“Yes, it is true,” Karen Johansen said. “We Greenlanders are too close to be intimate. And we all have so many burdens here, and none of us wants to add our burdens to the burdens of others.” Danish explorers of the early and middle twentieth century found three primary mental illnesses among the Inuit, described by the Inuit themselves time out of mind. These have now largely died out except in very remote locations. “Polar hysteria” was described by one man who had suffered it as “a rising of the sap, of young blood nourished by the blood of walruses, seals, and whales—sadness takes hold of you. At first you are agitated. It is to be sick of life.” A modified form of it exists to this day as what we might call activated depression or a mixed state; it is closely related to the Malaysian idea of “running amok.” “Mountain wanderer syndrome” affected those who turned their back on the community and left—in earlier times, they were never allowed to return and had to fend for themselves in absolute solitude until they died. “Kayak anxiety,” the belief contra reality that water is in your boat and you will sink and drown, was the most common form of paranoia. Though these terms are now primarily used historically, they still evoke some of the conflicts of Inuit life. In Umanaaq, according to René Birger Christiansen, head of public health for Greenland, there was recently a spate of complaints from people who believed they had water under their skin. The French explorer Jean Malaurie wrote in the 1950s, “There is an often dramatic contradiction between the Eskimo’s basically individualistic temperament and his conscious belief that solitude is synonymous with unhappiness. Abandoned by his fellowmen, he is overcome by the depression that always lies in wait for him. Is the communal life too much to bear? A network of obligations link one person to another and make a voluntary prisoner of the Eskimo.”
The women elders of Illiminaq had each borne her pain in silence for a long time. Karen Johansen said, “At first, I tried to tell other women how I felt, but they just ignored me. They did not want to talk about bad things. And they did not know how to have such a conversation; they had never heard anyone talk about her problems. Until my brother died, I was proud also not to be a cloud in the sky for other people. But after this shock of his suicide, I had to talk. People did not like it. In our way, it is rude to say to someone, even a friend, ‘I am sorry for your troubles.’ ” She describes her husband as a “man of silence” with whom she negotiated a way to weep while he listened, without either of them having to use the words that were so alien to him.
These three women were drawn to one another’s difficulties, and after many years, they spoke together about the depth of their anguish, about their loneliness, about all the feelings that were in them. Amalia Joelson had gone to the hospital in Ilulissat for training in midwifery, and there she had become aware of talking therapies. She found comfort in her conversation with these other two women, and she proposed an idea to them. It was a new idea for that society. In church one Sunday, Amelia Lange announced that they had formed a group and that they wanted to invite anyone who wished to talk about problems to come and see them, individually or together. She proposed that they use the consulting room at Amalia Joelson’s place. Lange promised that such meetings would remain entirely confidential. She said, “None of us needs be alone.”
In the following year, all the women of the village, one at a time, each unaware of how many others had taken up the offer, came to see them. Women who had never told their husbands or their children what was in their hearts came and wept in the midwife’s delivery room. And so this new tradition began, of openness. A few men came, though the men’s idea of toughness kept many of them away, at least at the beginning. I spent long hours in the houses of each of these three women. Amelia Lange said it had been a great insight for her to see how people were “released” after talking to her. Karen Johansen invited me in with her family and gave me a bowl of fresh whale soup, which she had said was often the best answer to one’s problems, and told me that she had found the real cure for sadness, which was to hear of the sadness of others. “I am not doing this only for the people who speak to me,” she said, “but also for myself.” In their homes and in their intimacies, the people of Illiminaq do not talk about each other. But they go to their three elders and draw strength from them. “I know that I have prevented many suicides,” Karen Johansen said. “I’m glad I could talk to them in time.” The matter of confidentiality was of the utmost importance; there are many hierarchies in a small settlement, and these cannot be disrupted without making problems far greater than the problem of silence. “I see the people outside who have told me their problems, and I never bring up those problems or ask in a different way about someone’s health,” Amalia Joelson said. “Only if, when I say politely, ‘How are you?’ they begin to cry, then I will bring them back with me to the house.”
The idea of talking therapies is frequently discussed in the West as though it had been made up by psychoanalysts. Depression is a disease of loneliness, and anyone who has suffered it acutely knows that it imposes a dread isolation, even for people surrounded by love—in this case, an isolation caused by crowding. The three women elders of Illiminaq had discovered the wonder of unburdening themselves and of helping others to do the same. Different cultures express pain in different ways, and members of different cultures experience different kinds of pain, but the quality of loneliness is infinitely plastic.
Those three women elders asked me about my depression too, and sitting in their houses and eating dried cod wrapped in seal blubber, I felt them reaching from their experience to mine. When we left the town, my translator said this had been the most exhausting experience of her life, but she said it with incandescent pride. “We are strong people, the Inuit,” she said. “If we did not solve all our problems, we would die here. So we have found our way to solve this problem, this depression, too.” Sara Lynge, a Greenlandic woman who has set up a suicide hot line in a large town, said, “First, people must see how easy it is to talk to someone, then how good it is. They don’t know that. We who have discovered that must do our best to spread the news.”
Confronted with worlds in which adversity is the norm, one sees shifting boundaries between the accurate reckoning of life’s difficulty and the state of depression. Inuit life is hard—not morally demeaning in the way of concentration camps, and not emotionally vacant in the mode of modern cities, but unrelentingly arduous and without the quotidian material luxuries that most Westerners take for granted. Until quite recently, the Inuit could not afford even the luxury of speaking their problems: they had to suppress all negative emotion lest it sweep away their entire society. The families I visited in Illiminaq made their way through tribulation by observing a pact of silence. It was an effective system for its purpose, and it saw many people through many cold, long winters. Our modern Western belief is that problems are best solved when they are pulled out of darkness, and the story of what has happened in Illiminaq bears out that theory; but the articulation is limited in scope and location. Let us remember that none of the depressed people in the village talked about their problems with the objects of those problems, and that they did not discuss their difficulties regularly even with the three women elders. It is often said that depression is a thing to which a leisured class falls prey in a developed society; in fact, it is a thing that a certain class has the luxury of articulating and addressing. For the Inuit, depression is so minor in the scale of things and so evident a part of everyone’s life that, except in severe cases of vegetative illness, they simply ignore it. Between their silence and our intensely verbalized self-awareness lie a multitude of ways of speaking of psychic pain, of knowing that pain. Context, race, gender, tradition, nation—all conspire to determine what is to be said and what is to be left unsaid—and to some extent they thereby determine what is to be alleviated, what exacerbated, what endured, what forsworn. The depression—its urgency, its symptoms, and the ways out of it—is all determined by forces quite outside of our individual biochemistry, by who we are, w
here we were born, what we believe, and how we live.
CHAPTER VI
Addiction
Depression and substance abuse form a cycle. People who are depressed abuse substances in a bid to free themselves of their depression. People who abuse substances disrupt their lives to the point that they become depressed by the damage. Do people who are “genetically inclined” to alcoholism become drinkers and then experience depression as a consequence of consuming a substance; or do people who are genetically inclined to depression use drink as a form of self-medication? The answer to both questions is yes. Falling serotonin appears to play a significant role in reinforcing alcoholism, so that an escalating depression might cause organic escalation of alcoholism. In fact there is an inverse relationship between serotonin levels in the nervous system and alcohol consumption. Self-medication with illicit drugs is frequently counterproductive: while licit antidepressant meds start off with side effects and build up to desirable effects, the substances of abuse usually start with desirable effects and build up to side effects. The decision to take Prozac instead of cocaine is a version of the strategy of deferred gratification, and the decision to take cocaine instead of antidepressants is predicated on a yearning for immediate gratification.
All substances of abuse—nicotine, alcohol, marijuana, cocaine, heroin, and about twenty others currently known—have major effects on the dopamine system. Some people have a genetic predisposition to use these substances. Substances of abuse act on the brain in three stages. The first stage is in the forebrain and affects cognition; this in turn excites fibers leading to the most primitive areas of the brain—the ones we have in common with reptiles—and these, finally, send tingling messages to many other parts of the brain, frequently affecting the dopamine system. Cocaine, for example, seems to block dopamine uptake, so that more dopamine is floating around in the brain; morphine causes the release of dopamine. Other neurotransmitters are also involved; alcohol affects serotonin, and several substances seem to raise levels of enkephalin. The brain, however, is self-regulating and tends to sustain constant levels of stimulation; if you keep flooding it with dopamine, it will develop resistance so that it will require more and more dopamine to trigger a response. It either increases the number of dopamine receptors or decreases the sensitivity of existing dopamine receptors. This is why addicts need escalating quantities of their substance of abuse; it is also why people in recovery, who are no longer stimulating the excessive release of dopamine through substances, usually feel flat and greyed out and depressed: their natural dopamine levels are, by the standards of their adapted brains, extremely low. When the brain adjusts itself anew, withdrawal is complete.
Most people, if they take enough of an abusable substance for long enough, will become addicted to it. A third of all people who ever smoke a cigarette go on to develop a nicotine addiction; about a quarter of those who try heroin become dependent on it; about a sixth of those who try alcohol become dependent on that. The speed with which substances cross the blood-brain barrier and so intoxicate the user is often determined by the way the substance is ingested, with injection being fastest, inhalation next, and oral consumption slowest. Of course the speed also varies from substance to substance and will determine how rapidly reinforcing the substance is. “The question of who tries a substance once is pretty random,” David McDowell, director of the Substance Treatment and Research Service of Columbia University, says. “It has to do with where someone is and what his social climate is. But the follow-up is anything but random. Some people who try a substance go on with their lives and never give it another thought; some get hooked almost immediately.” For substance abusers as for depressives, a genetic predisposition interacts with external experience; people are born with a capacity to become substance abusers and, once they have abused a given substance for long enough, will become addicted to it. Depressed people who tend toward alcoholism will usually begin chronic heavy drinking about five years after the first major depressive episode; those who tend toward cocaine will on average start abusing it chronically about seven years after such an episode. No test exists at present to show who can use what substances with what levels of risk, though attempts to formulate such tests, mostly on the basis of certain enzyme levels in the bloodstream, are under way. It is not yet possible to see whether a physiological transformation in depressed people makes them more vulnerable to substance abuse, or whether the increased vulnerability is primarily psychological.
Most depressed substance abusers have two linked illnesses running concurrently, each of which requires treatment and each of which exacerbates the other. These illnesses interact within the dopamine system. The popular idea that you have to get a person off substances before you pay attention to his depression is faintly ludicrous: you are asking someone who tamps down his misery to let that misery blossom before you do anything about it. The idea that you can ignore addiction and treat depression as the primary illness, helping someone feel so good that he won’t want substances anymore, overlooks the reality of physical dependence. “If there’s anything we’ve learned in the addiction field,” says Herbert Kleber, who was for some years deputy drug czar for the United States and who now heads Columbia University’s Center for Addiction and Substance Abuse, “it’s that once you get addicted—it doesn’t matter how you got there—you have a disease with a life of its own. If you treat a depressed alcoholic with an antidepressant, you produce a nondepressed alcoholic.” Taking away the original motivation for abusing substances does not free someone who has developed a pattern of substance abuse.
Theoreticians are keen to separate mood state and substance dependency. Some straightforward measures—family history of depression, for example—can identify a primary depression, and a family history of substance abuse may point to a primary substance problem. Beyond this, the terms get vague. Alcoholism causes the symptoms of depression. The mainstream therapeutic philosophy at present holds that substance abuse should be treated first, and that after a person has been “clean” or “sober” for about a month, his emotional condition should be assessed. If the person is feeling good, the addiction was probably the cause of the depression, and so lifting the addiction has lifted the depression. This is all well and good in principle, but in fact the upheaval caused by withdrawal is enormous. Someone who feels great at the end of a month off substances is probably suffused with pride at his self-control and is experiencing adjusted levels of all kinds of hormones, neurotransmitters, peptides, enzymes, and so on; such a person is not necessarily free of either his alcoholism or his depression. Someone who is depressed at the end of a month off substances may be depressed for life-related reasons that reflect neither the emotional state that first led him into substance abuse nor an underlying emotional state now laid bare. The notion that someone can be restored to a condition of purity, this idea that substances mask an abuser’s true self, is perfectly ludicrous. Furthermore, withdrawal-related mood problems may make their first appearance only after a sober month or two. It takes many months for the body to achieve optimal recovery from long-term substance abuse; some brain alteration “appears to be permanent,” according to Kleber, and some has a life of at least a year or two. Positron-emission tomography (PET) scans show the effects of various substances of abuse on the brain, and they show limited recovery even at the three-month point. There are persisting lesions, and chronic abusers of substances often suffer permanent memory damage.
If it is sadistic to begin by taking depressed substance abusers off their substances, then does it make sense to begin by giving them medication? The use of antidepressants on depressed alcoholics will cause some alleviation of their desire for drink if depression is a primary motive for their alcoholism. This mode of testing—to begin by alleviating the depression—is more generous than the stripping away of substances to reveal a person with or without a “real depression.” Antidepressant treatment is undeniably useful in reducing substance abuse; recent studies have shown th
at putting alcoholics on SSRIs increases the chances that they will be able to come off alcohol. Clearly, depression can be significantly ameliorated with psychodynamic therapy, or just with attention—and the close attention paid to people who participate in studies can have a beneficial effect on substance use quite apart from the protocol of the study. Depressed alcoholics tend to be terribly isolated, and interrupting that isolation often alleviates some depressive symptoms.
“There’s a certain judgmental quality in trying to get technical about what illness is primary and what is secondary, trying to apportion blame to self-indulgence or mental illness,” says Elinore McCance-Katz of Albert Einstein College of Medicine. “As someone who treats people with addiction problems and mental health problems, however, I do want to know because it may be predictive of how they’re going to do in the future; it’s going to be helpful to me in terms of how I educate and work with them; it’s going to be helpful to me in terms of what medications I may treat them with and for how long. But the bottom line is that if they have both disorders, both disorders have to be treated.” It is sometimes the case that self-medicators are using substances to control agitated depression that might, unchecked, include suicidal wishes or acts. If you get such a person off the alcohol without making plans to control the depression in some better way, you run a severe risk of creating a suicide. “When depression is not diagnosed because of the lack of abstinence,” David McDowell of Columbia says, “maintaining abstinence may hinge upon treating the depression.” In other words, if you’re depressed, you may not be able to cope with the stress of detoxifying.
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