Selected Minor Works: Is Depression a Medical Condition?

Justin E. H. Smith

In Harlem, ten years or so ago, I overheard two elderly ladies waiting for a bus underneath a billboard that read: "Depressed?  It's Chemistry, Not Character."  This slogan was followed by a 1-800 number which would put the caller in touch with a medical professional able to write a prescription for antidepressants, that is, to set the chemistry right by preventing the reuptake of serotonin.  The one lady said to the other: "I went to my doctor and he told me that's what I got.  Depression.  I always knew it was something."

I confess I feel tremendous inhibition at the thought of taking up the topic of reuptake inhibitors.  This is because it is, unlike my usual preoccupations (God, animals, language), by no means just an intellectual exercise for me.  Over the past 18 years I have been on at least six different kinds of SSRI, each one bearing a brand name that sounds more like a Lexus model than the last.  (Could I have been taking something called 'Selexa', or did I just see one parked outside of Starbuck's?)  In the long run, they never quite do the trick, or if they do, then they do that plus a whole lot more one would rather avoid.  And so invariably I wind up back where I started: lucid yet burdened, supremely sane yet stalked by a particularly dark demon, my constant companion, my familiar. 

I have chosen to write about this condition not out of desperation --no, the drama of it was all played out years ago, and now I am nothing if not stable--, but rather out of a sort of calling, rare for me, to enter into identity politics.  I am tired of all the stupid things I hear said about my fellow depressives.  It was not so long ago that Jesse Helms, or perhaps Strom Thurmond, described Jean-Bertrand Aristide as a confirmed 'psychotic' when he learned of the Haitian president's Prozac prescription.  My fellow philosophy professors thoughtlessly invoke 'happiness pills' as the easy way out for the philosophically lazy, while the general public seems to perceive antidepressants as a crutch for the frivolous, as a Hollywood indulgence, as a symptom of privileged frailty.  This moralistic condemnation is usually counterbalanced only be the equally unsubtle medicalistic reduction of our emotional lives to chemical imbalances.  I am neither crazy, nor lazy, nor is my state entirely explicable in terms of a certain disequilibrium of fluids.  I am a depressive, which is to say a person who experiences the world in a certain way.  Now I am every bit as materialist as the cynical doctors who paid for that billboard, yet I dare say that when I talk about my depression what I am talking about is nothing other than my 'character'. 

There I go philosophizing again.  I had set out to tell a little something about myself, and before I know it I'm talking about the mind-body problem.  I will not claim that to know that black dog, as Churchill put it, in itself gives one insight into this deep and intractable riddle.  What I will claim is that reflection upon the nature of depression, and upon the actual (as opposed to commercial) virtues of antidepressants is for me a central part of the Socratic project of self-knowledge.  Some people take paper-making classes, others learn the ancient art of retreating to weekend wellness spas.  And some heed the oracle.  Chacun son passe-temps.

My particular diagnosis has generally been depression with obsessive-compulsive symptoms, a mixture often found, they say, in 'high achievers'.  When I was an undergraduate I was so obsessed with obtaining top grades that I found myself symbolically swallowing every letter A I came across, and symbolically spitting out every B, C, D, and F.  If I accidentally swallowed while looking in the direction of a C or a D, I would have to quickly go in search of compensatory A's to ingest.  I cannot describe the deep sense of dread that such a mistake was able to bring about.  There were times when I would inadvertently swallow looking at the wrong part of a sign along the freeway, and I was thereby compelled to exit at the next off-ramp, drive back to a point before the sign, turn around again, and drive back past, swallowing up the A's, if there were any, or spitting out the low marks that I had inadvertently ingested on my first pass.  In reading books, if I came across a sentence with too many bad letters in it, I was compelled to look away from the book and to mouth any one of a stock of sentences containing no bad letters and plenty of A's. "That's not great, lovely man," was for some reason the most therapeutic sentence I could conjure.  It was (I think?) meaningless, but phonetically very satisfying.  The 'l' sound was also very satisfying, and sometimes I would add it in where it did not belong just to make sure to get the needed relief: "That's not great-l, lovely man-l."

My compulsions were not just orthographic and phonetic, but numerological as well.  I could not tolerate odd numbers, and if when walking along my head was grazed by a leaf hanging from a tree, I was often compelled to turn back around and let it touch me a second time. At times I could not resist breaking pencils in half in order that one would become two, and each half, now a whole, would have its other.   

I do not do these things anymore.  Today, I do other things, generally so subtle as to go unnoticed even by me.  I am one of the fortunate ones: I've learned to channel my possession into socially acceptable, because socially invisible, directions.  One channels, but one never exorcises.  The symptoms mutate, but the state causing the symptoms remains, one single and monolithic constant, a lifetime's fellow traveller, a Lebensgefährtin.  The woman always knew it was something.  It always was something.   

**

I am a materialist who nonetheless would be frightened in a graveyard by myself at night, and I am a good and intelligent reader of statistics who nonetheless gets sick with fear every time I am obliged to get into a goddamned airplane.  I believe in what Ernest Gellner described as "the world of regular, morally neutral, magically unmanipulable fact," yet I go about my life as though the world were some sentient agent ready to take its vengeance upon me should I fail to follow its harsh and arbitrary commands.  This condition has led me to believe that the stupid things we do generally have nothing to do with false beliefs.  Would that it were that simple!  Superstition bubbles up from the unperceived depths, and enlightenment is no cure.  My beliefs are just fine, yet I am sick.

Perhaps we focus on false belief as the root of our problems simply because it is relatively easy to correct.  Ever since the Stoics, cognitive therapy has stood out as a promising path towards feeling good about one's lot in life: belief modification, it has been thought, coming to live in the light of the truth, could free one from fearful superstition and thereby lead to emotional well-being.  And all without chemicals!  But I have been insisting that superstition is independent of belief, and that one's character, the general way one fits with the world, has little to do with the descriptions one gives of it, with the list of things and forces in one's ontology. 

Once one has solid first-person evidence of the futility of belief modification in the quest for happiness, chemical modification starts to seem like the best option.  If the eradication of false ideas changes nothing, then perhaps the simple accumulation of serotonin will help to make the universe a more charming place.  The genie of the future will not have to give a choice of wishes, for now we know that all of that stuff about finding love or treasure or gaining power was really just about stimulating the pleasure centers in the brain, and any  scientifically literate wisher would do better to just wish for that directly: constant and intense neural euphoria.  I can remember being on a new SSRI at a conference in Rome or New Orleans, or somewhere else one is supposed to want to go, and thinking: I'm just going to lie down there on that hotel bed and enjoy my brain.  Everything else --the Colosseum, the French Quarter, the entire world beyond my neurons-- was superfluous.  My happiness, such as it was, did not come from making my thoughts fit the world, as the Stoics had counseled, but by cutting the world altogether out of the picture. 

**

Jede Krankheit ist eine Geisteskrankheit, said Novalis: Every illness is a mental illness. This inverts the billboard's message, according to which every mental illness is an illness plain and simple.  For Novalis, it is not that the soul should be assimilated to the pancreas, but vice versa: that diseases of the body, like depression, have their meaning only in the way they are experienced. This is not to say that your illness is your own damned fault and that you are simply being punished for your failure, as was vividly imagined in Samuel Butler's Erewhon.  It is to say that any illness, 'physical' or 'mental', is an illness at all only insofar as it is experienced by some subject.  A rusting bar does not suffer from the metallic equivalent of cancer. 

**

Whether we are going to speak about a tortured soul or about a defective brain seems to depend mostly on the rhetorical purpose at hand.  Students hoping to be excused from some responsibility or other have learned to talk the medical talk very skillfully: how can a mere Ph.D. in philosophy, they seem to be saying to me, possibly argue with a medical note from a real doctor?  We're talking about an illness here, not some fleeting mood.  Doctors take on the social role of magicians, able to transfigure any procrastinating or hard-partying adolescent into a special kind of creature --a depressive, a manic-depressive, an obsessive compulsive, a sufferer from attention deficit disorder-- usually with nothing more than the most perfunctory speech act.  I am not saying these categories do not exist (at least as far as the first three are concerned).  Indeed, I have claimed some of them for myself. But I doubt that their reduction to medical conditions like any other is what best helps us to understand them, or to live with them.

In the past several decades we have witnessed the encroachment of medical talk into nearly all domains of social life.  The refusal of some drivers to wear seatbelts is spoken of as a 'public health problem'.  Of course, a smashed skull is truly a medical condition, but must that mean that every course of action that could lead to its smashing is also medical?  Similarly, is the undeniable existence of a chemical substratum to our conscious experience sufficient reason to conceptualize unpleasant or burdensome mental states as medical?

I do not want to take this line of questioning too far.  I have cited Novalis's idealist motto as a counterbalance to the prevailing view that every illness, including mental ones, is a medical condition.  But I am not an idealist, as I believe the body is its own thing and there are plenty of context-independent facts about it.  I am willing to concede that chemotheraphy works on cancer cells in the same way whether one takes cancer to be the consequence of witchcraft or of environmental pollution; and an insulin shot will do the same good in a superstitious diabetic as in a scientistic one.  But SSRI's have turned out to function in society rather less like medical insulin than like herbal infusions, yoga, or the cocaine that Freud once thought, not too long ago, would bring about a revolution in the treatment of mental illness: that is, they have vastly different effects depending on what is expected of them.  And this only shows that the well-being of the soul is something not nearly as easy to control with medicine as is blood-sugar level.   

Somewhere Lévi-Strauss discusses the magic-mushroom habit of the berserkers-- i.e., those medieval Scandinavian warriors who put on the 'bear shirt' and were thereby transformed into bears during battle, giving them full license to rape and kill with extra ursine vigor. Now, those of you who have dabbled with psylocibin will probably agree that raping and killing were not foremost among your desires during your trip.  The trip was all-natural, indeed, as shroomers never tire of pointing out, yet it was strongly mediated by culture.  And this is why your reaction to mushrooms was different from that of a Viking warrior.  I can imagine, similarly, a culture that takes Zoloft before raiding coastal villages, and another that reserves it for monks in an ascetic order dedicated to knowing God, and perhaps another culture still, a tightly controlled millenarian sect, that distributes it to its initiates in preparation for mass suicide.  (This last case is not so far from reality, as antidepressants have been shown to increase the risk of suicide-- a fact that should cause any thinking person to doubt the simple, reductionist belief in a cause-and-effect relation between the inhibition of serotonin reuptake and the qualitative experience of well-being.) 

Why is the experience of antidepressants so variable?  Medical anthropologists have known for a long time that medicines are not just taken by bodies; they are incorporated into cultures, that is to say into preexisting cosmologies that permit certain reponses to things ingested, encourage some, and exclude others.  There may be a single, context-neutral fact about what St. John's Wort does in the body (as it happens, probably nothing); but there is no such fact about the role that said wort will play in a culture.  In our bodies, it brings about its minor effects and passes through; in our culture's fantasies --and in our culture's economy-- it does a good deal more: it contributes to that nebulous condition we call 'wellness'; it cleanses its consumer of vaguely defined toxins; it purges 'free radicals', whatever the hell those might be; it signals 'consciousness' to other consumers.  It is not to be mixed with gin or Diet Dr. Pepper.  Now of course consumers of St. John's Wort are likely to be suspicious of chemical antidepressants, but many of the same considerations may be brought to bear in the one case as in the other.  For both, success in our culture depends upon the substance's symbolic role in a system of oppositions.  Better living through mere chemistry is never enough; the pharmaceutical companies  understand that it is principally through marketing --that is, positioning some chemical or other in the desired social role-- that that chemical comes to be perceived as a means to better living.

**

It should not be controversial for me to say that the reason for the existence of antidepressants is the profit of the pharmaceutical companies that produce them.  This is not to say they don't work. People who are made happy by new products, who can invest their hopes in wellness accessories available for purchase in Skymall catalogs, people who get a wellness charge from St. John's Wort or from hot stones strategically placed on the back, might also be made happy by the opportunity to take a new antidepressant (one of these, 'Wellbutrin,' has explicitly incorporated 'wellness' --a term that only caught on because those who stood to profit from it were unable to gain permission to make explicit health claims on their product labels-- into its name.)  Things are rather more complicated for those of us who live under the black sun, as Julia Kristeva called it, but are nonetheless perfectly clear-sighted about our plights, and about the real prospects for escaping them.

Berlin, August 17, 2007

--

For a comprehensive archive of Justin Smith's writing, please visit www.jehsmith.com.   

Comments

[Abbas Raza]

Justin, you are one of the smartest, bravest, sanest people I've ever met. Thank you for this brilliant and fascinating piece. You have made some of the darkness visible.

P.S. My favorite line: "A rusting bar does not suffer from the metallic equivalent of cancer."

[Robin]

Brilliant and well-said. I'd like to also suggest that at a more primitive level "well-functioning", especially mental well-functioning, is dependent on our culture and social context, however much we recognize the biological infrastructure that it rests on.

[aguy109]

What a marvelous piece, thanks so much. I'm glad you don't take the easy route of knocking the pharma companies, because many of these (highly profitable) substances actually do help millions of people to cope and lead better,less unhappy lives.

[Bill]

Speaking as someone with Major Depressive Disorder myself, this essay is so wrong-headed I don't know where to start.

I am unaware of cultural variation in the efficacy of SSRIs. There is good solid evidence that hypericin is bioactive and its effects differ from placebo controls in trials against depression.

Chemotherapy against depression exists, not so that Big Pharma can profit, but because depression is an illness with a physiological component which is amenable to biochemical intervention. Do you claim that hospitals are only built because HMOs can profit thereby? (Which is not to say that there are no problems with Big Pharma, but that's a different discussion.)

People with depression are not "made happy by the opportunity to take a new drug" -- this is utter drivel, as anyone will tell you who, like me, owes a good deal of their quality of life to chemotherapy against depression.

If you had a point, I'm afraid it escaped me.

[Tasnim]

You ned to be congratulated for this very personal essay. It takes a lot of guts to share with every one one's own weakenesses, perhaps having overcome them makes it a little easier to talk about it. Having lived with multiple family members with various forms of depression I must admit I never understood what and why it happens to them. The same things that I enojy in life they would be depressed about. One thing did become clear to me is that medicines do help at least in some stages of the problem. Just to get through the worst stages and then perhaps you are right that in the long run it is better not to be on them because they cause more side effects than cure the problem. Enjoyed the essay.

[beajerry]

I was going to talk about Fight Club, but then I remembered the 1st rule.

[Jill]

"conceptualize unpleasant or burdensome mental states as medical?"

It's surprising that someone who has "suffered" from depression and OCD symptoms would characterize it so cursorily. Unpleasant? Waiting in line at the DMV is unpleasant. Acute Major Depression can be positively crippling. Appetite disturbance, sleep disturbance, fatigue, anhedonia, suicidal ideation...do I really need to list these? I'm sure you know them but perhaps you would sum them up as tummy ache, sleepy head, out of shape, party pooper, emo...

Not everyone is "lucid yet burdened" with their "companion". Every case is unique. Many depressives never get the chance to try 1 medication, let alone 6. This essay seems to be primarily about how psychiatry functions in mainstream culture. Yes, overdiagnosis is a problem and, yes, I am very annoyed by the scores of people I've heard, who've never opened a psychological or medical text, describe themselves as hypochondriacs.

It appears that annoyance, coupled with what sounds like a desultory history with pharmacotherapy, has lead to a dangerous conclusion. Namely, that depression is something that can be willed away, it's a burnt hamburger to be assuaged by an ice cream cone. This is how stigma breeds.

"Why is the experience of antidepressants so variable?"

Perhaps because the brain is more complex than the leg, treating a mental illness is more complex than treating a broken leg. How and why antidepressants work is largely a mystery, one which is being continually researched. Chalking their varible efficacy up to cultural superstitions as opposed to the immense complexity of individual neurological milieus is short-sighted, at best. Yes, there is a feedback loop between the brain and consciousness in which culture plays an important role. That very fact is focused upon in many non-pharmacological psychiatric interventions. However, to completely dismiss the chemical aspect because we do not understand it is wrong.

[Akbi]

This was, as always, Justin, an excellent essay. In response to Bill, I would say that Mr. Smith is making several points, one of which is that there is no one single point about depression or one panacea. Thanks, Justin--so well-written!!!!!!!! (I'm pretty much on the medical side of depression, just for the record).

[Maeve Adams]

Justin,

This is truly excellent. I applaud your honesty and bravery in using your experiences to launch this illuminating critique.

To the critics, I think this line (among others) says it all, "For both [St. John's Wart and pharmacological drugs], success in our culture depends upon the substance's symbolic role in a system of oppositions. Better living through mere chemistry is never enough." I do not believe that Justin is commenting on the medical/chemical effectiveness of these drugs. I also do not believe that he is suggesting that people who take the drugs and experience benefits are duped by social or cultural approval of the drugs. Rather, I think he is saying that the success of these drugs on the market is, in large part, an effect of how they are valued within culture and thanks to marketing. The success of any given drug has little to do with their ability to help people. Ecstasy might be a relevant example here as a drug whose image has shifted radically over the last century: many psychotherapists in the 1970s believed that it could legitimately help people and now it is treated in anti-drug compaigns as a social blight.

These are extremely sensitive matters. But, it is important for us to think about the role of marketing, writ large: that is, not merely about ad campaigns, but also about how we constantly re-make our selves (and our "well-being") according to the received images of consumers (and commodity swallowers) of various kinds.

[ed rackley]

justin, many thanks for this.

[Bill Ectric]

I want to agree what the "other Bill" says a above; and in case you're wondering: No, I'm not the same Bill trying to double-dip.

SSRI's have vastly improved my life. The side effects, at least in my case, are minimal. It is hard for me to relate to people who decide to quit using SSRI's for any reason.

I will say this in regard to increased suicide risk in teens. Before I began taking an SSRI, I was constantly dieting. One of the effects of Zoloft was that I was so happy, I didn't care if I got fat. It just didn't seem to matter anymore. It took about two years for me to get back into dieting an excerise, but now I'm finally starting to get back into shape. What, you ask, does that have to do with suicide?

I think that many teenagers haven't developed a real appreciation of life. They haven't learned how precious life is. So, whereas I felt so good, I didn't care if I got fat, they feel so good, they don't care if they die.

I know that sounds strange. I have no research to back it up; it's just a hunch.

I, personally, love life!

[kynefski]

Excellent, moving essay.

You may want to edit the paragraph referring to Scandinavian mushroom eaters. These would be anamitas, the active compounds of which are very different from psilocybin. (I'm not a historical anthropologist, but I'd suspect there's probably an account of meso-American violence that would be appropriate to your point here, which is well taken.)

[Elatia Harris]

Justin, thanks to personal courage and the willingness to be unguarded, you've started a truly productive discussion -- one that cannot help being colored by the subjective, however, for these are the reaches of the mind where the self experiencing the self is all there is, each person the only true authority on what works.

The trouble with mental illness, as they say, is that the organ affected is the organ making the decisions. If this is how you have come to terms with the hellish problem you describe, then no one -- not even Zarathustra -- should be suggesting to you that different altitudes and electricities and purer, more ferocious poisons are actually a better way.

At the risk of seeming to romanticize depression -- something I would just never do -- I want to quote the poem of Byron about transitions occurring in what was for him late adulthood. He wrote it just before becoming thirty, when his thoughts had already turned to Greece -- and death. He knew what there was to know about outliving heightened states of extraordinary menace that would bring him regularly to his knees. As follows --

So we'll go no more a-roving
So late into the night,
Though the heart still be as loving,
And the moon still be as bright.

For the sword outwears its sheath,
And the soul outwears the breast,
And the heart must pause to breathe,
And love itself have rest.

Though the night was made for loving,
And the day returns too soon,
Yet we'll go no more a-roving
By the light of the moon.

[Baduin]

You misunderstood Stoics. They spoke about pneumopathology, which is quite different from psychopathology. In other word, one is false belief, the other chemical imbalance.

Also, Materialism according to Stoics was the root of the sickness.

[Justin]

Thanks to everybody for their comments, except for Beajerry's, which I did not understand.

It is heartening to see such lively response. I can't respond to every point that's been made, but it is clearly the first Bill's that calls out most urgently for comment.

I assure you, if there were a scale of depression, I would be way up there. But there is not, and so each of us is left to describe our own depression in our own way, to downplay it or emphasize it as a part of our identity, and to conceptualize it as a disease or as an existential challenge, as we see fit.

For some, the most satisfying way to conveive the burden is as an illness like any other: not "spirit is a bone," as the Kabbalists used to say, but perhaps "the soul is an organ," and the depressed soul is a malfunctioning organ. But any thinking depressive will at some point have to concede that there are certain points of disanalogy between depression and other illnesses. Now, it has been shown in a number of studies that the difference between antidepressants and the placebos against which they are tested is statistically negligible. Can the same thing be said of chemotherapy? No, of course not. Why not? Because the reports of cancer patients as to whether their chemotherapy is working or not are irrelevant. The only thing that matters is whether the chemicals are having the relevant effect on the cancer cells, and this is something that can be solidly established from a third-person perspective, without any input from the patient about how he or she feels. The only thing that can be established about the effects of antidepressants from a third-person perspective is that they are, or are not, inhibiting serotonin reuptake, but no one, neither the patient nor the scientists monitoring him, has any idea what the actual correlation between serotonin accumulation and the subjective experience of well-being really is. If happiness were just a matter of serotonin levels, just as diabetes treatment is just a matter of blood-sugar levels, then indeed the problem of depression would have been solved by antidepressants. But it is an empirical fact, and not just my judgment, that the problem has turned out to be far more intractable: by no means is everybody who is given antidepressants thereby helped. And I thus repeat my concluding claim, that their success has more to do with marketing than with chemistry.

My point, in any case, had been to come out in solidarity with those in a similar plight, not to antagonize them. If the pills work, good, take them. But there are many for whom they don't work, and I think I speak for at least some of them when I say that the insistence on reducing the problem to a mere medical condition represents something of an obstacle in our path towards self-understanding.

[Baduin]

To be precise:

Cicero's Tusculan Disputation IV,

"Illud animorum corporumque dissimile, quod animi valentes morbo temptari non possunt, corpora possunt; sed corporum offensiones sine culpa accidere possunt, animorum non item, quorum omnes morbi et perturbationes ex aspernatione rationis eveniunt. Itaque in hominibus solum existunt; nam bestiae simile quiddam faciunt, sed in perturbationes non incidunt."

The soul cannot get sick without wishing it, and body can. Sickness of body can happen without our fault, but not sickness of the soul. That is so because all sicknesses and disorders of the soul are caused by the contempt of reason.

(the Reason for Stoics is of course also the divine Logos, the Word and Spirit moving the world).

According to that definition depression is a sickness of the body, IF it is caused by chemical imbalance.

It is an unpleasant truth that we can destroy our mind without any mental illness, and even without using any drugs, except perhaps alcohol.

I had to meet many such people, clinically without any mental disorder but simply unable and unwilling to think reasonably. The technical term was often something like - personality disorder without symptoms of mental illness.

On the other hand, persons with even quite severe psychosis, eg schizophrenia, can function more or less normally most of the time, if they have insight and cooperate with psychiatrists.

Concluding - there are two different things which can have sometimes similar symptoms, but quite different reasons.

If someone's problems are caused by chemical imbalance, medication can be useful. If they are caused by unwillingness to face reality, it will be always detrimental.

The second problem is much more widespread, and so treating it chemically is much more profitable.

[Rebecca]

On the same lines as this article are our Medical Monday's posts from the new book THE LOSS OF SADNESS, check them out here: http://blog.oup.com/2007/08/sadness/
http://blog.oup.com/2007/08/depression/

[Velvet Elvis]

The reason for all medications is profit, not just psychiatric ones. An anti-depressant is no different from hemroidial cream which is no different from experimental AIDS vaccines. I fail to see how you can make the leap from the existence of for-profit pharmaceuticals to supporting a view that drips with Cartesian dualism despite your professed statement of being a materialist. Check out this recent editorial from Psychiatric News calling for an end to the mind/brain split: http://pn.psychiatryonline.org/cgi/content/short/42/15/11?rss=1 On a related note, here's a piece in the Psychiatric Times discussing free will. St. John's wort is a mild MAO-I, fwiw. Once a molecule gets past the blood-brain barrier, it's irrelevant if it's plant-derived or made in a lab. A lot of modern pharmacopoeia is plant derived. The stuff from plants is just more likely to have animal urine on it.

[dimitri fanourakis]

It's taken a lifetime
To crawl out
Of the mind
I was born with.

And now, over.

Just who is it walking around on SSRI's, certainly not oneself.

[Bill the first]

if there were a scale of depression, I would be way up there. But there is not

Yes there is: the DSM-IV. Like all models it's wrong; like all models that persist, it's useful.

...it has been shown in a number of studies that the difference between antidepressants and the placebos against which they are tested is statistically negligible.

As far as I am aware, a much greater weight of evidence demonstrates that antidepressants have a significantly greater effect than placebo controls. (We should beware generalizations, too -- for instance hypericin is useless against severe depression, but as good as cognitive behaviour therapy and well out in front of placebo controls against mild depression and dysthymia.) I am speaking from my impressions of the literature though and cannot cite relevant meta-studies off the top of my head. Perhaps you can point me to some references?

Can the same thing be said of chemotherapy?

You misconstrued my use of the word "chemotherapy" -- or I misused it. I meant merely chemical therapy (against depression) -- that is, antidepressants. (Is "chemotherapy" generally understood to relate only to cancer? If so, I was not aware of that usage and I apologize for the confusion.)

I thus repeat my concluding claim, that their success has more to do with marketing than with chemistry.

The success (that is, profitability) of the drugs as objects of trade, or the success (that is, efficacy) of the drugs as clinical instruments? If the former, I agree; but if the latter, I largely disagree. That marketing plays a role is almost certain: the more a patient believes a treatment will help, the more it helps in many cases, not just mental illness. But that it plays a primary role I simply cannot believe -- in light of both my own subjective experience and what I have seen of empirical evidence.

As you point out, pharmacological management of serotonin and other neurotransmitter levels does not work for every depressed patient. That does not necessarily mean that depression does not reduce to physiology, only that we do not yet understand the relevant physiology well enough. We do not yet even have a complete catalog of molecules that act as neurotransmitters!

You say: the insistence on reducing the problem to a mere medical condition represents something of an obstacle in our path towards self-understanding.

I continue, however, to insist that it is a medical condition -- nothing "mere" about it, very complex, and as yet not at all well understood or controlled, but a medical condition nonetheless. I see empirical research as the path to a solution. You say:

each of us is left to describe our own depression in our own way, to downplay it or emphasize it as a part of our identity, and to conceptualize it as a disease or as an existential challenge, as we see fit

but I think that the vast majority of us would do best to treat our depression as a disease, because that is what it is, and modern pharmaceutical research is our best bet.

In the meantime, as that research closes in on treatments for more and more variations on the depression theme, those who do not find current therapies useful are left with -- whatever they can find. (I think you are probably in this category.) I do not mean to rob you of any possible agent of relief and wish you only success; but I do insist on pushing back when you generalize from your own personal hell in such a way as to undermine what I see as the best way out of mine.

[Ag]

Justin,

I would like to thank you for a well written essay on a difficult topic; but why no discussion or mention of the placebo effect? Are the mind /soul and body totally separated from each other to the extent that the body is just a generic vessel used to hold the soul?

I have no answers just questions.

[Chip Gibbons]

Something to think about (but not too seriously):

"All are lunatics, but he who can analyze his delusion is called a philosopher." Ambrose Bierce

Source

[Jordynne]

Like you, Justin, I've come, through and yet still in major depression (none of the New Wonderful pharmaceuticals dispelled, palliated, or mitigated my symptoms - indeed most them worsened them gravely), to something like balance.

From most people I seem to differ in that my sense of life's bittersweetness is unbidden, nigh ominpresent, and almost always overwhelming, rarely lovely, always provocative of weeping. What I most envy in non-depressives is their lack of tension, and their glibness, born of the freedom of not having constantly, of not feeling driven constantly, to parse one's own mind, one's own self, one's every stimulus and motivation, action and inaction - and their consequences. Depression never stops being an ever-deepening hole one never sought to dig, and despite one's intense ache to put down the shovel, down in this hole there comes eventually, perhaps inevitably, the deadly apprehension that one cannot ever, may not, put it down. Unlike Churchill and others, I've never been able to conceive of my depression as a visting antagonist, because my depression IS I.

[Alex de Lucena]

i say i agree to cultural differences vis-a-vis meds. Because of the efforts of big pharma, for good reasons and a bunch of bad ones, we as a culture do the pill thing, and we wonder why other people don't do pills and on. Which isn't to take away from how much pills help people, the seriousness of depression and so forth. And likewise, I can't say whether other are better. What I will say, is that cultural differences are not, some people plain have better aptitudes fro pills than others. An easy and lighter example is birth control. I know women who go crazy, just totally change, and others who take them for years no problem. And I've known people effected very differently by meds. The pro-pills response is to assume well then, why not try this one. I say pills aren't perfect if they work for you great, but if they don't for the next guy, stop bringing him down with all the talk of pills, the man's had enough.

For the record, Aristide never took Prozac. A CIA officer, Brian Latelle, presented forged documents that he had been in a Canadian psychiatric ward, to Jesse Helms and others in a closed briefing. The information was given to Bob Novak. Helms spoke, Novak wrote. The documents were proven false and by then the damage was done and non one cared

[Bill Ectric]

Bill the first knows what he's talking about.

Maybe I'm just lucky, but to me, a sugar pill is to sertraline what ginger ale is to vodka.

It probably just comes down to individual body chemistry.

[oxstu]

Sir,

You should be commended for dealing with MDD and OCD in a public forum.

However, while all experience is personal, I do fear you're working with either dated or reductionist models.

First, there is indeed a depression scale (and not the DSM IV). It's called the Hamilton Depression Index, and it rates the severity of the disorder. Which is what you're missing in the studies citing equivilence in placebo and SSRI efficacy. That idea was most notably put forward in an article by Kirsch called the "Emperor's New Drugs". However, his studies were flawed. Kirsch set a baseline score on the Hamilton Index, and ignored progressive severity above that. It has since been shown that SSRI efficicy corresponds to the severity of one's depression. The more depressed you are, the more effective SSRIs will be. Furthermore, there is no doubt whatsoever that SSRIs are far more effective than placebos for treatment of anxiety disorders.

Secondly, your points regarding SSRIs, suicidality and cultural difference need to be addressed. The finding that SSRIs increased the chances of suicidality was done in a literature review, and was fairly inconclusive in the first place (it showed a very small chance of increase: I believe 1.4 to 1.8%, but could be wrong). It has since been challenged. Consider the following: Depressed people commit suicide more often than those who aren't; depressed people sometimes take SSRIs; depressed people on SSRIs sometimes commit suicide. Why does it follow that SSRIs are to blame? Beyond that, consider how hard this proposition is to test for since you can't actually measure suicidal ideation. In anycase, there have been at least three or four significant studies showing that the increase is, at most, nominal.

Which leads me to your culture point. Similar studies following on the SSRI/suicidality model have found significant decreases in suicide in those societies where SSRIs are most prescribed. How does one explain this except through a biochemical model?

As an aside, since the FDA Black Box warning regarding adolescent suicidality and SSRIs, there has been a large decline in the number diagnoses and corresponding treatment of paediatric depression. I'm not so sure this is a positive development or just the return of the depression stigma. What is also known is that SSRIs do not play well with bipolars (I can personally attest to this). A leading theory is that suicidality ideation with SSRIs is really a result of unmasked dysphoric mania.

Finally, and most contentiously, I would argue that the idea of "chemical imbalance" being involved in MDD is a little simplistic. The phrase itself is, to the best of my understanding, misleading. The more subtle (though here still hopelessly reduced) view is that normative neurotransmitter function is responsible for feelings: Something bad happens, serotonergic functioning changes to make you feel it. It is repeated stress, quite possibly coupled with a genetic predisposition, that causes the critical biochemical stroke. Recent studies, combined with neurologic imaging, suggest that parts of the brain, such as the hipocampus, which normally regenerate are atrophied or smaller in cases of MDD. My understanding is that serotonin is somehow either involved with the reproduction of healthy new cells, or responsible for the overall health of the affected area. The action of SSRIs is now thought to be neurorestoritive to these parts of the brain. The current model has MDD as less of a chemical imbalance, and more an actual physical change within the structure of the brain itself.

All of which is to say that depression is a vicious circle. We naturally respond in certain ways to environmental stress. For whatever reason that natural action gets taken too far, and therein lies the trap. You cross that line and it isn't your environment anymore. Then it has become ontological.

You are right, treatments must be individual, and patients must be knowledgable about and comfortable with their treatments. Somewhere I was told that if each neuron in your brain was a twelve inch tv, then they would cover the entirety of the surface of one of the WTC towers. Finding a problem in there is inevitably difficult. But anti-depressants certainly have a role to play beyond lining the pockets of "big pharma".

[Nick Smyth]

Bill the first, your comments are well-informed but exceedingly myopic in light of what Justin is trying to do, here.

The point is that everything has been medicalized in the past 150 years. The problem with such medicalization is not that it does not produce results (at least, for some) but that it ignores the real issue: getting the sufferer to contextualize and understand their own difficulty. Regardless of the succes or failure of medication, surely this is important!

You can see a strong parallel in anorexia. Anorexia has long been classified as a mental disorder. Few anorexics are told by their doctors (or by anyone, for that matter) that there is a thousand year-old tradition in the West centred around women fasting, being blessed by God for being able to stay alive on almost nothing. This is the context through which a patient may begin to understand the cultural influence surrounding her own disorder and come to terms with it, rather than simply be forced, through behaviour modification and medication, to eat regularly again. Surely this is the desirable mode of healing, but it is absolutely not encouraged by the simple classification of the problem as a brain-illness.

No-one is claiming that depression isn't a terrible thing or that medication can't be helpful for a large number of people. But the spirit of Justin's essay is clearly to point towards his own first-personal experience and the unhelpfulness of modern medicine in light of his own desire to understand what it is. If someone really, truly wants to tunnel-vision their way through life and never step back to ask what cultural and philosophical patterns are operating, popping pills until they die, that's obviously their perogative.

Oh, and Justin, Bruno G. says hi!

[Bell]

I feel like a basic philosophical point is being missed here, and it goes all the way down to mind-body dualism. To say that depression has "a medical component" is nonsense. Unless you believe in soul-stuff, EVERY thought, notion, mood, whim, impression or vague feeling has physical components because that is what creates them.

Likewise, to say that cause lies either on the level of a chemical imbalance or in somehow being stuck in a certain mode of thought is wrong and misunderstands reductionism.

When you zoom in from looking a behaviour (psychology) to cell function (neuroscience) you're not witnessing different patterns, you're witnessing the same patterns in different levels of detail. Now, it could be that a certain pattern exists in microscale (zoomed in) but cancels out at higher levels (like random quantum fluctuations averaging out at our level to create a seemingly deterministic universe), and other patterns will be apparent at high levels but be unrecognizable at low levels. But they will always be one and the same, just viewed from different ideological vantage points.

Perhaps you shake your head at this (or already skimmed to the next entry), but I think it's worth bearing in mind, if you ever want to get your head around this stuff, that the dichotomy between "depression is chemical disease" and "depression is thought problems" is a false one.

[Bill the first]

there is indeed a depression scale (and not the DSM IV). It's called the Hamilton Depression Index

Quite right; my mistake, thank you for catching it.

[Justin]

The Hamilton Depression Scale's principle interest is in its near perfect illustration of the impossibility of quantifying experiential states. As far as I can tell, the various items on the checklist are either only dubiously correlated with depression (e.g., weight loss, rapid heart beat), or they are near or full synonyms of depression (feeling blue, etc.).

Asking someone if they "feel blue," and then getting the report, "yes, quite," is not in any serious sense a measurement of depression. The severity of constipation --still another item on the list-- is rather easier to measure, but its relevance to the issue at hand is unclear to me.

Qualitative scales can be useful: Moe's Hardness Scale, for example, helps us to place minerals in relation to one another. But Hamilton, in contrast with Moe, does not rely on properties of the object of study that may be mutually inspected by third-party observers; it relies only --as it must-- on the self-descriptions of depressives, e.g. "I feel really really really blue all the time!" This, again, is a point of disanalogy with diabetes or cancer, cases in which the patient's qualitative description of how he or she feels is irrelevant. Hamilton gives a veneer of medicality to a condition that is best described in other terms. This should not be all that surprising, in a culture in which the humanities --the disciplines that reflect upon the human condition-- are obligated, for their very survival, to conform to the model of the natural sciences and speak in terms of 'methodology' and 'results'. The result is an impoverished understanding of our condition, whether we are talking about the experience of depression, or, I add, of joy.

[Nathan]

Those that live in the past/future tend to succumb to various lurgies and perceived anxieties however those living in the present never seem to have such problems.

I have also found that those grappling with depression have the luxury to do so, a warm duvet on an endlessly rainy Sunday morning, that they can pull over their heads whenever life comes calling.

The key is to throw back the duvet, get on the road and change the aspects of your life that are causing you not to embrace it.

Perhaps it's our modern static existence, the houses lived in for a lifetime, the jobs that go nowhere, the memories that stain the walls, reminding us of the past/future when we should be focusing on the present.

It takes bad times to know good times and I would never wish it any other way.

[rjg]

Very good essay Justin. Having been MDD a big chunk of my life and on SSRIs most of it since, I think you've captured the strange dilemma of saying just what depression is. Yeah, I think a purely medical conception of depression (outside of a clinic when treatment is really needed)by society shortchanges our understanding. But I can't be surprised -- we are a consumer society that functions on marketing. I've long since stopped worrying about how our society sees depression and medication for it -- it is such a unique thing and so subtle, that a general understanding of it is probably impossible. Of course, I can't separate any of my views from my psychological history. Depression does teach one about the fragility of perception. It's taught me a lot of valuable things (like: thank god for medication!!) -- the most valuable is an understanding of faith, which being an atheist I might not otherwise have stumbled upon. FWIW, the early reports of increased suicide related to anti-depressants, at the time not supported by data, were disseminated dishonestly by the Scientologists. Which leads me to another point, you'd think clinical evidence of the efficacy of SSRIs would eradicate the stigma of depression as a disease of character. Even though most people would now say it's a "medical" problem, underneath I think there is still a strong current of blaming the victim. It's just the way people are.

Nathan: Power of Now only goes so far. I'm all for it but mileage really varies.

[Enchanted Pony]

http://www.mindfully.org/Health/2003/Mad-In-AmericaJun03.htm

Mad in America
Bad Science and Bad Medicine
TERRY MESSMAN / Street Spirit (San Francisco) Jun03
[Robert Whitaker interview below]

"In Mad In America, one lone author bears moral witness to the suffering of hundreds of thousands of people, and names the names that deserve to live in infamy."

Maeve Adams wrote:
"Rather, I think he is saying that the success of these drugs on the market is, in large part, an effect of how they are valued within culture and thanks to marketing. The success of any given drug has little to do with their ability to help people . . . .

These are extremely sensitive matters. But, it is important for us to think about the role of marketing, writ large: that is, not merely about ad campaigns, but also about how we constantly re-make our selves (and our "well-being") according to the received images of consumers (and commodity swallowers) of various kinds."

That's for sure. Be careful what you swallow. Could damage brain, liver, pancreas . . .

Thank you, Justin, for writing about your experience with depression.

E. P.

[oxstu]

"When you zoom in from looking a behaviour (psychology) to cell function (neuroscience) you're not witnessing different patterns, you're witnessing the same patterns in different levels of detail."

Yes. I stated it poorly, but that is what I was trying to get across. Case in point, there are studies suggesting talk therapy might approximate the same biochemical changes stimulated by anti-depressants.

"The Hamilton Depression Scale's principle interest is in its near perfect illustration of the impossibility of quantifying experiential states."

Sure, clinical evaluation doesn't do a good job of describing how you feel or immediately helping you cope with it. But that doesn't change the fact that there is a correlation between Hamilton score and SSRI efficacy. Something you call into question above.

"Hamilton gives a veneer of medicality to a condition that is best described in other terms. ... The result is an impoverished understanding of our condition, whether we are talking about the experience of depression, or, I add, of joy."

I agree. And you make a compelling case. I just wanted to register some objections to specific points you made, since I feel medicalisation has aided my understanding of how I experience being as a manic-depressive.

[Janet]

Hai Justin,
I really, really appreciate what your wrote.

[oaxca]

The berserkers didn't use psilocybin mushrooms - they used Amanita Muscaria ('fly agaric'), whose active ingredient is muscimol. Amanitas don't contain psilocybin. They are a very different drug unrelated to the psilocybes.

Great writing, very thoughtful.. It hit me as important and I took time to hear what you were saying. I'm glad you post your thoughts online.

Probably ought correct that drug reference, though :)