Manufacturing depression (19 page)

The solution to this problem is obvious in retrospect: to swallow psychoanalysis and all the psychotherapies it spawned, to turn them into a specialized branch of medicine, the depression doctors had to turn away from biography and back to biology. They eventually had to declare that the mind does not exist except as a property of the brain. Which meant that doctors could have it both ways: dominion over our discontents
and
a claim to scientific knowledge about them. Only then would
das Unbehagen
be folded into major depressive disorder, the disease at which my doctors, funded by the federal government and employed by the most prestigious university in the country, could aim their magic bullets.

The most fun part of my clinical trial came on my fifth visit. By then I’d been dutifully taking my pills—five glistening amber gelcaps a day—for six weeks. I’d been asked the same questions, filled out the same forms, gotten my parking ticket stamped by the same receptionist four times. I knew the combination to the lock on the men’s room door by heart.

I’d also been told that I was improving. And maybe I was feeling a little better, a circumstance that I would normally have attributed to some minor successes or to the relative ease of life in the summer or to the random nature of emotional life or to increasing maturity and wisdom or to the fact that I was finally getting my book off the ground or indeed to nearly anything other than a daily dose of three grams of omega-3 fatty acids.

Or maybe I wouldn’t have ventured any explanation at all. After a while, you just start to think that depression and its remission just can’t be explained, not fully anyway. You look at your immediate circumstances and see if there is one you can change, some trouble to manage or irritant to eliminate, some loss to mourn. You take the steps, make the change, spill the tears or voice the rage, and if that doesn’t make you feel better, if you still wake up nauseated and afraid and spend your day that way, you contemplate other measures, therapy maybe or some distraction or maybe even psychiatric
drugs, but all the time you are doing this you are also just waiting for it to pass like bad weather. Maybe you regret that you are built this way, the same way that you regret that your musical talent is limited, that you are losing your hair, that you drive away some people and attract others, and maybe you stand in alternating awe and resentment at just how narrowly the margins are drawn around what you can change, and you take all this as a reason to develop your humility before the indignities really catch up with you. But mostly you can’t really know what made life turn ugly any more than Job could.

Because you can’t live an experimental life and a control life at the same time. You just take your best guess at what causes what and try to live accordingly. And by the time you’re fifty, you like to think that the few things of which you are certain—beyond, of course, the increasing impossibility of being certain about anything—are also true, that you haven’t just snared yourself in some unjustified faith, some ideology, held against science and, increasingly, common sense, that posits that consciousness has to be more than the sum of its parts, that history is important, that self-examination is, if not a cure, then surely more than a mere consolation. So when the doctors start not only to tell you that they know what is wrong with you better than you do, but also to show you the proof that you are actually getting better in exactly the way they predicted, when they add up their numbers and the survey says you have improved, when their certainty about where your depression resides and what ought to be done about it has the ring of scientific truth, you really have to wonder about the conclusions you’ve arrived at. Maybe you have to face the possibility that you are like Schopenhauer, in William James’s version, barking at the moon. Maybe you have to choose between being right about the ways of the world and being happier.

But I couldn’t decide. I kept taking my pills, but I never totally got on board with the doctors, no matter what the numbers said. This was partly my native orneriness, a pigheaded clinging to my
worldview over theirs. But it seemed to me there was a big problem even within their world. It was those tests, the ones they were using to measure my depression and to tell me that I was improving.

In addition to the HAM-D and a questionnaire filled out by the doctor about constipation and fevers and other possible side effects, I was completing a battery of forms on every visit—the Q-LES-Q, which rated my life enjoyment and satisfaction, the Quick Inventory of Depressive Symptomatology (QIDS), which asked me to circle a number on an item like this one:

View of Myself

0. I see myself as equally worthwhile and deserving as other people

1. I am more self-blaming than usual

2. I largely believe that I cause problems for others

3. I think almost constantly about major and minor defects in myself

And the Ryff Well-Being Scale, which measured my emotional state by asking me to rate on a scale of one to six how much I agreed with statements like “For me, life has been a continuous process of learning, changing, and growth” or “My daily activities often seem trivial and unimportant.”

What was bothering me about the tests wasn’t only that they seemed inane and puny compared to what they were trying to measure. It was also their logic—or their lack of it. It’s the burden the depression doctors took on when they revived Kraepelin: you have to assume that the patient is depressed in order for his feelings to be considered symptoms, but the symptoms are the only evidence of the depression. Wondering if “life is empty” or “if it’s worth living,” may be, as the QIDS insists it is, a thought of suicide or death—but only if you’re depressed. Otherwise, it’s just a common, if disturbing, thought. To logicians, this is known as assuming your conclusion as your premise, or begging the question.

The depression doctors know about this problem. Even the best doctors are skeptical of the ability of these tests to parse inner life. On an early visit, I complained to Papakostas about having to choose from one of four options, or worse, a yes or no, to describe what I thought were complex, sometimes even incomprehensible experiences. “I’m sorry to seem dense about this,” I said, “but it’s just not how I usually think about things.”

Papakostas was reassuring. “You know, this question condenses a lot of areas of life into just a number. It doesn’t work well,” he said. “Some questions we just don’t like.”

Since condensing life into a number seemed to be more or less exactly what we were supposed to be doing here, and since the results were the basis of my diagnosis and the claim that the drugs were treating it (not to mention of the whole antidepressant industry) this seemed like a startling admission—sort of like a priest telling me from his side of the confessional that he’s not so crazy about this venial sins business. And later, when we got to the question about my naps (I had snoozed four times for thirty minutes or more that particular week) and Papakostas said, “See, some of the questions are really nice in terms of being objective,” it seemed like the right time to speak up, to remind him that when doctors and drug companies tell people that drugs cure the disease of depression, they don’t add, “But by the way, the tests that allow us to say so are really bullshit.”

But I didn’t protest. Quite the opposite, I sympathized. “I suppose it would be easier if there were biochemical markers,” I said. “Otherwise, you’re just stuck with language.”

And even when Papakostas said, “Hey, we’re psychiatrists. Language is good,” as if this entire enterprise weren’t an attempt to avoid the uncertainties of language, I still didn’t speak up.

Maybe it was the abrupt change from Papakostas to Dording, or just the fact that I didn’t like her so well, but by the time of my fifth visit, I was over my attack of Stockholm syndrome and ready to stop giving the depression doctors a free ride.

My chance came when Dording, administering the HAM-D, asked (as Papakostas had already asked four times), “In the past two weeks, have you been feeling excessively self-critical?” There’s no doubt that I am a very self-critical person. If there’s a problem somewhere in my vicinity, if someone I care about is unhappy, I assume that it’s at least partly my fault. I don’t particularly enjoy this about myself. But is it excessive? Or is it what makes me caring, responsible for myself, a conscientious citizen, an effective therapist, a decent writer? And to what or whom am I supposed to compare my self-criticism to determine its excessiveness? To another depressed patient? To the way I wish I were or think I ought to be? So I asked.

“If there’s a comparator implied, it’s always to when you’re not depressed,” she answered crisply, as if no one had ever asked such a silly question, as if it was as plain as the nose on my depressed face. She seemed so sure of herself that I began to wonder if her answer really was as circular as it sounded, if it meant more than saying self-criticism is a problem when it’s a problem and not when it’s not, and if it wasn’t a call, if ever there was one, for some self-criticism on the psychiatrists’ part. It seemed like a denial of the basic assumption of this whole clinical trial—that they were the experts about my mental health, that depression isn’t something I’m equipped to detect in myself, because if I was, I’d have been in the other study, the one for the minor depression I thought I had in the first place. I began to wonder if this was really the old Kraepelinian problem or if all this wondering and my resulting inability to blurt out a yes or a no was just another example of my excessive self-criticism.

But I was staying on my side that day, on the side of language and meaning. So I asked her if she really thought self-criticism is pathological.

“Pathological?” she asked, as if she’d never heard the word. “I don’t know if I’d call it pathological.”

“Symptomatic, then,” I offered.

“Well, it’s certainly not optimal.”

“Optimal,” I said, deploying the therapist’s repeat-and-pause tactic, hoping she would tell me exactly how much self-criticism is optimal and how she knew.

“Certainly not optimal.” She did her own pause.

“But being self-critical is something that helps people achieve, isn’t it?”

“Sometimes yes, sometimes no. I don’t think being excessively self-critical is ever a great thing. No.” She started turning pages again, trying to resume the interview.

But I didn’t want to let it drop. I went back to the question I should have asked Papakostas a long time before. The numbers aside, I wanted to know, just between us pros, did I really seem depressed to her?
Majorly
depressed? I couldn’t quite get myself to ask it this way, so instead I asked her what she thought the difference was between minor depression and dysthymia, a DSM-IV mood disorder that, at least until minor depression makes it into the diagnostic big leagues, comes closest to capturing my melancholy.

“You’re getting into close quarters here,” she said.

I think she really meant to say that I was getting into fine diagnostic distinctions here. In another world, one in which psychiatrists actually liked language, we might have explored this unintended revelation of discomfort at my intrusion into her professional space. In this world, however, there was no room for discussing such slips. But that doesn’t mean she didn’t make one, and as she explained that “dysthymia is more low-level chronic; minor depression may or may not be long term, but it’s typically less criteria than major depression,” and then closed her notebook to walk me out, I was feeling vindicated.

And, of course, guilty.

I’m not sure what it says about me that my little quarrel with Dording was fun. But I’m not the first person to make this kind of mischief, to enter the belly of the beast and give it a little heartburn.
I’ve already told you about David Rosenhan and his seven friends who, three decades before my Mass General caper, infiltrated mental hospitals across the country. Their biggest mischief, of course, was placing their write-up in
Science,
but there were other little pleasures along the way, like catching the attendants rousting the patients in the morning by screaming, “
Come on, you motherfuckers
, out of bed!” or keeping track of the time doctors actually spent with patients and determining that it amounted to an average of 6.8 minutes per day. My personal favorite moment in “On Being Sane in Insane Places” comes when “a nurse unbuttoned her uniform to adjust her brassiere in the presence of an entire ward of viewing men. One did not have the sense that she was being seductive. Rather, she didn’t notice us.” That must have been fun to watch while jotting in a notebook what the unsuspecting nurse thought was just another manifestation of your insanity.

But Rosenhan wasn’t the first guy to pull this kind of stunt either, and his results and mine put together can’t hold a candle to those of the man who was. To be fair to us, even if we’d had the moxie, neither Rosenhan nor I could possibly have done what Joseph Wortis did in 1934. We were born too late to show up at Berggasse 19 in Vienna, lie down on the most famous couch in the world, and prank Sigmund Freud.

That’s not how Wortis, who was born in Brooklyn in 1906, described what he did. His account starts with the suicide of a wealthy Harvard art historian, Kingsley Porter, who threw himself off a cliff in Ireland in 1933 when his lover, Alan Campbell, rejected him. Porter was married and, Wortis recalled, “
the bereaved widow
went to Havelock Ellis, who was a friend of Kingsley Porter, saying she wanted to use her wealth to do something for the cause of homosexuality.” Ellis, a British psychologist, was famous for his matter-of-fact research on human sexuality, which included not only the deviance studied by Richard von Krafft-Ebing in his 1886
Psychopathia Sexualis
or the polymorphous perversity Freud was so interested in, but also your normal day-to-day man/woman sex.