Manufacturing depression (51 page)

Every year, DBSA holds a national conference, part rally, part
seminar, part bazaar. In a ballroom, vendors await customers. They’re hawking membership in patient advocacy groups, handing out brochures that explain just how real depression is, soliciting subjects for clinical trials. The closest thing to an actual product on display is psychTracker. Sean, a vice-president of the company that developed it, is manning the booth. He shows me how I can use his Web-based program to chart my emotional life. All I have to do is log on, record how many hours I slept last night, and then rate myself from one to ten on a hundred or so items ranging from
happy
and
sad
through
delusions of grandeur
and
inappropriate affect
to
thoughts of death
. If I do this every day (and Sean hopes I do; psychTracker’s revenues are ad based, so keyclicks and eyeballs are the key to prosperity) then I will end up with a graph like the one Sean is displaying. It charts my moods across time, like a corporate profit-and-loss poster, so my doctor and I can see the short-and long-term trends. (Sean adds that his company is also trying to amass “a database of the emotional health of the country,” but it’s not clear what they intend to do with it.)

Kathy Cronkite is here. She’s Walter’s daughter. In 1995, she put together
On the Edge of Darkness
, a book of celebrities’ accounts of their depressions. Joan Rivers talked to her, as did Dick Clark and Rod Steiger. Cronkite’s story leads off the book, and she’s recounting it now as part of her keynote address. She says she too was once a “young adult, lying on the floor staring at the ceiling for days on end.” She tried harder than I did to fix herself, working with “dozens of social workers, psychiatrists, and physicians who failed to recognize my illness,” and who wanted to blame it on “my father’s position” or something else in her past. Until she met the heroes of her story, a wise psychologist and the doctor he sent her to, who, in a speech that would have made Frank Ayd proud, said:

Here’s what we do about it. Like other illnesses, he said, the earlier it’s treated the better. What works best for most people, he said, is a combination of talk therapy and medication,
and he said, you’ve had years of talk therapy, how about we try some medication?

And, she tells us, that after she got over her worries—“Would it take away the richness of emotional life? Would I still be me?”—and tried medication, in a “miraculously short period of time,” she was transformed. It wasn’t your usual transformation, the kind where a person leaps into a new and extraordinary role, but nearly the exact opposite. The drugs, she says, made her normal.

Outside of this room, most people think normal means boring and bland, but we know, I hope we all know, that normal is the most glorious feeling there is. And when you’re depressed you can’t even imagine the magnificence of normal… The medicine didn’t take away myself. The medicine gave me back myself.

That’s not the only miracle that the medicine performed. The drugs gave her suffering a new meaning—“I am not crazy or bad or lacking in faith. I have a disease. It’s called depression.” Her deliverance from abnormality was so magnificent that she has devoted her life since then to “spread[ing] the word that depression is… a real, treatable, medical condition, with real treatments—and real recovery.”

While this is a gospel of hope, she cautions, recovery should not be confused with cure. Indeed, it would be a mistake to think that depression will ever really go away. “I have a chronic illness that I will always be aware of, and always be susceptible to, and probably will always take medication for, much like diabetes,” she says. “And much like diabetes, if I take good care of myself… it will be no more than a background of my life.”

This, it seems, is where the depressed pilgrim’s progress ends: in the movable city of recovery, where entry is granted to those born with an affliction. “I’ve found the reason for depression,” Cronkite says. “Bad luck.” The “magnificence of normal” is the highest aspiration
here, emotion traded like currency and comity achieved by mutual confession in the recovery groups, modeled on Alcoholics Anonymous’s twelve-step groups, that are DBSA’s stock in trade. One attendee—dressed in houndstooth pants and a striped shirt, grabbing a smoke in the Florida sun—tells me (and anyone else in earshot) about his pilgrimage across the South, driving his RV from twelve-step group to twelve-step group, all that fellowship capped off by his arrival here, on what just happens to be his two thousandth day of sobriety. And as he concludes in his gravelly Tennessee drawl, “They ought to just give us a state!” it occurs to me that this might be a glimpse of the future, in which we sort ourselves according to our diagnoses and where our vital associations will be with other like-minded (or is it like-brained?) people.

Is this what Alexis de Tocqueville had in mind when he said “Nothing… is more deserving of our attention than the intellectual and moral associations of America”? Tocqueville went on: “If men are to remain civilized or to become so, the art of associating together must grow and improve in the same ratio in which the quality of conditions is increased.” Here in this republic of the afflicted, the citizens are, as Cronkite puts it, not patients or victims or even sufferers, but “consumers of mental health services” whose recovery includes driving a hard bargain with legislators and hospitals and drug companies and universities, demanding more insurance coverage, more research, more treatment.

But at least these consumers are taking care of each other. I can’t help but be moved by the way people here accommodate one another’s disabilities, their shuffling gaits and off-kilter questions, commiserate about psychiatrists and insurers, and share secrets about medications. They listen to one another’s stories—a form of love if there ever was one—even if they are largely stories about the tyranny of their own brains. They haven’t taken diagnosis as a call to retreat to their sickrooms and whine to their
decreasingly sympathetic support systems
. Instead, they are coming together to demand services. It is tempting to think that a society organized
around
making the recovery connection
might not be any worse than the society we have.

If you think that’s damnation with faint praise, you’re probably right. But it is worth pointing out that it’s not such a bad thing that the bar to entry is set so low, or as one DBSA speaker put it, that “you have a diagnosis. You just don’t know what it is yet.” I don’t think she was trying to destigmatize mental illness, which would, in that setting, only have been preaching to the converted. I think she was saying that
mental illness
is a valid way to think of our troubles. To say that we’re all mentally ill is only to say that we are flawed people living in a broken world. If that’s true, then one state might not be enough.

But much depends on what demands a diagnosis leads us to make. To say that we have a chronic illness is to direct our attention to the health care system and not to other social institutions. And there is a danger here: that to be a consumer, whether of health care services or flat screen televisions, is to be essentially passive, to choose only from among the available options. When your choices are only Paxil or Zoloft, it’s worth wondering whether you have any real choices at all.

Peter Kramer noticed this danger and considered whether it was built into the pharmacological effects of the drugs, whether antidepressants are a “
modern opiate
” that “supports social stasis by allowing people to move toward a cultural ideal—the flexible, contented, energetic, pleasure-driven consumer.” He was quick to reassure us on this count. We needn’t be concerned because Prozac can also “catalyze the vitality and sense of self that allow people to leave abusive relationships or stand up to overbearing bosses.” And besides, even if the drug “
induces conformity
, it is to an ideal of assertiveness, but assertiveness can be in the service of social reform of the sort ordinarily understood as nonconformity or rebellion.” That’s why he was confident that Prozac will be “
on balance a progressive force
.”

I’m not so sure about this. Prozac doesn’t seem to have told any of Kramer’s patients to take to the streets. It certainly hasn’t done that for mine, and while it does occasionally help to give someone the courage to leave a bad marriage, it just as often helps them to adapt and stay. The two decades since Prozac was introduced have seen enormous increases in injustices like the widening gap between rich and poor, in opportunities to feel hurt and victimized or just plain worried sick about the future, in horror and atrocity in which our own complicity is hard to ignore, but they haven’t exactly been a period of nonconformity or rebellion. Indeed, what SSRIs seem to do best, when they work at all, is to help patients live with less anguish in the world as they have found it. That’s why the drugs have the reputation as “
so-what drugs
,” why critics like Erik Parens accuse them of “
facilitat[ing] better performance
in an often cruelly competitive, ‘capitalist’ culture,” and why we wring our hands about where resilience ends and tolerating the intolerable begins: because it seems that the drugs make people less responsive to the irritations and outrages of daily life.

It’s particularly hard to avoid noticing that those twenty years have been an age of irrational exuberance, when confidence and flexibility have been deployed to no other ends than more confidence and flexibility, when the only rebellion that assertiveness has served is a rebellion against certain realities: that you can’t count on an economy built on debt that can’t be paid back, that neither the planet nor the housing markets can sustain growth forever, that optimism, no matter how good it feels, is not always warranted. Of course, we have no way of knowing how many of those forward-looking masters of the universe were taking SSRIs while they confidently invented and implemented increasingly bizarre ways to make money for nothing. We do have some idea of how many of the rest of us had a little chemical help to feel contented while they were robbing us blind—and it’s a lot. I have a hard time believing this is a coincidence.

Still, as tempting as it is to say that Kramer is wrong, that Prozac is anything but a neutral technology, that
so what
is an essential,
and therefore dangerous, effect of the drug, we have to remember what Norman Zinberg said about drug, set, and setting. Maybe the reason that the SSRIs seem to foster conformity is that they are prescribed by doctors as the cure for a disease. If you think that what was wrong with you was that your brain chemicals were imbalanced, and the drug makes you feel better, then why look elsewhere for the source of your suffering? Why not just take your improvement and go home to consume mental health services for your chronic illness?

So Kramer may well be right to say that SSRIs are neutral—not because they have no real effects on the mind or because they merely help us to overcome our sickness and get back to the “healthy” way of being human, but because those effects are so protean that they can be shaped in virtually any way. Perhaps doctors could replace Frank Ayd’s spiel with a rap about how the drugs are an antidote to a toxic society, something you need because consumer capitalism is much better at creating need than satisfaction, that this indeed is how the system works, and when that gap opens up between what you long for and what you can have, and you conclude, as you must, that the fault is yours, or when you reproach yourself for your failure to be clever or strong or smart enough to reap the bounty—material and otherwise—that is surely out there, or when your disappointment and demoralization seem unbearable, in short, when you feel like Job, the drugs may well give you comfort. Perhaps if the story about the drugs were told this way, if people thought that it was their social arrangements, and not their brain chemistry, that had made it necessary to trade in their orgasms for antidepression, they would use their newfound energy and confidence “in service of social reform.”

Kramer’s concern is misplaced: the dangers of complacency are not in the drugs but in the diagnosis. Kramer is not the first observer of the American landscape to worry about this kind of hazard. Traveling through America in the early nineteenth century, Alexis de Tocqueville thought he had glimpsed a crucial problem:
that the pursuit of happiness alone was not enough to ensure a vibrant and free society. “
A nation that asks
nothing of its government but the maintenance of order,” he wrote, “is already a slave at heart, the slave of its own well-being awaiting nothing but the hand that binds it.”

Because that’s what calling our suffering a disease provides: a way to ask something of government—which, in a democracy, means one another. And surely there are other demands we can imagine—and other ways to take care of one another—than better treatments and the money to pay for them. What would happen to the depression statistics if people were less worried about paying for health care, for college, for retirement? Or if we weren’t left to our own devices to figure out how to work and take care of our families and have a little time left over to actually enjoy ourselves and one another? Or if we weren’t constantly being reminded by advertisers of all the ways we fall short of achieving the good life? Or if we felt that we had some influence with our legislators, our presidents, our financiers, or anyone else who exerts power over what we care about? Or if we thought there was something we could actually change other than our neurochemistry?

There’s no double-blind study that can answer these questions, and anyway it’s not up to doctors to tell us that there’s something wrong with the way we’re living. But—and here is another unintended benefit of the diseasing of depression—they have managed to point out that people are suffering from recalcitrant unhappiness in epidemic numbers. I don’t doubt that this is true, but I also don’t think that it is merely because of something that has gone awry in our wiring. The depression doctors would have us think that this is the case, and that we should ask of one another nothing but the drugs and the cognitive-behavioral therapy that will ensure our well-being. They would have us believe that the subject of our unhappiness, the content of our discontents, is just so much electromolecular static.