We are always most comfortable when the events of our lives fit into a clear and meaningful narrative, when we can assign significance to the inexplicable. When the facts are lacking, imagination steps in. The ancient Greeks explained natural disasters as a kind of collateral damage caused by the ongoing squabbles of the gods. Even today it's religion, not science, that for most people provides answers about the meaning of life and the mystery of death.
We cannot let the inexplicable alone. In many cases our desire for clarity leads us to assign moral and political meanings to things that are morally and politically meaningless. The writer who has offered the most eloquent protest of this misguided tendency has been Susan Sontag, who in two books has attempted to remove illness from the realm of metaphor--to wrest cancer, AIDS, and other diseases free from the meanings that have become, improperly and in some cases dangerously, attached to them. In Illness as Metaphor, she argues that illness should be regarded apart from the "punitive and sentimental fantasies" that surround it. In the 19th century, tuberculosis was "often regarded sentimentally, as an enhancement of identity," a romantic affliction of poets and sensitive souls. In the 20th, cancer has been "regarded with irrational revulsion, as a diminution of the self." And AIDS, as Sontag points out in AIDS and Its Metaphors, has been enveloped in moralistic narratives powered by guilt, fear, and hatred.
Aside from AIDS and other sexually transmitted diseases, the illnesses most loaded with inappropriate meaning--both glorified and stigmatized--have been mental. The radical antipsychiatrist R.D. Laing celebrated madness: he said he hoped in his practice to "help future patients go mad" so that they could take something like a psychedelic voyage of discovery and come back to share their new knowledge with the "sane." "Perhaps we will learn to accord to so-called schizophrenics who have come back to us . . . no less respect than the . . . explorers of the Renaissance," he wrote. Future generations "will see that what we call 'schizophrenia' was one of the forms in which, often through quite ordinary people, the light began to break through the cracks in our all-too-closed minds."
But this kind of reverence rarely extends beyond rhetoric. In real life, schizophrenics wandering the streets--immersed in their own virtual reality, gesturing and talking to imaginary others--are barely regarded with pity, let alone awe. But at least schizophrenia is regarded as a disease; it's sufficiently strange and remote enough from everyday experience that we can acknowledge that something has gone wrong with the brain chemistry.
Depression is another thing--over the years it's been regarded as almost anything but a disease. In the 19th century, melancholy (like tuberculosis) seemed positively romantic. "A fitful strain of melancholy," Edgar Allan Poe wrote, "will ever be found inseparable from the perfection of the beautiful." Today the mythology of depression is different, despite some lingering romanticism and sentimentality. "Depression," Sontag observes, "is melancholy minus its charms."
These days depression is often regarded as little more than a failure of will--as a self-indulgent tendency to dwell on the negative, a malingering codependency of the soul. In this view, the depressed suffer not from a disease but from their own bad attitude. Those with depression are told, often by well-meaning friends, to just snap out of it, to cheer up, that all will be well if they can somehow get their lives together. It's not true, but it's an interpretation that meshes all too well with the tendency of many depressed people, enveloped by the shame and self-hatred typical of the disease, to blame themselves for their suffering.
William Styron attempted to convey the experience of depression in Darkness Visible, a harrowing account of his own plunge into and painful recovery from the disease. He describes an endless succession of sleepless nights and "days . . . pervaded by a gray drizzle of unrelenting horror." This gifted novelist, who in Sophie's Choice had given voice to the ultimate horror of the Holocaust, finds himself for once at a loss for words. "This horror is virtually indescribable," Styron writes, "since it bears no relation to ordinary suffering. In depression, a kind of biochemical meltdown, it is the brain as well as the mind that becomes ill--as ill as any other besieged organ. The sick brain plays tricks on its inhabiting spirit. Slowly overwhelmed by the struggle, the intellect blurs into stupidity. All capacity for pleasure disappears, and despair maintains a merciless daily drumming. The smallest commonplace of daily life, so amenable to the healthy mind, lacerates like a blade."
Styron's painful eloquence almost gives the experience, even in its ignoble horror, a certain romantic grandeur. But there is nothing even vaguely romantic about depression, nothing that warrants the slightest glorification: it sucks the life out of you, drains the color from your days. Like Styron, I suffered from depression for many years; only recently was I able to escape from it with the help of therapy and, yes, Prozac. My experience was not as dramatic as his, but it was certainly painful. During the worst years of the ordeal I was so fragile, so sensitive to slights, that even the smallest social awkwardness, the tiniest criticism, would leave me fighting off tears. I thought of little but my own problems, and spent my days trying to keep my emotions at bay. It took me a long time even to recognize my suffering as depression; with no self-esteem to speak of, I thought I was simply getting what I deserved, that a pathetic person like me could not (and in some sense should not) escape a pathetic life.
Like many, maybe most of those who suffer the disease, I blamed myself--trying determinedly to "snap out of it," to "cheer up," to "get my act together." Indeed, I thought of little else but of ways to control my feelings, to force myself to dwell on things other than my pain. But feelings are not so easily controlled. You may mitigate some of the symptoms--and through my efforts I did. But you cannot, through an act of sheer will, banish a disease from your brain.
To an outsider, depression may be almost indistinguishable from feelings of sadness and grief. But even the early psychologists recognized that there was something different about depression, that it was more mysterious and more intractable than "normal" neuroses. It can come without warning, and it resists not only the sufferer's efforts but also traditional "talking therapies." Freud recognized early on that his psychology of insight had little to offer those he called "melancholics."
Nowadays specific diagnostic categories have been developed to distinguish clinical depression from ordinary feelings of grief and pain. Sadness stems from loss and disappointment; depression, by contrast, is inexplicable, and often close to indescribable. It arrives unannounced, for no apparent reason (though depressed people are often quite creative in constructing reasons afterward), and the feelings it produces are less the pangs of loss than the empty pain of life drained away. Psychiatrists P.H. Wender and D.L. Klein describe depression as a "painful anesthesia--painful because the patient remembers that life used to be pleasurable . . . anesthesia because of the general numbness." The symptoms of depression can range from obvious feelings of sadness to the more subtle (but no less painful) condition called "anhedonia," which deprives its victims of the ability to experience pleasure. Depressed people may feel hopeless, worthless, helpless, racked with shame and guilt. They may think of or attempt suicide. They may feel restless, anxious, unable to sleep, constantly obsessing over illnesses real or imagined. They may--as I did--cover over their feelings of sadness with a fragile (and often quite transparent) veneer of sociability, leaving themselves acutely vulnerable to even the most insignificant setbacks and slights.
But however useful the clinical terms may be in diagnosing depression, they can't truly delineate the experience. This is a point Styron makes eloquently in his book, which he wrote after his depression had subsided. Struggling to explain an experience that is almost incomprehensible to those who haven't suffered it, he sets down his impressions in a series of fragmentary phrases that come closer than anything else I've read to capturing "a form of torment . . . alien to everyday experience." Styron describes his feelings as those of "drowning or suffocation," saying he felt caught in "a storm of murk"; his surroundings took on "an almost palpable quality of ominousness"; he felt he'd fallen into "a condition of helpless stupor in which cognition was replaced by . . . [what William James called] 'positive and active anguish.'" Each person's experience of depression is unique, each has his or her own collection of symptoms. But Styron captures well the slow, passive horror of the depressed mood, the tedium of its despair, the mental devolution in which one's "thought processes [become] engulfed by a toxic and unnameable tide that obiliterate[s] any enjoyable response to the living world."
Until the relatively recent discovery of effective psychiatric drugs, the only real cure for depression was time. For many, depression eventually vanishes as mysteriously as it first appeared. For others, depression is a chronic problem; the depression never really lifts, or when it does there's only a brief period of normality before it returns. The discovery of antidepressants utterly changed both the understanding and the treatment of the disease; more precisely, for the first time genuine treatment was possible.
The first antidepressant was discovered in the mid 1950s, largely by accident, when doctors noticed that a drug called iproniazid, used to treat tuberculosis, had the side effect of lifting patients' moods. Soon it was being prescribed as a treatment for depression. But other side effects--notably jaundice--were discovered and the drug was taken off the market. Since then a host of new antidepressants has been discovered. But until recently most of them, like iproniazid, came with side effects--dry mouth, constipation, blurry vision, dizziness, fatigue, skin rashes, the shakes--and in some cases these proved more frustrating than the illness itself. One class of antidepressants, the monoamine oxidase inhibitors (MAOIs), can be dangerous when combined with chemicals found in certain common foods, so their users are burdened with a long list of dietary restrictions--forced to avoid everything from pizza to pickles, from bologna to bananas, so as not to send their blood pressure through the ceiling.
But despite their dangers these drugs can be lifesavers, rescuing patients from suicide, from lives of misery and pain. But there has always been a cost; doctors and patients have spent as much time monitoring the unintended effects of treatment as they have watching the progress of the illness. Recently, though, new antidepressants have appeared--Prozac, Zoloft, and Welbutrin--that provide many of the benefits of the earlier medications without, it seems, the side effects.
Prozac, the most famous of the bunch, was hailed as a miracle drug when it was introduced on the market in late 1987. At the height of its early glory, in 1990, a cover story in Newsweek hailed "the promise of Prozac," representing the drug as the cutting edge of a revolution in psychiatry, the first in what could be a series of "breakthrough drugs [that] may change the lives of millions--not because they're inherently more effective in treating depression (they're not) but because they're far easier to tolerate and have a broader range of applications."
Within a few years, though, Prozac was awash in controversy: there were reports that patients taking the drug had suddenly become obsessed with violent thoughts, that some had committed suicide and others had killed. The first such study, a report by Martin Teicher in the American Journal of Psychiatry, described six seriously depressed patients who seemed to have developed "intense, violent suicidal preoccupations" after treatment with Prozac. In media accounts, the few cases quickly became hundreds. One Phil Donahue show was called "Prozac: Medication That Makes You Kill." The Scientologists, backed by money if not scientific evidence, poured fuel on the flames as part of a campaign against psychiatry in general (they'd prefer troubled souls to turn to Dianetics).
But negative reports about Prozac have by and large proved no more substantial than the reports last year of tainted Pepsi. "The vast majority of cases in the media of violence towards others seem to have evaporated under scrutiny," Peter Kramer, the author of Listening to Prozac, explained to me. Those who blamed Prozac for their violent outbursts were often taking other medications as well, had deeply troubled lives to begin with, and had engaged in similar acts of violence before. Subsequent studies, as Kramer recounts in his book, indicate that "Prozac is a remarkably safe drug, perhaps safer than other antidepressants in terms of any tendency to induce suicidality."
Like most drugs, Prozac is not entirely free of side effects. But it does not turn those who take it into monsters. Kramer acknowledges that there is a small risk "that Prozac may, in rare cases, stimulate or worsen suicidal thoughts and impulses." But, he goes on to observe, "the public worry about this possibility is . . . so exaggerated as to be dangerous, because it tends to discourage people from taking Prozac even when it is very likely to do them good and very unlikely to cause harm."
Despite some lingering notoriety--and a few recent studies indicating that a small but noticeable percentage of men taking the drug have had problems with impotence--Prozac has once again become the drug of choice for many kinds of depression, particularly the milder varieties. Nearly ten million people--half of them in the United States--have taken the medication. And it has improved its public image as well, at least among those whove benefited from it themselves or know someone who has. Indeed, the positive response to Kramer's gently enthusiastic paean to the medication suggests that Prozac has begun to lose its Jekyll and Hyde image.
Prozac still carries a whiff of the illicit that I suspect no amount of studies will be able to erase. Like the words "Dan Quayle" a few years ago, the word "Prozac" provides an instant punch line for late-night TV comedians. I don't think it's the alleged side effects that bother people. It's that Prozac promises a quick, simple, and relatively safe remedy for psychic pain. The very simplicity of the cure must be disconcerting to many. Americans have a deeply ingrained sense of what psychiatric researcher Gerald Klerman calls "pharmacological Calvinism," looking upon cures for depression with a puritan's suspicion of pleasure. We're convinced, he says, that "if a drug 'makes you feel good, it must be morally bad.'"
I imagine that what troubles many people most about antidepressants is not the potential for failure but the potential for success. Antidepressants disrupt the noble narratives with which we surround our suffering. They seem self-indulgent. And Americans are oddly "contemptuous of cheerful people," Kramer suggests, just as many people are suspicious of those made suddenly cheerful by medication. Our culture promotes what Kramer calls "melancholic superiority," convincing people "that somehow being melancholic is superior to being happy."
Because Prozac and the other new antidepressants lack the debilitating side effects of the earlier psychiatric drugs, they promise in effect a psychic free lunch. The side effects of the earlier medications were oddly comforting: sufferers could not simply take a pill and free themselves from pain. The best they could hope for was to exchange one kind of suffering for another. Prozac seems quite literally too good to be true--which is probably why so many were willing to believe the worst when rumors of Prozac-induced violence began to circulate.
Remarkably, psychiatric drugs are still regarded with suspicion even by those who use mood altering drugs like alcohol that have far worse side effects and an infinitely greater potential for addiction and abuse. "I treat a number of college students," Kramer told me. "And it's not unusual for someone to come in who's quite willing to use alcohol, marijuana, cocaine but who wouldn't 'pollute' his or her body with an antidepressant. There's a great willingness to take almost anything except what a doctor prescribes."
Those who are suspicious of psychiatry span the political spectrum. In conservative polemicist Charles Sykes's recent book A Nation of Victims, he describes modern psychiatry as little more than an elaborate con job, a "new legal/therapeutic/sick-making industry" created by money-hungry psychiatrists and self-pitying patients. Eager to cast the ordinary problems of life as medical disorders, psychologists "define as symptoms traits that are not exceptionally unusual, create . . . anxiety about them, and promise . . . help. That formula, repeated over and over, is the mark of the therapeutic culture and the foundation of the addiction-recovery industry." Sykes seems particularly perturbed that many recently discovered disorders are relatively common; this seems to him a mark of illegitimacy, as if diseases were only real when rare.
Those on the left have been even more fervently opposed to psychology and psychiatry. R.D. Laing may be generally passe now, but in various forms his premise--that psychic liberation is possible only when one is liberated from psychiatry--is still common among those who consider themselves progressives, though generally in a stripped-down form, bereft of Laing's extravagant, Aquarian-era utopianism.
The most influential recent statement of the "progressive" stance against psychology is Wendy Kaminer's 1992 I'm Dysfunctional, You're Dysfunctional. Though Kaminer writes with a good deal of intelligence and wit, she regards even the briefest acquaintance with self-help literature (not to mention therapy) as an act of cowardice, reflecting an unwillingness to take a properly existential leap into the void of life. "Merely buying a self-help book is an act of dependence," she writes, "a refusal to confront the complexities of a solitary creative act and to endure the loneliness and failures that are the price of its surprises." Her attack on the excesses and imbecilities of the self-help culture slips all too easily into a snide, misguided, and frequently mean-spirited dismissal of psychology as a whole. She has no sympathy for or real understanding of the therapeutic process--claiming in one breath "not [to be] impugning therapy" but in the next "wish[ing] that people would keep [it] off the streets." To her, therapy is little more than an indulgence: "Most of us do love to talk about ourselves," she remarks blithely, "although I've always regarded it as a slightly illicit pleasure or one you pay for by the hour."
Now, it may be distressing to hear psychological insights mangled by celebrity psyche healers on Oprah or to see shoddy self-help books that promise salvation through simplistic formulas, but these things don't prove that psychological suffering is itself a fraudulent notion. In one particularly disgraceful section of her book, Kaminer contrasts the sufferings of people in recovery with the "real" suffering of Cambodian refugees. The logic behind the comparison is as absurd as it is offensive--as if the undeniable reality of political terrorism simply canceled out the more subtle but no less real fact of psychological pain.
The most pernicious effect of the assault on psychiatry has been to encourage the widespread delusion that mental health care is somehow a self-indulgent luxury, the ultimate example of conspicuous consumption. To attack psychiatry, therefore, is to attack the effete decadence of the monied elite. In fact there is nothing progressive about this stance. Poor and rich alike suffer from psychiatric disorders. Those who have belittled psychology and psychiatry over the years as a luxury for the elite have helped to keep it that way, effectively preventing the poor from getting the treatment they need and deserve. Those without insurance find it nearly impossible to get affordable care, and those with insurance find that their coverage is often woefully inadequate in all but crisis situations. When the time for budget cuts comes around, mental health care is often the first to go; when serious negotiations over the Clintons' health care plan begin, it's likely that mental health coverage will be "compromised" out of existence. This despite the fact that the damaging effects of psychiatric disorders are abundantly clear--some 30,000 Americans commit suicide every year, most of them driven by the irrational logic of depressive illness. With proper treatment, many if not most of these deaths could be prevented. But the money is not there.
Advocates of mental health care--in particular those attempting to promote a better public understanding of depression--face a peculiar dilemma. In some ways their task is straightforward: public ignorance of depression is so pervasive that even the most rudimentary explanation is bound to help. But in a broader sense, it's not clear what form their advocacy should take.
Other diseases and conditions cripple the body; depression cripples the soul. In recent years those who suffer from bodily handicaps have gone to great lengths to assert their own dignity, thwarting derision and pity alike, presenting themselves as something more than victims. And the language of disability has shifted. No one would think of calling anyone a "cripple" these days--the debate is over which contemporary moniker ("handicapped," "person with disabilities," "physically challenged") is least destructive. When Jerry Lewis refers to "his kids," many of those he's purporting to help wince. The disabled assert that they too are "normal," that patronizing them is as detrimental as ignorant dismissal. They wish to prove that they can be as self-reliant as anyone else.
Those who suffer from depression face the opposite problem. We don't need to prove our "self-reliance"--in fact we've been doubly handicapped by those who, misunderstanding our complaints as signs of weakness and self-indulgence, have demanded from us a self-reliance that depression makes impossible, at least temporarily. Depression breeds illogic, incapacity; the task is not to show that we can function as well as anyone else but to show in some ways the opposite--that for us "normal" functioning is much harder than it is for almost everyone else. We don't need pity any more than other "cripples," but we do need help.
There is nothing so frustrating for the depressed as to have someone blithely tell them that things aren't as bad as they seem. There is nothing so infuriating as listening to advice from people eager to see you "snap out" of your despair--as if depression could be cleared up with the proper hobby, with a better diet, by just getting out more. Underlying the advice in many cases is a kind of anger: why can't these people get their lives together like the rest of us?
The reply is nearly as frustrating to outsiders as the question is to the depressed: because they can't. The logic of everyday life does not apply. The depressed cannot cure themselves of their despair any more than someone can "snap out" of heart disease. And only when we as a society recognize depression as a disease, not as a moral or social failure, can we begin to talk about a solution.
Art accompanying story in printed newspaper (not available in this archive): illustration/Kevin Kurtz.