The feminist critic Dana Crowley Jack has systematized these ideas as components of women’s loss of voice or loss of self. “As these women fail to hear themselves speak to their partners, they are unable to sustain the convictions and feelings of ‘I’ and slip, instead, into self-doubt about the legitimacy of their privately held experience.” Jack’s thesis is that women who cannot communicate effectively with their partner (most frequently, she suggests, because the partner is not willing to hear) lapse into silence. They actually talk less frequently, and they undermine their own assertions with phrases such as “I don’t know” or “I’m not sure anymore.” To keep their fractured marriages or relationships from breaking up entirely, these women attempt to fit to an ideal of womanhood in which they say what they think their partner wants to hear—and so become false even in intimate interactions, simply dissolving as people. Jack states, “Women undertake massive self-negation as part of their search for intimacy.” In fact, successful relationships are usually partnerships in which power can be passed back and forth between man and woman to suit the various circumstances that they encounter together and separately. It is true, however, that women frequently have less money or less financial control, and that in flawed relationships women accept abuse and battering more readily than do men. This is one more of depression’s seemingly endless run of chicken-egg scenarios: depressed women are less able to defend themselves against abuse and are therefore abused more, becoming more depressed as a consequence of abuse, which makes them even less able to defend themselves.
Jack believes that the male power system scorns women’s depression. In one of her moments of excess, Jack describes marriage itself as “the most persistent of myths imprisoning women,” and elsewhere she writes that women are “easy targets for depression, a depression bound by patriarchy and robbed of its organic, mythic nature and consequently, its healing properties.” This refrain is echoed in other radical feminist writing about women’s depression. Another critic, Jill Astbury, suggests in her review of the subject that our notion of female depression is entirely a male construction: “The question about women’s proneness to depression contains an assumption that is rarely made explicit. It has to do with seeing female rates of depression as pathological, too high and a problem. The only vantage point from which such a view is possible is that which assumes male rates of depression constitute a norm, are in themselves completely unproblematic and provide the only reasonable point of departure from which pathology in women can be measured. The pervasiveness of the androcentric approach can be appreciated if, instead of asking about the problem of women’s depression, the rates of depression in men are positioned instead as problematic, perplexing and in need of clarification. Why, it could be asked but usually isn’t, are male rates so abnormally low? Does testosterone interfere with the development of full humanity and emotional sensitivity?” and on and on and on. These recurring arguments made by reputable scholars in this field, usually in books published by major university houses (Jack is published by Harvard University Press; Astbury by Oxford), seem to focus on society’s demonization of women’s depression, as though that depression itself were innocuous. I would argue that if you do not experience personal distress over your symptoms, you don’t have depression. If you do suffer personal distress, it is reasonable and perhaps even generous of the establishment to invest in finding solutions to your distress. Since the high rates of women’s depression do not reflect a genetic predisposition that we can currently locate, we can say with some assurance that the rates of depression among women could be significantly reduced in a more equitable society. In the meanwhile, however, it is in general the depressed women who find their depression abnormal and who wish to do something about it. Abusive husbands, patriarchal oppressors that they are, tend to like depressed women and not to see those women’s depression as symptomatic: it is empowered women who are most likely to recognize, name, and treat their depression. The idea that women are depressed because of the patriarchal conspiracy has some validity; the idea that we make women feel bad about their depression as part of the patriarchal conspiracy ignores women’s own assertions of their experience of depression.
The
literature makes much of the distinctive qualities of women’s depression and says very little about any distinctive qualities of men’s depression. Many depressed men are not diagnosed because they tend to deal with feelings of depression not by withdrawing into the silence of despondency, but by withdrawing into the noise of violence, substance abuse, or workaholism. Women report twice as much depression as men, but men are four times as likely to commit suicide as women. Single, divorced, or widowed men have a much higher rate of depression than married men. Depressed men may show what is somewhat euphemistically called “irritability”—they lash out at strangers, beat their wives, take drugs, and shoot people. The writer Andrew Sullivan recently wrote that injecting himself with testosterone, which he was doing as part of a regimen of HIV treatment, increased his tendency toward violence. In a series of interviews I did with wife batterers, I found consistent complaints of organic depression symptoms. “I get home and I feel all tired out the whole time,” one man said, “and there is that woman asking me all these damn questions, and the noise of it just starts thumping in my head like hammers. I can’t eat with it, I can’t sleep with it, it’s just she’s there the whole time. I don’t wanna hurt her but I gotta do something, I’m going crazy, you understand?” Someone else said that when he saw his wife he felt “so worthless on this earth I might never do nothing again if I don’t fire out a punch or something.”
Wife battering is obviously an inappropriate response to feelings of depression, but frequently the syndromes are closely tied. It seems likely that many other confrontational, injurious behaviors are manifestations of male depression. In most Western societies, admissions of weakness are held to be feminine. This has a negative effect on men, preventing them from crying, making them feel shame in the face of irrational fear and anxiety. The batterer who believes that hitting his wife is the only way for him to exist in the world manifestly buys into the idea that emotional pain is always a call to action, and that emotion without action negates him as a man. It is unfortunate that many men who—in the broadest sense—behave badly are not given antidepressant treatment. If women exacerbate their depression because they are not as happy as they think they should be, men exacerbate their depression because they are not as courageous as they think they should be. Most abuse is a form of cowardice, and some cowardice is a reasonable symptom of depression. I should know: I was once afraid of a lamb chop, and it’s a very disempowering feeling.
The Noonday Demon Page 25
