Paul Kurdyak at CAMH is on board. “A lot of practitioners will say to patients, ‘We’re giving you Prozac or Zoloft or whatever because it increases the serotonin in your brain and that’s what’s going to make you feel better.’ I think that’s a highly reductionist explanation. I say, ‘It seems as though you’re depressed. I’m going to prescribe a medication that, according to the evidence, has the best balance of efficacy and side effects.’…I like saying that, because it’s honest.”7
Gary Greenberg is cool with the idea of psychiatrists psychiatristing, so long as they’re forthcoming about what they know and what they don’t know and their rationale for pursuing the treatment modalities that they do. “If every psychiatrist would just go and say, ‘Okay, here’s what your symptoms are: you’re not sleeping, you’re not eating, blah, blah. The thing that I’ve found, in my experience, helps those symptoms is this drug. And I have no idea why.’…If a doctor was just to do that with a patient, it might diminish the placebo effect but…it might also increase trust and intimacy with the doctor and that might actually make their depression better. There might be more honesty. If there’s honesty going in one direction there might be honesty going both ways. Who knows?”
But why is it radical—why does it even need stating—that a professional who deals with the most intimate and vulnerable aspects of human selfhood should be honest and open about what they’re doing and why? Should treat patients as people, as partners in care, rather than as a flawed mental vessel needing their unadulterated expertise, no questions brooked?
One thing I’ve heard (and seen) over and over is how much deeper an understanding people have of mental illness once they’ve gone through it themselves (directly or indirectly via someone they love). Any experience cuts closer when you know it firsthand. It follows that health practitioners care better for depressed and suicidal people if they’ve been there. But imagine if the only competent oncologists were ones in remission for cancer; if the only decent obstetricians were ones who’d given birth; if only the superannuated could be geriatricians and a neurosurgery prerequisite was having had someone slice into their own brain. Surely the very starting point for trained clinicians in a “caring profession” is basic human empathy—and learning! And putting learning into practice!—to be able to provide adequate, evidence-based mental health care and not be insensitive assholes about it.
Even Bonnie Burstow, who endowed the antipsychiatry scholarship at OISE, agrees that paralytic despair, impenetrable suicidality, psychosis benefit from intervention—she just favours psychotherapy, exercise, social supports over drugs and other medical interventions. The mode of therapy she extols—enlisting suicidal people as “co-investigators” examining their despair and alternate ways out of it—is strikingly similar to that advocated by David Jobes and others pioneering the Collaborative Assessment and Management of Suicidality model. I suggest to her that she’s perhaps not so philosophically different from the psychiatrists she holds in contempt. They both recognize something is wrong. They both think things can be done to alleviate the wrongness, to help make life better or bearable. Both favour an intervention, backed by evidence, that puts the patient in the therapeutic driver’s seat.
Mistake. “It is a huge philosophical difference to believe things are diseases of the brain and to believe that people have problems living that they need help with. It is an unbelievably big philosophical difference.” She pauses. “You haven’t read my book, have you?” You know you’re in huge trouble, as an interviewer, when someone is asking whether you’ve read their book. (And, full disclosure, I had not. I’ve since read several, those she’s written and a couple she’s edited.)
I do understand the rejection of the very idea of mental illness, a repudiation of any medicalizing of the mind. Many people reject the idea that the things that make them unique creatures are reducible to a series of electric impulses. (Although it sounds pretty gorgeous and cool to me.) And, as a patient, whether you classify the thing ripping you apart as an illness or you don’t doesn’t change what it does to you and your life; it doesn’t change which interventions alleviate the awfulness and which don’t. It does, however, change your ability to access interventions and it changes incentives for funding research into new ones. It changes the rules around who provides which interventions and who gets to decide what to call the thing ripping you apart. That’s worth making a fuss over.
Illnesses get coverage. Treatments for illnesses get research resources. People with illnesses have a shot at time off work. People with chronic illnesses and disabilities have rights under human rights codes. Philosophical debates and professional turf wars are well and good until they impinge on individuals’ ability to get care that works, to get respect and compassion.
Whether or not you believe that chronic mood disorders are the result of a faulty brain, the need to classify these despair-states as illnesses and treat them as such remains.
But people don’t seek treatment they don’t trust. The most strident, consistent, compelling objections to psychiatry in general and depression in particular—the science is perceived to be a sham; the treatment is seen as harmful and coercive—are rooted in legitimacy. Industry and clinicians have overstated depression drugs’ efficacy and oversimplified the way depression works. There are side effects to all medical interventions, some more serious than others. People with mental illness or people believed to have mental illness are hospitalized and treated involuntarily. But none of this means that depression isn’t a real, debilitating illness. Depression is a genuine and genuinely awful condition; we just don’t understand it. Drugs, psychotherapy, electroconvulsive therapy, repetitive transcranial magnetic stimulation, exercise, all work on some people to some degree. Depression’s treatment toolbox remains inadequate. Coercing people into getting care is crappy no matter how necessary it is (and people will always disagree as to what justifies that suspension of basic liberty; this is why recourse is important). What this means is that failing to address psychiatry’s credibility problem means people will go untreated or under-treated or die.
“It wouldn’t be psychiatry” if it didn’t involve losing people’s trust, Bonnie Burstow says. I’d like to believe that’s wrong. Because if losing trust is a necessary part of a given field of medicine, it is a bad field of medicine.
PATRICK
Patrick had been a mess for more than half his life. On good days, he sleepwalked through the motions; on bad days, he was paralyzed by anxiety and self-recrimination.8
It started in Grade 9. He became lethargic, lost energy. Fixated on a growing list of his own shortcomings, things he needed to fix within himself to make everything better. Learned to cope with a subsuming sense of worthlessness by retreating into mental haze. “I was kind of out to lunch,” he says. “Normal situations gave me anxiety. So I avoided them.”
That fog makes it hard, even now, for him to recall specific events in his past. It’s like he’s straining to observe the details of someone else’s dream. Chronic mental illnesses mess with both the way you perceive your world and your ability to recall it later. Many of my more intrusive personal interviews for this book were exercises in frustration as I prodded people to recall episodes distorted by cognitive biases and glitchy memory systems.
“All I have to do,” Patrick told himself over the course of decades, “is solve this endless list of things and then everything will be better. You very much tend to blame yourself for all these symptoms. You feel you’re worthless. Yeah, it kind of sucked. But it was just my daily life. I still managed to do things, but I didn’t do very well. I didn’t really talk to anyone, didn’t do well socially, didn’t date. Just trying to get through the day. It was a slog, basically. It was a huge slog.”
Outwardly, he was coping. Excelling, even. Graduated from university with a degree in political science. Spent years teaching English in Korea, backpacking across Southeast Asia. “I was trying to get away from my problems but I just brought my problems
with me. Kind of like wherever you go, there you are.”
He worked as a temp for the Ontario government, as a bike messenger, managing an inventory yard at a construction site. Sought treatment when his motivation was robust enough not to be eclipsed by the hurdles and wait lists. Saw a family doctor “who was totally afraid to write any kind of prescription at all,” waited five months to see a psychiatrist for what felt like a “weird, useless kind of consultation.”
“A lot of psychiatrists are just jerks. Like, they’re very condescending….The bedside manner was usually very cold and dry. A lot of them, I couldn’t even get a word in. It was a very mechanical kind of process. And those are the kind of people who are telling me to go on medication.” How could he trust them?
Patrick went on and off antidepressants for a few years. Mostly off. In part because they never kicked in before his own self-loathing convinced him the issue was himself and his failings—“just a few problems I need to figure out”—not his illness. In part because of a deep-rooted aversion to psychopharmaceuticals reinforced by the information he sought out online.
“You’re still afraid of the side effects, even though the side effects really are nothing compared to depression itself. Like, I was talking to one guy on the internet, on a forum. He was in his late thirties, pretty severe depression. I was trying to convince him to try medication, and he was like, ‘Yeah, but won’t that affect my libido?’ Uh, you already said your libido is nonexistent.” There’s a tendency to think, “‘I don’t want to be a slave to medication.’ People kind of self-sabotage sometimes.”
For all his reluctance to put his trust in conventional antidepressants, Patrick’s need for amelioration led him to Peru for an ayahuasca retreat.
The plant-derived psychedelic drug has become trendy among the wealthy in search of a wellness fix. In elaborate ceremonies, shamans combine leaves from Psychotria viridis with vines from Banisteriopsis caapi—mixing serotonin-targeting hallucinogen N,N-dimethyltryptamine with harmala alkaloids that act as monoamine oxidase inhibitors.9 The same kind of thing, in other words, that I spent years trying, but with an organic substance of uncertain potency and purity consumed in an uncontrolled environment without close medical supervision.
“I started reading on the internet about it….It was all success stories. I was like, ‘Wow. This is the real deal.’”
So he went for it. Booked a retreat at a place in the mountains that got rave reviews online. Sat with fellow acolytes in a circle in a yurt, on a mat with a vomit bucket beside him. Drank the psychedelic brew. Results were not as advertised.
“It was a disaster. A complete disaster,” he says. “The first time was pretty bad but the second time was a nightmare. I don’t even know where to start.” He recalls gory imagery, the horrifying feeling he was about to strangle someone to death. He thought, “I’m going to be in a Peruvian mental asylum for the rest of my life.” For the first time in all his years of melancholic fog, Patrick says, he felt suicidal. Even back in Canada, he was in rough shape. “Not so much flashbacks as just not being able to handle having really horrible thoughts, not being able to handle life, seeing it as kind of meaningless.”
His online search for solutions then led him to ketamine. The party drug was making a name for itself as a potential panacea for treatment-resistant depression. Patrick went to New York to a clinic where an anaesthesiologist administered ketamine intravenously off-label, for a fee.
This cross-border, self-funded test of a relatively unproven treatment turned out better than the last: before the hour-long intravenous drip was even complete, Patrick sat and watched the liquid disappear into his arm and felt…better. “My thinking got really rational all of a sudden. Problems that had seemed totally insurmountable suddenly became so easy to overcome.”
He felt, briefly, like the conductor of his own brain.
“I didn’t hallucinate or anything, but I had this kind of idea that I was in my head and everything was spinning like crazy and I was like, ‘Augh, it’s really crazy here. Just calm down.’ And the spinning got slower and slower and then it was stable. Calm and optimistic. Secure. Social interaction suddenly was very, very easy. Whereas previously it had been incredibly difficult. I could walk into a coffee shop and talk to a barista.”
Patrick got three $400 injections over the course of a week before heading back home to Toronto. “I started dating a lot. It’s always been something I avoided. You feel like you’re the worst person: Why would anyone want to date me? But I was dating up a storm. It was really great.” But the awesomeness wore off gradually; within two months, “I felt like crap again, basically.”
He tried to find a Toronto doctor who’d give him ketamine and restore that magic feeling. Easier said than done. “People are pretty conservative here. Especially with mental health, people have a hard time. You don’t have a bone sticking out of your leg,” so there’s less a sense of try-anything urgency. Most places he asked, he didn’t get past the receptionist. “I mostly just got laughed at. Like, are you crazy? Prescribe ketamine?”
Eventually, he was referred to a Toronto doctor who’d been running trials on ketamine but had since switched to repetitive transcranial magnetic stimulation (rTMS). He joined the trial; it didn’t work. He recalls a mechanical arm and a large disc against his head, and a painful sensation “like someone had a fishhook through your head.”
But he didn’t give up. He got a new doctor. Hearing him describe this individual after his litany of less-than-stellar treatment felt like watching two figures run in slow motion toward each other through a field of wildflowers.
“She was awesome….She was just super-compassionate. A good listener.”
To be clear, this was also the first Canadian doctor who agreed to prescribe him ketamine; people tend to like clinicians who give them what they want. But it still floors me that this dude, after eighteen years of severe depression and a deep distrust of the medical field, waxes lyrical over the prospect of an empathic physician. What a concept!
Now Patrick was getting intranasal ketamine—syringe-type vials with misters attached that he’d spray up his nose once every two or three days. He’d pick up a month or two or three from the one pharmacist in the city that dispensed take-home ketamine (this is not, incidentally, something even the boldest ketamine-boosters I spoke with would recommend you try). “The weirdest part was being high on ketamine every three nights,” Patrick says. “It was kind of fun. Especially at first. Just to be able to legally do that is pretty nice.”
But the antidepressant effect wasn’t there. He got high but remained hopeless. And he was developing worrying signs of dependence—feeling like he needed more, getting antsy as time ticked toward his next dose even as he felt it was now making him physically ill.
Even then he was resistant to traditional antidepressants. “She kept suggesting I try medication again, and I was really stubborn about it.” He avoided them for the same reasons he’d avoided them for years—fear of becoming dependent, of being changed in some fundamental way. “I’d just heard about bad reactions. I was very worried about anything that would change my brain chemistry.”
Yes, someone who tried to treat his depression with ayahuasca and ketamine, who experimented with LSD in his early twenties, was so fearful of antidepressants’ effects on his brain chemistry that he kept refusing to try them even at the urging of the first doctor he’d ever truly trusted. This is not unusual: this is what society thinks of psychiatry and pharmacotherapy. I know plenty of people who’d sooner take mind-altering recreational drugs than anything that operates on those same pathways but comes from a prescription pad and a pharmacy. This trust crisis kills people. Or it destroys their lives when they don’t get effective treatment.
“So it took a lot of convincing. [My doctor] just kept bringing it up. She’s really great…the best person. She just kept subtly implying, maybe it’s time to give this up. Maybe we should try something else. At some point I was like, yeah, this i
sn’t working. I’m just getting high.”
So he started on escitalopram, the run-of-the-mill selective serotonin reuptake inhibitor I’d tried following my first suicide attempt. “And that actually started to work. Gradually, very slowly, as months went by….And I gradually started to kind of turn my life around.” He went back to school. Studied web design. Got a job he genuinely enjoyed. Started meditating on the subway. “It’s relaxing, and it kind of organizes your thoughts more….It’s like creating your own safe zone in your head. A little bit of distance from what’s going on.”
Dating is still tough. Self-esteem is still an issue. But “relatively speaking, I’m doing great compared to where I was before.”
I’m not the hopey-changey type. But hearing this inspires both a vicarious, celebratory joy and a murderous envy.
I’ll have what he’s having.
PART V
A DENOUEMENT OF SORTS
28
First Person Afterword
The worst moment of this chasing was with a woman I met for an interview at a Tim Hortons in Toronto. I arrived late, asked what I could get her. She had the world’s most convoluted request: a small black coffee filled all the way up, with an extra cup, and two milks, and a cup of ice water, and a toasted multigrain bun with light cream cheese on the side and cucumber on the side. So I did. But I also, idiot, offered to get her something more—a proper sandwich—so she asked for Tuscan chicken on a bun but they only had chipotle chicken in a wrap so I got the wrap and an extra bun and sat and watched her meticulously deconstruct and reconstruct the food and drink in front of her as I tried and failed to ask her questions. She didn’t want to talk. Got upset when I asked anything personal or painful, which was every single question: if she was hoping for small talk and a coffee, she was sitting across from the wrong girl. “Let’s just eat first, okay?” she suggested.
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