The Noonday Demon

by Solomon, Andrew

  None of this is discouraging to Rogers. He has forced the closing of hospitals by using the carrot-and-stick approach, ingratiating himself with highly placed government officials and also suing them in class action suits that cite the Americans with Disabilities Act. Rogers has modeled his efforts on Cesar Chavez’s United Farm Workers movement; he has, in effect, attempted to unionize the mentally ill, giving that extremely diffuse body of disenfranchised people a collective voice. In the 1950s, during the heyday of institutionalization, about fifteen thousand patients were warehoused in facilities around Philadelphia. Rogers has closed down two of these, and Norristown, the last one standing, numbers its patients in the hundreds. The primary opposition to Rogers’s class action lawsuits has come from the unionized workers (mostly in maintenance) at the hospitals. The closing of the hospitals has been achieved by moving people out as they achieve sufficient health to enter long-term community-care facilities. “We close them down gradually and through attrition,” Rogers says.

  If major hospitals have been sites of abuse, the chances are that community-based programs will become sites of comparable or worse abuse. The checks and balances within these programs are hard to maintain. Large numbers of officials and mental health workers rule over tiny principalities of care, each with its own internal workings. How can the operations of such centers be fully visible to those who in principle oversee them, people who usually come through only for occasional, quick visits? Is it possible to sustain high standards of vigilance when authority has undergone devolution?

  The question of what constitutes mental illness and who should be treated rides very much on the back of public perceptions about sanity. There is such a thing as sanity and there is such a thing as madness, and the difference is both categorical and dimensional, of kind and of degree. Ultimately there is a politics of what one asks of one’s own brain and of the brains of others. There is nothing wrong with this politics. It is an essential part of our self-definition, a cornerstone of the social order. It is wrong to spot collusion behind it; unless one believes that consensus on complex subjects can emerge uncorrupted, one must work with that curious mix of personal opinion and public history that determines all our ways as social animals. The problem is not so much the politics of depression as our failure to recognize that there is a politics of depression. There is no freedom from this politics. For those without money there is less freedom than for those who have the prerogatives of financial wherewithal; the politics of depression echoes the rest of life. For those whose disease is mild there is more freedom than for those who are vastly ill; and this is probably as it should be. In the late 1970s, Thomas Szasz, most famous for his defense of the right to suicide, put forward arguments against the use of medications, claiming that there was no natural law according to which the psychiatrist was entitled to intervene in the personal life of the patient with prescriptions. It’s interesting to learn that one has a right to be depressed. It’s just as well to know that under the right rational circumstances one can decide not to take medication. Szasz, however, exceeded his mandate and enabled the belief among his patients that they were being powerfully self-realizing in giving up their medications. Is it a political act to do this? Some of Szasz’s patients believed that it was. Our definitions of “responsible behavior” from psychiatrists are also political. As a society, we take exception to Szasz’s viewpoint, and he had to pay $650,000 to the widow of one of his patients after that patient killed himself in a particularly brutal and distressing way.

  Is it more important to protect someone from his death or to allow him the civil liberty to avoid treatment? The problem has been much debated. A particularly disturbing recent op-ed article in the New York Times, written by a psychiatrist at a conservative think tank in Washington in response to the new Surgeon General’s Report on Mental Health, proposed that helping the mildly ill would deprive the seriously ill, as though mental health care were a finite mineral resource. She stated categorically that it was not possible to get unsupervised people to take their medications and proposed that those mentally ill (“with debilitating illnesses like schizophrenia and bipolar disorder”) who end up in prison probably need to be there. At the same time, she proposed that the 20 percent of the U.S. citizenry who carry the burden of some kind of mental illness (including, apparently, all those who have major depression) in many instances do not need therapy and therefore should not get it. The key word here is need—because the question of need turns on quality of life rather than on existence of life. It is true that many people can stay alive with crippling depression, but they can also stay alive, for example, with no teeth. That one could manage okay on yogurt and bananas for the rest of one’s life is not a reason to leave modern people toothless. A person can also live with a clubfoot, but these days it’s not unusual to take measures to reconstruct one. The argument in effect comes down to the same one that is heard over and over again from outside the world of mental illness, which is that the only people who must be treated are those who pose an immediate expense or threat to others.

  Doctors, especially those who are not attached to teaching hospitals, often learn about advances in medicine from pharmaceutical salesmen. This is a mixed blessing. It ensures that doctors do get continuing education, and that they learn about the merits of new products as those products become available. It is not an adequate form of continuing education. The industry focuses on drugs over other therapies. “This has helped to prejudice us toward medications,” says Elliot Valenstein, professor emeritus of psychology and neuroscience at the University of Michigan. “The medications are excellent and we are grateful to the companies for making them, but it’s a shame that the educational process isn’t balanced better.” Further, because industry funds many of the largest and most comprehensive studies, there are better studies of patentable substances than there are of nonpatentable ones such as Saint-John’s-wort; there are more studies of new drug therapies than of other new treatments such as EMDR (eye movement desensitization and reprocessing). We have no national programs sufficient to balance against the work sponsored by the pharmaceutical companies. In a recent article in The Lancet, a leading medical journal, Professor Jonathan Rees proposed a complete reconception of the patent process to put a profit motive into therapies that are currently nonpatentable, including what he calls “genomics and informatics.” For the time being, however, little financial incentive exists in this area.

  Members of the pharmaceutical industry know that in the free marketplace the best cures are likely to be the most successful. Their pursuit of good treatments is of course entwined with their pursuit of lucre; but I believe, contrary to some grandstanding politicians, that pharmaceutical executives are less wantonly exploitative of their society than are people in most other industries. Many of the discoveries that distinguish modern medicine have been possible only because of the huge research and development programs of the pharmaceutical trade, which spends about seven times as much on developing new products as do other industries. These programs are predicated on profit; but it is perhaps nobler to make a profit by inventing cures for the ill than by inventing powerful armaments or producing pandering magazines. “It had to be in industry,” said David Chow, one of the three scientists at Eli Lilly who invented Prozac. William Potter, also now at Lilly after departing from the NIMH, said, “It was the lab scientists here who drove the development of Prozac. The important research is funded by industry. Society has made that choice and given us this system of great progress.” I tremble to think where I would be if industry had not developed the medications that have saved my life.

  For all the good that the industry has done, however, it is an industry, afflicted with all the bizarre trappings of modern capitalism. I have attended any number of educational sessions staged by companies torn between research and material seduction. At one of these, held at the Baltimore Aquarium, a choice was offered between a lecture on “Neurobiology and Treatment of Bipolar Disorder” and
a “Stingray Feeding and Presentation for Special Guests and Their Families.” I eventually attended the U.S. launch of one of the major antidepressants, a product that was quickly to capture a significant market share. Though the launch operated under the constraints of a tight regulatory body—the Food and Drug Administration (FDA)—which governed what could be said about the product, it was something of a circus at which emotions were tuned with a deliberateness that no flying Wallendas could ever achieve. It was, further, an incongruously wild fiesta, replete with disco parties, barbecues, and hatching romances. It was the epitome of corporate America high on its commodities. This is how salesmen for any product are motivated to sell in the intensely competitive promotional U.S. marketplace, and the glitz was, I think, harmless; but it was somewhat anomalous for the promotion of a product for people suffering from a terrible affliction.

  For the keynote addresses, the salespeople assembled in a hulking conference center. The size of the audience—more than two thousand people—was overwhelming. When we all were seated, there rose out of the stage, like the cats in Cats, an entire orchestra, playing “Forget Your Troubles, C’mon Get Happy” and then Tears for Fears’s “Everybody Wants to Rule the World.” Against this backdrop, a Wizard of Oz voice welcomed us to the launch of a fantastic new product. Gigantic photos of the Grand Canyon and a sylvan stream were projected onto twenty-foot screens, and the lights went up to reveal a set built to resemble a construction site. The orchestra began playing selections from Pink Floyd’s The Wall. A wall of gigantic bricks slowly rose at the back of the stage, and on it the names of competitive products appeared. While a chorus of kick dancers wearing mining helmets and carrying pickaxes performed athletic contortions on an electronically controlled scaffold, a rainbow of lasers in the form of the product logo shot from a stagecraft spaceship at the back of the room and knocked out the other antidepressants. The dancers kicked up their workboots and did an incongruous Irish jig as the bricks, apparently made of stage plaster, crashed down in thuds of dust. The head of the sales force stepped over the ruins to crow gleefully as numbers appeared on a screen; he enthused about future profits as though he had just won on Family Feud.

  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 nex
t. 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?