At some point, however, carrying on is a mistake. If an effort is never likely to succeed, cold-eyed objective assessment becomes necessary. Dozens of studies show that low mood makes people more realistic, a phenomenon called depressive realism.91 People generally are unjustifiably optimistic.92 When asked to press a button to control a light that flashes at random times, most subjects think their presses control the flashes. Depressed subjects, by contrast, soon recognize their helplessness. Depressive realism has been documented in many cultures.93 Using sad stories or films to induce low mood shifts people’s assessments of themselves and the future toward greater accuracy,94,95,96 although the effect may be smaller than once thought.97
When a major life goal is slipping away despite major efforts, low mood dispels optimistic illusions and promotes objective consideration of alternatives. The shift is often painful. I have talked with many patients who thought that their marriages could recover, until a moment when suddenly all hope fell away, as if their rose-colored lenses had suddenly gone dark. However, the lenses of depression are not just gray; they distort reality so people can’t see opportunities that others find obvious. Some unemployed people believe that they will never get another job. Some recently divorced people believe that they are inherently unlovable. Frustrated researchers may believe that their careers are over. What gives?
Pessimism prevents hasty moves. If bad stretches in marriages, jobs, or even writing projects quickly aroused optimism about alternatives, we would move on quickly, oblivious to the costs of starting fresh. Negative views of the self and the future delay big changes, giving time for the original enterprise to bounce back. Sometimes it is best to pull up anchor and move to a different fishing spot, but extra consideration and hesitation are worthwhile if waves or weather make moving risky. The costs and risks of moving to a new city, job, or marriage are larger. I suspect that persistence in failing big life enterprises and accompanying low mood are proportional to the costs and risks of finding something better. But so far as I know, the idea has not been tested.
Finally, as we prepare to shift focus from ordinary low mood to mood disorders, it is worth asking why low mood feels so awful. Why doesn’t the system respond to failing efforts by assessing the alternatives objectively and shifting to the next best one at the right time, without self-doubt, rumination, and psychic pain? Multiple explanations contribute, but I think the main one is the same as the explanation for why physical pain hurts. The suffering that accompanies nausea, vomiting, diarrhea, cough, fever, fatigue, pain, anxiety, and low mood motivates escape from a current bad situation and avoidance of future similar situations. Individuals who do not experience physical pain accumulate injuries and usually die by early adulthood. People who don’t feel bad when pursuing unreachable goals spend their lives in contented useless efforts. More low mood might help their genes, but a clinic to boost low mood would be about as popular as a clinic to help people feel more anxious.
Solved?
While attributing specific functions to specific mood states is a mistake, the capacity for mood can be said to have a general function: mood reallocates investments of time, effort, resources, and risk taking to maximize Darwinian fitness in situations of varying propitiousness. High and low moods adjust cognition and behavior to cope with propitious and unpropitious situations.
This global summary makes a large tacit assumption: that mood is one thing. It certainly seems like one thing. We have a word for it, and most people readily recognize descriptions of low and high mood. But do the various parts of low and high mood always come together in consistent packages? Do enthusiasm, risk taking, fast thinking, and optimism always arise in synchrony? Does low self-esteem always come along with pessimism, fearfulness, and low energy?
The different aspects of low mood arise together in the same way as the different symptoms of a cold. They are closely associated but in patterns that differ depending on the specifics of the problem. Matthew Keller took on the risky project of looking to see if different kinds of problems aroused different depression symptoms. Three different studies confirmed his hypothesis. In particular, loss of a partner aroused crying, emotional pain, and a desire for social support, while a failing effort caused pessimism, fatigue, and lack of ability to experience pleasure.98 Another former student, Eiko Fried, took this to the next level with a series of studies showing that the common practice of measuring depression severity by summing up the number and intensity of symptoms tosses out the most interesting and important variations. Analyzing individual symptoms may provide data that help demonstrate the effectiveness of antidepressant drugs and help find the brain mechanisms that go awry in serious depression.99
Relieving Mental Pain
Finally, a caution about a common but dangerous bit of illogic. On learning that low mood can be useful, some people conclude that it therefore should not be treated. This mistake is like the one that arose when anesthesia was first invented: some doctors refused to use it, even during surgery, because, they said, pain is normal. We must not let new understanding of the utility of low mood interfere with our efforts to relieve mental pain.
People come for treatment because they are suffering. Whether pain is physical or mental, finding and eliminating the cause provides the best solution. Sometimes low mood should be respected as normal and useful to help adjust a person’s motivation and life directions. However, often the situation can’t be changed. The loss of a friend, continuing abuse, inability to get a job, trying every night to help a child get off drugs, finding no relief from chronic pain—those are good reasons, but the resulting bad feelings are harmful even if they are normal. In other situations, low mood can be normal and useful for a person’s genes but harmful for the person. Sometimes it is normal but useless in the specific instance because of the Smoke Detector Principle. Sometimes it is normal but useless because we live in social environments so different from those we evolved in. And sometimes low mood is caused by abnormalities in the mood regulation system. Considering all the possibilities allows clinicians and patients to take the same medical approach to low mood that they would for physical pain. Try to find the cause and fix it, but always do what you can to relieve suffering.
CHAPTER 7
BAD FEELINGS FOR NO GOOD REASON: WHEN THE MOODOSTAT FAILS
Sadness is to depression what normal growth is to cancer.
—Lewis Wolpert, Malignant Sadness: The Anatomy of Depression1
If any could desire what he is incapable of possessing, despair must be his eternal lot.
—William Blake, “There Is No Natural Religion,” 1788
Ordinary low mood is like the pain caused by a broken leg. Abnormal depression is like chronic pain caused by a defective pain regulation mechanism. Mania is like an engine without a governor. Mood disorders result when the moodostat fails.
I had just met my new patient, a professor in his early sixties. He sat up in his hospital bed, looked out the window, and spoke painfully slowly. “It looks like the smoke is clearing.”
“What smoke is that?” I asked. He replied, “It’s all gone now, isn’t it, the whole city, all burned. But you can still smell it.”
There had been no fire, the city was fine, and no one else could smell smoke. He went on slowly, “I would help, but I have nothing now. I can’t pay for being here. I should leave. I’ll probably have to go to prison.”
His wife spoke up. “He has been talking like this for weeks, but no matter how many times I tell him that we have a retirement account, he keeps saying that all our money is gone and it doesn’t matter because he will die soon.” His psychotic depression gave him delusions of poverty, olfactory hallucinations, and visions of imaginary catastrophes. He got better, but it took several weeks of electroconvulsive therapy.
The police are more familiar with mania. I was on call the evening they were called to a fine dining restaurant because a woman in her early thirties was gyrating unstead
ily on a tabletop, taking off her clothes, and singing garbled ditties at the top of her voice. She said she was the dancer for the evening’s entertainment, but that fancy boring restaurant never scheduled entertainment. She started yelling and fighting as the police took her down from the table. In the emergency room, she talked a mile a minute, shouting incoherent phrases about winning a television dance contest and wanting to give a preview for her fans. She was not drunk or on drugs. A review of her hospital record showed five previous admissions for manic episodes. A friend said she had stopped her medications two weeks previously “to prepare for the dance contest.”
There is nothing normal or useful about psychotic depression or mania. Both are serious diseases that result from broken mood regulation mechanisms. Discovering why those mechanisms fail in some individuals is a huge, well-funded enterprise that is making slow progress. Its accomplishments and limitations were on display at the mood disorders conference I attended at a posh resort hotel, where three hundred psychiatrists heard elegant talks summarizing the latest research findings.
The meeting opened with reports about depression prevalence so appalling it was hard to know whether to get motivated or get out of the room. On any given day, 350 million people suffer from a mood disorder that makes them miserable, unable to work, and, all too often, unable to go on living.2 In the United States alone, depression costs the economy $210 billion, about three times as much as all food supplement programs. A powerful editorial in Nature with the title “If Depression Were Cancer” noted that the $400 million the US National Institutes of Health invests each year in depression research is less than 10 percent of the amount allocated to cancer research.3,4 Mood disorders pose a gigantic public health crisis that requires urgent efforts to find the causes and better treatments.
The experts at the conference summarized the results of hundreds of studies about how the brain influences mood and how drugs influence the brain. The science was spectacular, but the takeaway message was, in a word, depressing. Despite the wonderful research, no specific brain or genetic abnormality that causes depression has been found. Studies of treatment were equally sophisticated but only a bit more optimistic. Most patients get some benefit, but many are “treatment resistant” or experience intolerable side effects. Only a minority of patients gets enduring complete relief.
Some new findings were surprising and solid advances. For depression that is a part of bipolar disorder, it is now clear that the usual antidepressants don’t work but other drugs do. In other good news, some new antidepressants may have fewer sexual side effects than older drugs. Overall, the conference demonstrated the amazing progress in understanding the brain mechanisms that influence mood and the slow progress in finding causes and better treatments. The participants came away better prepared to provide optimal treatment for their patients.
During one particularly technical talk just before lunch, my mind drifted to the Sherlock Holmes story in which the crucial clue was a dog that didn’t bark in the night. Why did my mind drift there? Was something missing?
At lunch I asked other psychiatrists why they thought the capacity for low mood existed at all. Their answers were miles away from biology. “Depression is what makes us human.” “Depression is essential for relationships to be meaningful.” “I never even thought of that. Does there have to be a reason?” “Depression is a brain disorder, there is nothing useful about it.”
When I suggested that there must be some reason evolution shaped a capacity for mood, their comments ranged from the shocking to the perplexing. “Hasn’t evolution been disproven?” “I think it is learning and culture, not biology.” “That sounds like one of those just-so stories.” “Mood is caused by chemical imbalances, not evolution.” Hearing those comments from friendly, well-educated doctors forced me to recognize that psychiatrists were not even thinking about the utility of mood, much less its evolutionary origins.
By the end of the day, I felt hopeless, frustrated, inadequate, lonely, anxious, fatigued, and pessimistic. My brain had changed. Was it the spontaneous onset of an episode of depression? Did a day with no exercise and too high a ratio of cookies to sunshine create a chemical imbalance? Or were my symptoms caused by being forced to recognize that my years of effort to get psychiatrists to think about the evolution of mood had come to nothing?
If my symptoms had persisted for two weeks, I would have qualified for a diagnosis of major depression. Fortunately, on the second day of the conference I sat next to a friend, Cynthia Stonnington, who leads the psychiatry department at the Mayo Clinic in Arizona. Her whispers and timely arched eyebrows suggested that I was not the only one who noticed that something was missing. We skipped the drug company–sponsored lunch and found a sunny patio, where we tried to figure out what bothered us about the morning’s presentations.
We soon realized that the experts had focused exclusively on what is wrong with some individuals that make them vulnerable to depression. They never mentioned how life situations influence mood in everyone. They had mentioned “stress” in the abstract, but no one talked about patients trapped in abusive marriages or dead-end jobs. No one described treating a parent who feels hopeless, exhausted, fearful, and depressed because of the inability to help a psychotic teenage child who screams and threatens mayhem at random times in the night. No one mentioned the despair of an addict begging for a tenth try at detox or a patient who has just heard that a cancer has recurred.
The focus had been entirely on characteristics of the person. Life situations had been ignored. I recalled the first principle of social psychology, laid out by the field’s founder, Kurt Lewin, in a simple formula: B = f(P, E): Behavior is a function of a Person in his or her Environment. Characteristics of a person—things like genes and personality—stay the same.5 Environments change. Both must be considered together for a full explanation.
As noted in the chapter about diagnosis, humans are prone to the fundamental attribution error, blaming characteristics of individuals and neglecting the effects of environments and situations.6,7 Once you recognize it, you can see that the error is everywhere. If someone takes a cup of coffee from a shared pot without contributing to the donations jar, it is easy to label the person “dishonest” without considering that the person might have put in five dollars yesterday. If an acquaintance walks by without greeting you, it is easy to assume that the person is an oblivious jerk, although the person might be on the way to chemotherapy. If someone is downcast, it is easy to attribute the state to a pessimistic personality. In a conversation with a colleague with a private practice about psychotherapists who were having affairs, I suggested that it might be because people especially interested in sex might be likely to become therapists. He replied, “Therapists are no different from anyone else. It is having a private office. It makes having affairs so easy, there is no resisting. Get a private office, you will see.”
A Scholar’s Depression
The morning after the conference, I was dejectedly browsing The Atlantic, where I came across an article by the famous child psychologist Alison Gopnik entitled “How an 18th-Century Philosopher Helped Solve My Midlife Crisis.”8 Like many a “midlife crisis,” hers was actually a classic episode of depression. Her symptoms were set off by the end of her twenty-year marriage, her children leaving home, and moving to lonely new lodgings. Soon she was convinced that she would never again accomplish anything significant. Her symptoms seemed to justify that conclusion: she was spending hours each day crying and could not work. She knew she needed help, but she was not a compliant patient. “My doctors prescribed Prozac, yoga, and meditation. I hated Prozac. I was terrible at yoga. But meditation seemed to help, and it was interesting, at least. In fact, researching meditation seemed to help as much as actually doing it. Where did it come from? Why did it work?”
Being an academic, she turned to David Hume, the eighteenth-century Scottish philosopher who is remembered for his penetrating insights i
nto the subjectivity of human experience, the impossibility of ever satisfying our desires, and his good humor despite all. His was not, however, a carefree life. At age twenty-three he fell apart, convinced, like Gopnik, that he would never again accomplish anything. However, in the subsequent three years, he wrote A Treatise of Human Nature, now recognized as one of the great books in Western philosophy—an inspiring role model for a depressed ambitious academic three centuries later.9
As she read Hume, Gopnik thought she detected a whiff of Buddhism in his attitudes toward desire. She followed the scent like the bloodhound scholar she is. I was fascinated because Buddhist ideas have so much to say about how desire causes depression.10,11,12 Did anyone in Europe even know about Buddhism in the early 1700s? Gopnik discovered a Jesuit missionary, Ippolito Desideri, who had studied Buddhism at a monastery in Tibet from 1716 to 1721. He completed his book on the topic in 1728, a year after returning to Europe. The church did not allow publication of books about competing religions, so Hume probably never saw a copy. However, Gopnik discovered a remarkable coincidence. Desideri had spent time at the monastery in La Flèche, a small town south of Paris. David Hume lived in that same town eight years later and talked with the monks there as he was writing his Treatise.
Gopnik soon met a man who shared her passion for investigating this mystery and fell in love with him. Her depression vanished. Was this a spontaneous remission? Or was it new love, a new social network, new career opportunities, and perhaps a new recognition that desires are illusions that can never be satisfied?
Her account was deeply moving. She described without flinching how her terrible depression had been set off by major life enterprises coming to dead ends. She did not, like some other famous authors, minimize and conceal the roles of personal conflicts and losses by attributing her symptoms to the spontaneous onset of a brain disease. Instead, she went into darkness and came out with new understanding and purpose.
Good Reasons for Bad Feelings Page 14
