Manufacturing depression (36 page)

The answer, of course, is that the therapist is supposed to do no such thing. If the symptoms are present, and if they are causing trouble for the patient, then it shouldn’t matter if the loved one is a close relative, a celebrity, or even a fictional character whose television
show has ended its run. In real life, however, it is hard to imagine that a clinician is going to count the days or consult the family tree as he decides who among the mourning is sick and who is only walking wounded. I haven’t polled my colleagues on this, but I think they do take actual circumstances into consideration when trying to understand and diagnose someone else’s misery. It seems nearly inhuman not to.

I confess that I do.

Not that that makes things any less confusing. Consider my patient Eliza. A couple of years ago, a sheriff called to tell her that her mother had been found in her apartment, dead from a drug overdose. That wasn’t the only momentous news Eliza received that day. Her mother had once, in a druggy fog, mentioned that it was possible that the man whom Eliza had always known as her father, the parent who remained when her mother was on her benders, who had terrified her and cared for her in equal measure, was very likely not her biological father. Eliza’s mother mentioned the other man’s name. Eliza tracked him down on the Internet, and he agreed to a DNA test, which, an e-mail on the day of her mother’s death informed her, was positive.

Eliza showed me a photo of her biological father, taken when she went to meet him. His daughters—four of them now, not three as they had once thought—descended a staircase in front of his large and lovely home. He stood on the landing, above this quartet of pretty blond women, strong and confident and protective. He told Eliza that day that he was terribly sorry that her mother had never informed him of Eliza’s existence, that he would of course have taken care of her, had he only known.

When she talks about her week with her new father, when she recalls her terror of her old father, when she describes her mother’s chaotic life and squalid death, and above all when she remembers the day that her entire history was rewritten, Eliza is often overwhelmed with grief and regret—and with a self-pity that she finds as contemptible as it is inescapable. She has, in other words, at least the
requisite five of the current symptoms (the DSM-IV has rearranged the DSM-III’s diagnostic menu a little), they cause her distress, and they have persisted well beyond two months from her bereavement. Nine out of ten doctors (or clerks) would agree that Eliza qualifies.

But is Eliza’s depression really best understood as an illness? Is this a valid way to think of her suffering?

These are exactly the questions that the DSM-III and its successors are designed to avoid. Looking to the symptom itself, and not to what lies behind it, means that it doesn’t matter how Eliza came by her depression any more than it matters if a person with lung cancer smoked three packs a day or never touched a cigarette in his life. There is no difference, except perhaps in degree, between my major depression and Eliza’s and that of someone whose suffering seems entirely unrelated to circumstances. They’re all the same disease, ready to be coded on the insurance form.

Here’s another confession: that is exactly what I did with Eliza—so that I could get paid for seeing her. I didn’t anguish over this decision, and I’ll bet her psychiatrist didn’t either when he billed the insurance company for her visits (which in turn meant that the costs would be covered). Certainly Eliza benefited from her diagnosis, but that’s probably more of a comment about how we define and fund health care than about her actual suffering. She could get the benefit of therapy without a diagnosis, but it’s not clear that her psychiatrist and I could get our benefits that way.

Which is the whole point of turning psychic suffering into mental illness and diagnosis into a bureaucratic function in the first place: to take these questions out of the therapists’ hands and so to eliminate the possibility of the professional embarrassments wrought by Rosenhan or Katz or gay people marching and demanding to be struck from the sick rolls. Erasing reaction, deleting neurosis, overlooking nature and cause, the DSM version of depression realizes its major goal: enhancing the reputation of psychiatry, consolidating its power, turning it into real medicine. Inner life—personal and political—remains important, if it is important at all, only as symptom,
only as the evidence that the diagnostic criteria are met, as the raw material for a disease the mental health industry has become expert at churning out.

This may be the most brilliant achievement of the DSM. By adopting and deploying a scientific rhetoric, it has not narrowed the patient pool at all. Instead, it has given increased authority to the pronouncements of people like me—so much so that state and federal governments have determined that insurers must pay for the treatment of depression in the same way they pay for any other illness—and at the same time have given us opportunity to apply the diagnostic criteria as broadly as possible, to turn everyday suffering into a disease. We may have given Blue Cross the “clarity and uniformity of terminology concerning mental diagnoses” that they wanted, but those diagnoses, and especially the diagnosis of depression, have been rendered by doctors for their own use. So everyone can be insane, only now insanity is a real illness, deserving of health care dollars.

This creates a perverse incentive to render diagnoses, which may have something to do with the ever-burgeoning statistics on the prevalence of depression. This in turn has led therapists to do what my Mass General doctors did with me—to tell more patients than they once would have that they are depressed, and to tell them why: because they have this symptom and that, and because those symptoms have lasted for more than two weeks. Which, of course, the patients are primed to hear because a friend has confided that they have been diagnosed in this fashion, or they saw a discussion of depression on
Oprah,
or because they overheard a conversation at the 7-Eleven. When people are more likely to think of themselves as depressed, to pay attention to certain feelings as symptoms, it’s only a matter of time before those statistics start to rocket skyward and before a doctor says, in a prominent, peer-reviewed medical journal, that
“depression in the Western world
will affect half the population during their lifetime.”

There are some other perversities that follow on the DSM revolution—notably, that insurance companies are increasingly insisting that treatment go a certain way, that if a patient is to have any therapy at all, it should be cognitive-behavioral therapy, which I’ll tell you about in chapter 13. But the biggest problem with the DSM-III approach to mental illness is that while it hinges on the elimination of theory—which is to say on the elimination of metaphysics, of any kind of preconceived notion of where our suffering comes from or what it means to who we are—it has silently substituted its own metaphysics.

Because there is a theory behind the DSM’s atheoretical approach. If your mental illness isn’t a function of history or culture or geography, if it doesn’t matter whether you got your five symptoms because you were abused and abandoned and then one day bereaved of everything that was familiar or because you show up one day at a clinical trial with a melancholy cultivated through fifty years of absorbing life’s quotidian blows, if it’s not a reaction or a neurosis, if there is nothing behind its symptoms and nothing of psychological or spiritual significance in them, if depression is not, in short, about your transactions with the universe, but only about whether or not you have the signs of the illness, then there is only one thing left for it to be: an internal dysfunction, as stupid and brutal and meaningless as diabetes or cancer. It’s inside you—not in your thoughts and aspirations and dreams, in your fulfillments and frustrations, in your terror or despair or uncomprehending recognition of the irreducible gap between your little life and the infinity of time, not in a flaw in your soul, but in the vast and complex apparatus that gives rise to those thoughts and feelings and apprehensions, and that could just as easily, so it would seem, give rise to others. It’s in your molecules. What matters, when it comes to depression, is matter. The rest is for the poets to worry about.

Toward the end of my second visit to Mass General, just before I got my pills, George Papakostas asked me how long it had been since I had felt good for any appreciable time.

“Good?” I asked him.

“Symptom free,” he said.

“For how long?” I asked.

“Thirty days,” he said. “Or more.”

I wanted to remind him that I was a writer, that I counted myself lucky to feel good from the beginning of a sentence to the period. I wanted to ask him if he had ever heard of betrayal, of disappointment, of mortality.

But after having spent nearly two hours cooperating with him, helping him to transmute my messy words into precise data, my inner world into bits as smooth and featureless as Chicken McNuggets, I somehow didn’t feel free to remind him that we hadn’t really agreed that I had symptoms. I’d submitted to his alchemy. I couldn’t just turn myself back into lead.

“I’m sorry,” I said. “But I have no idea what a month of feeling good would feel like.”

I’m sure this only confirmed his diagnosis.

But “thirty days” was ringing in my ears as I left his office with my brown bag full of pills. And much as I wanted to dismiss the
very possibility of that symptom-free month, chalk up the idea to a laughably circumscribed view of humankind, much as I wanted to cite the research about depressive realism and to point to Aristotle and Lincoln and the James brothers and other important sad sacks as evidence against the neurochemical reductionism that lay behind this whole enterprise, I had to admit something: thirty days of unbroken contentment, of peace of mind, of resilience and, yes, even of optimism, a month of bright light unfiltered by a black veil—that sounds pretty good. If that was what I’d been missing, if that’s what happens if you take the cure or have been lucky enough to elude the scourge in the first place, if health is happiness in month-long blocks, then suddenly the idea that unhappiness is a curable disease didn’t seem like such a bad one.

I ducked inside a restaurant. I wasn’t hungry, but I ordered a sandwich anyway. And a glass of water. I gulped down my six golden pills. I waited for my month to begin.

Was George Papakostas thinking of the placebo effect when he asked me that question? I don’t think so. But maybe he should have been.

Placebos trouble doctors. There’s too much magic in them and not enough science. They highlight a subject that most physicians would prefer to avoid: that they may not entirely deserve the power that they wield. The word itself, which is Latin for
I will please,
contains more than a hint of condescension, as if the doctor is merely tossing a pill at whiners, and as if the reason that the placebo effect persists is that people are too credulous (or perhaps too dumb) to get well by virtue of science alone.

So if it weren’t for methodological necessity, researchers would probably forget about the placebo effect. And the game is set up so they can almost do that. They certainly don’t really have to explore or explain or try to harness it, at least not in the laboratory.

In the clinic, however, the story is a little different. Practicing doctors use placebo effects all the time, on purpose. They generally don’t admit this—at least not to patients; that might spoil the ruse. But when a team of their colleagues at the National Institutes of Health asked 1,200 American internists and rheumatologists if they prescribed placebos, more than half ’fessed up. Usually, they said, they didn’t use sugar pills, but rather drugs that were pharmacologically active—over-the-counter analgesics and vitamins, and prescription antibiotics and sedatives—but had no reason to work for the patient’s complaint. They told the NIH researchers that they made the prescription simply for the sake of providing a treatment, any treatment. To patients, however, they merely explained that the drug was
“not typically used for your condition
, but might benefit you.”

Doctors could always furnish a sugar pill along with that explanation and thus avoid risks to patients (or, in the case of antibiotics, to the public health), but they are caught in a dilemma. Deception is necessary to the placebo effect (or so we think; no one has actually done that research) but unethical, and honesty is ethical but potentially ineffective. By prescribing a real drug, doctors steer between the rock and the hard place. When they tell their patients that a pharmacologically active drug might be of benefit, they are leaving out the part about how there is no particular reason why it should be, letting the implication of cause and effect hang in the air. They are also preserving their own plausible deniability—not to mention the dignity of all concerned. No one, it seems, wants to believe that something as unscientific (and as cheap) as hope could actually cure us.

The doctors in the NIH study said that they didn’t tell their patients just exactly how the Tylenol or vitamin B might make them feel. They probably didn’t have to—most of the patients treated this way are complaining of pain or fatigue or some other hard-to-specify condition, and they will know better than the doctor
what kind of relief they are looking for. But it is possible to specify how a placebo will affect its taker. Especially when it comes to psychoactive drugs, you can fool many of the people a great deal of the time. You can, for instance, give people fake alcohol (without, of course, telling them that it only tastes like the real thing) and put them in a crowd of socializing drinkers and watch them get “drunk.” You can give them fake morphine and hear them sigh in relief as their pain goes away. You can tell one group of subjects that caffeine will impede their coordination, another group that it will improve it, give both groups decaf, and observe as both groups behave accordingly.