Manufacturing depression (48 page)

But you would be wrong.

Because I’m sitting here with these pictures. I’m holding my brain in my hands. My brain on no drugs, not even caffeine, my brain concentrating here and bored there. I’m thinking about Daniel Amen telling me I have ADHD and how I’ve taken Adderall a few times, and how sharp it made me feel, how it turned my work into metal and my brain into a magnet, and I’m wondering if this means it was really making me well. Maybe my brain knows more than I do.

I’m also thinking about what happened when Arvid Carlsson unveiled his photos of neurotransmitters at work to the scientists who had held out for a decade, hoping against hope that something inhabited us, that the brain only served the mind, and who clung to their notion that we couldn’t possibly be just a chemical soup, that the spark of God had to animate us, and who finally, in the face of incontrovertible photographic evidence, had to relent and admit they had been wrong. Those white bundles wrapped in the blue and red tendrils—they aren’t ghosts trapped in a machine. They’re chemicals, made up of molecules made up of atoms made up of ever tinier particles, and I am nowhere to be found in them, I am not behind them looking out. They are me.

Which, as I said before, is not how I want this to turn out. I have a favorite rejoinder to this conclusion—that to learn about the pipes and wires of the brain is to discover the necessary but not the sufficient conditions for our selves and our suffering, only the infrastructure
and not the edifice, that it’s like cataloging the pigments of the Mona Lisa and claiming that you’ve said something about why it is beautiful. But even this response seems inadequate right now. Maybe I’m just tired after a couple of years of swimming upstream, maybe I’m depressed, but even if I know that Daniel Amen has only prettied up pictures of the blood rocketing around in my brain, even if I think that this is a crabbed and even repellent way to look at us, I can’t deny what’s in my hands and before my eyes. I can’t deny that all that stands between me and accepting this idea—that every thought and feeling, not to mention my depression, is just the outcome of biochemical events that could easily, with a change in my cerebral climate, be otherwise—is the simple desire for it not to be so, and the conviction that it isn’t, which, for all I know, will someday be found in my brain and become a page in Dr. Amen’s book. I can’t prove that they are wrong.

All I really have is belief. That’s all the manufacturers of depression have too, and much as I wish they would admit this or at least not so ruthlessly exploit their claim to be on the side of the facts and the facts alone, much as I think their failure to do so is just plain bad faith, I can’t deny the attractions of their conviction. They are on the side of progress and optimism and I am on the side of… what? Of suffering? Of some ancient, outmoded idea about the necessity of storytelling, the inescapability of tragedy, the uniqueness of consciousness, the importance of meaning?

I once talked to Donald Klein, the Columbia psychopharmacologist, about the placebo effect. Or I should say, I tried to talk to him. He wouldn’t engage the subject. “For the same reason that I don’t debate creationists,” he told me.

Maybe I’m just a creationist. Maybe I don’t want to accept that the world simply showed up one day and started evolving stuff, which eventually included people who could, if they were unlucky, be depressed. Maybe I don’t want to accept that when I am lying on the floor of my study and I can’t get up, when my discontents multiply into despair, when I qualify for the diagnosis that I am just
experiencing some neurochemical bad weather. Maybe I don’t want to live under this climate of opinion, any more than your average geocentrist wanted to live under Copernicus’s sky. Maybe I don’t want to believe that depression is a disease of the brain because I am a coward, afraid of a not-so-distant future when doctors know more about me than I possibly can, including how to make me better, when the self that suffers finally surrenders to their certainty that it is nothing but a few millimeters of neural tissue, its suffering reduced to renegade molecules that can be brought to ground with well-placed bullets.

I’m not going to stop there either. You’ve stuck with me this far, so you deserve something more for your trouble than a gloomy forecast of inexorable climate change—some consolation at least, maybe even some advice.

Not that kind of advice. If you or your doctor thinks you are depressed and you want to know what to do about it, you already have many places to go: self-help books, biographies of depressives like Abraham Lincoln, memoirs like Andrew Solomon’s or William Styron’s (both of which are beautiful and fascinating), Internet support groups, your pharmacist, your therapist, your friends. You won’t necessarily get coherent advice from these sources. More likely you’ll hear cacophony and contradiction, one voice beckoning you this way and another that way. But you shouldn’t be afraid of complexity. We’re pretty complicated creatures, no more so than when in the throes of an emotional state that colors all of our experience. And among all those voices, chances are good that sooner or later you will hear something that hits home, reaches down to you and lifts you out of your darkness. That’s part of how the placebo effect works: a doctor, someone you trust and look to for help, gives you reason to hope that things will be getting better soon.

But simplicity can be a good thing too, at least once in a while, and here’s the simplest thing I’m going to tell you, the closest to advice I’m going to come.

Whatever else you do, don’t let the depression doctors make you sick.

This is harder to do than it sounds. Because you have to grant the brilliance, the irresistible narrative power of the story they have manufactured. The depression doctors have found a middle way between Job and Eliphaz, one that can be truly comforting: that your depression is a flaw, in you but not of you, that causes you to see the world as darker and meaner than it really is and that can be corrected with a quick trip to the drugstore. And especially as we move into a time of deep uncertainty, economic and otherwise, and the opportunities to feel worried and disconsolate and even despairing increase, as more and more patients show up in doctors’ offices sleepless and upset and agitated and worried and wondering whether life is worth the candle now that their jobs and their 401(k)s have disappeared, or now that they have to tell their kids that they’re losing their house or moving from their hometown because there just aren’t any jobs left, or now that they realize they may never be able to retire—as, in short, more and more of us meet the criteria, doctors are going to be dispensing the diagnosis even more often than they already are.

If you’re going to resist this prescription, which has the signal virtue of leaving the world intact and giving you the opportunity to live in it more comfortably, you will have to remember that the depression doctors exact a price for their diagnosis. They want to tell you who you are. They want you to see yourself as the kind of being whose unhappiness is a sign that you need to buy their services. And you’re going to have to remember that hidden in the diagnosis, and in the vast assumptions about humankind behind it, is a whole history of accident and misunderstanding and overreaching, of unwarranted leaps of logic and wishful thinking and the misapplication of scientific rhetoric, of bad faith and greed. They
don’t teach this history in medical school, and few doctors have the time or patience or inclination to learn it. So now that you know more than they do, you’re going to have to consider the possibility that even if you take their drugs and feel better, that doesn’t mean you were sick in the first place. And then you are going to need new ways to understand your discontents.

I’m not going to tell you what those new ways should be. You’d want to be pretty sure of yourself before you try to convince people you’ve never met that you know what causes them to feel a certain way and what they ought to do about it. And the simple fact is I’ve been working with depressed people and I’ve been depressed on and off myself for a quarter century, and I’ve spent the last couple of years writing a book on the subject. And I still don’t know the answer to those questions.

Because you could write that book, as I have, and then as your reward you could take yourself to a tiny cabin on an island without either cars or roads (and whose sole concrete sidewalk features speed bumps), and you could be awakened at three in the morning by a sudden shift of the wind, by palm leaves slapping the sides of your cabin and an occasional quarter-sized raindrop plunking its tin roof. You could sit up in bed and look out your window at an orange crescent moon on the eastern horizon, lighting a faint path across the sea, and before you could congratulate yourself for having found such a place, before you could even begin to try to tame this riot of beauty with words, you could become aware of something else: your pounding heart, your stomach hollow with nausea, the sudden dead certainty that something is wrong and will never be put right. This is all so disappointingly familiar, and because you don’t want to be depressed on your vacation, you hope that this ill tiding blown across a vast ocean from an unseen continent is bound for some other destination.

The feeling has descended like the weather, unbidden and dismal and blacker than the night, and you can’t help but think that this is a random event, a synaptic thunderstorm signifying nothing that you don’t already know or need to be reminded of: that the flesh is infinitely vulnerable, that our lives are lived inside the thinnest of biochemical margins. This rude awakening may even be the vestige of some adaptation, the remnant of a capacity developed hundreds of thousands of years ago to respond to some forgotten contingency of prehistoric life—the presence of the sublime triggering the genetic impulse to curl up and wait for danger to pass—but now just an unpleasant paleontological curiosity.

But then again, maybe not. Maybe this is a visitation from your own distant reaches, the solitariness you’ve been reveling in transformed into loneliness and the memory of an uncomforted childhood, the sudden tempest, reminiscent of the roiling and dangerous household in which you once lived, plunging you into that familiar miasma of fear and self-loathing, into the echoing prison of depression. Maybe, in other words, it is the margins of biography that are narrow. Maybe there is no escape from a story so deeply inscribed.

Or perhaps it is a visitation of a different order, the intrusion of another unwelcome fact: that just beyond the ersatz poverty of your crude wooden shack lies the real thing and just beyond that a skein of injustice and suffering and exploitation in which you have a hand and that seems illimitable. Maybe what has crept over you is only the hopeless truth behind your ecotourist pretenses, the knowledge that you would rather live with the self-devouring discontents of bad faith than chuck your comfort and your familiar life into the sea. Or the fear that whatever is important to you will crumble, that even love will disappear.

Or maybe Hippocrates was right all along. Maybe you really do have out-of-whack humors, but they are in a place where scientists haven’t yet thought to look or that their instruments won’t find anymore than a magnet can find feathers. Or maybe it’s karma or the
alignment of the planets or the chemicals in your food. Or, as you will think later, standing behind a beautiful young couple kneeling together under a stained glass window in the transept of a church on the mainland, praying (or so you imagine) for a happy marriage or a pregnancy or the good health of a loved one, devotion radiating like sunlight off their bowed shoulders, maybe none of these stories make much sense. Maybe these children of Job—who believe (so you think) that good and bad fortune reflect a heavenly order—are right, maybe hope and despair, pain and consolation are part of the battle between God and Satan, and maybe you should get down on your knees and pray.

Every one of these accounts of depression—and there are undoubtedly others—can account for this sudden malaise, and each has its uses. I’m not going to tell you which one is right, because I don’t know. I’m just going to tell you to be wary of people who tout certainty at the expense of truth, especially when what they are certain about is something so complex and baffling and weighty: the nature and causes of our suffering and what we ought to do about it.

Even some depression doctors are beginning to wonder about the truthfulness of their story. They’re beginning in particular to think they might have rendered too much of the world insane. Some of this concern is sparked by business considerations. The widespread distribution of the depression diagnosis, they worry, can result in brand dilution or in other marketing difficulties. Darrel Regier, the American Psychiatric Association’s chief of research, put the problem this way:

Various critics of the current diagnostic system
have characterized the expansion of diagnostic categories as a “guild” attempt to justify payment for any condition a psychiatrist might see in practice, or as fabrications of the pharmaceutical industry to justify the sale of their products.

Regier went on to point out that the dire estimates of mental illness in the population—in any one year, using DSM criteria, something like 30 percent of Americans qualify for one diagnosis or another—raise some red flags even without the critics. For instance, he wrote, the mental health treatment system is in no way prepared to treat the 100 million patients forecast to meet the criteria every year. This embarrassment of riches could be a public relations disaster.

Regier is among the psychiatrists who think the ease of diagnosis is mischief wrought by Kraepelin’s ghost, that running down a checklist of symptoms and concluding that people are sick if they say yes often enough is bound to lead to overestimates. What’s missing, they think, is sufficient consideration of whether and to what extent those symptoms are actually problems for people—“
clinical significance
,” they call it. This standard was supposed to replace intrapsychic conflict as the übercriterion of mental illness when the DSM-III was revamped in the wake of the homosexuality debacle. But Regier believes, and more psychiatrists are coming to agree, that doctors are not any better at agreeing on how to assess significance than they were at standardizing intrapsychic conflict. Nor are they particularly eager to try: