E Scott Fitzgerald wrote in The Crack-Up that “at three o’clock in the morning, a forgotten package has the same importance as a death sentence, and the cure doesn’t work—and in a real dark night of the soul it is always three o’clock in the morning, day after day.” That demon of three o’clock has visited me.
When I am most depressed, I do feel a gradual lifting during the day, and though I become exhausted easily, the late, late night is my functional period—indeed, if I were to choose by mood states, I’d live my life at midnight. There has been limited research in this area because it is nonpatentable, but some studies indicate that the mechanisms are complicated and depend on when you sleep, what part of sleep you are in when you wake up, and a variety of other technical factors. Sleep is the primary determinant of circadian body patterns, and altering sleep disrupts the timing of neurotransmitter and endocrine release. But though we can identify much of what happens during sleep and can observe the emotional dip that sleep enables, we cannot yet draw direct correlations. Thyroid-releasing hormone goes down during sleep; is that what causes the emotional dip? Norepinephrine and serotonin go down; acetylcholine goes up. Some theorize that sleep deprivation increases dopamine levels; one series of experiments suggests that blinking causes dopamine release and that a long period of having your eyes shut therefore cuts down on dopamine.
You clearly can’t deprive someone of sleep altogether, but you can keep people from going through the late stage of restless REM sleep by waking them up when it begins, and this can be an excellent way to keep a depression in check. I’ve tried it myself and it works. Napping, which I long to do during depressions, is counterproductive and can undo all the good achieved through being awake. Professor M. Berger of the University of Freiburg has practiced so-called sleep advancement, in which people are put to bed at five in the afternoon and woken up before midnight. This can have a beneficial effect, though no one seems to understand why. “These treatments sound kind of wacky,” Thomas Wehr acknowledges. “But frankly, if you said to someone, ‘I’d like to put some wires on your head and run electricity through your brain and induce a seizure because I think that might help your depression,’ and if that were not a widely practiced and well-established treatment, it might be hard to get it going.”
Michael Thase, of the University of Pittsburgh, has observed that many depressed people have substantially reduced sleep altogether, and that insomnia during depression is a predictor of suicidality. Even for those who can sleep, the quality of sleep is substantially altered during depression. Depressed people tend to have low sleep efficiency; they seldom or never enter the deep-wave sleep that is associated with feelings of being refreshed and well rested. They may have many brief episodes of REM sleep rather than the fewer and more protracted episodes typical of a healthy individual. Since REM sleep may be described as a minor awakening, this repetitive REM is exhausting rather than restful. Most antidepressants reduce REM sleep, though they don’t necessarily improve the overall quality of sleep. Whether this is part of their mechanism of action is hard to know. Thase has observed that depressives with normal sleep may be more responsive to psychotherapy, and that those with abnormal sleep tend to require medication.
Though sleep during depression brings you down, chronic undersleeping may be the thing that triggers depression. Since the invention of TV, the average night’s sleep has gone down by two hours. Could society-wide increased depression be a result in part of decreased sleep? Of course we have a basic problem here: we not only don’t know much about depression, but also don’t know what sleep is for.
All the other body systems can be muddled in ways that appear to be productive. Cold exposure can have similar effects to sleep deprivation. Caribou who stand still through the relentless night of a northern winter before beginning to move again in the spring are in “arctic resignation,” which can look a lot like human depression. Cold does, in some animals at least, cause a general slowdown.
Saint-John’s-wort is an attractive shrub that blossoms around Saint John’s Day (June 24). Its usefulness as a medicine has been established at least since Pliny the Elder, in the first century A.D., who took it for bladder troubles. In the thirteenth century, it was held to chase away the devil. In the United States at this time, Saint-John’s-wort is sold in extracts; as a powder; in tea; as a tincture; and as an ingredient in everything from feel-good shakes to nutritional supplements. It is all the rage in northern Europe. Since there is no financial incentive to research naturally occurring substances that are not subject to patent, there have been relatively few controlled studies of Saint-John’s-wort, though some government-sponsored research is underway at this time. Saint-John’s-wort certainly appears to work, alleviating both anxiety and depression. What is not clear is how it works; in fact, it is not even clear which of the many biologically active substances in the plant does the working. The substance about which most is known is hypericum, which is usually about 0.3 percent of a given extract of the drug. Hypericum seems to be capable of inhibiting the reuptake of all three neurotransmitters. It is said to lower the production of interleukin-6, a protein involved in immune response, excessive quantities of which make people feel generally miserable.
The natural-medicine guru Andrew Weil claims that plant extracts are effective because they operate on multiple systems; his view is that many potent agents working in concert are better than overdesigned molecules, though how or whether these agents actually aid one another is pure conjecture. He celebrates the dirtiness of the plant remedies, the way they act in multiple ways on multiple systems of the body. His theories have limited scientific backing but a certain conceptual charm. Most people who choose to take Saint-John’s-wort are not taking it for its therapeutic dirtiness. Rather, they have selected it because of a sentimental view that it is better to take a plant than to take a synthesized substance. The marketing of Saint-John’s-wort exploits this prejudice. In an advertisement that ran for a while in the London Underground, a blonde woman with an expression of bliss on her face was identified as “Kira, sunshine girl,” who was kept in high spirits by the “gently dried leaves” and “cheerful yellow flowers” of Saint-John’s-wort. The implication of this ludicrous ad—as if the gentle drying or yellow color had anything at all to do with the efficacy of the treatment—reflects the sappy approach that has made Saint-John’s-wort such a popular remedy. It is hardly “natural” to take Saint-John’s-wort in a specified quantity regularly. That God put a certain configuration of molecule into a plant and left another configuration of molecule to be developed by human science hardly recommends the first arrangement over the second. There is nothing particularly attractive about “natural” illnesses such as pneumonia or “natural” substances such as arsenic or “natural” phenomena such as tooth decay. It should be remembered that many naturally occurring substances are extremely toxic.
I have noted that some people have adverse responses to the SSRIs. It is worth noting that Saint-John’s-wort, for all that it grows wild in meadows, is not more innocent. Natural substances are sold in poorly controlled ways, so that you cannot be sure you are getting the same amount of the active ingredients from pill to pill, and they can certainly have dangerous interactions with other drugs. Saint-John’s-wort can, for example, decrease the effectiveness of (among others) oral contraceptives, cholesterol-lowering statin drugs, beta blockers, calcium-channel blockers for high blood pressure and coronary heart disease, and protease inhibitors for HIV infection. My own view is that nothing is wrong with Saint-John’s-wort, but nothing is particularly right about it either. It’s less well regulated, less studied, and more fragile than the synthetic molecules, and it tends to be taken in a less consistent way than Prozac.
In the lusty search for “natural” remedies, researchers have dug up another curative substance, this one called S-adenosylmethionine, or SAMe for short. While Saint-John’s-wort has been a psychological panacea in northern Europe, SAMe has been the most popular treatme
nt in southern Europe, with a particularly large following in Italy. Like Saint-John’s-wort, it is unregulated, available from health food stores as a small white pill. SAMe does not come from a cheerful flower, as Saint-John’s-wort does, but rather is found in the human body. The level of SAMe in individuals varies with age and gender. SAMe occurs all over the body and enables many chemical functions. Though depressed people do not have low levels of SAMe, studies of the substance’s efficacy as an antidepressant have been encouraging. SAMe consistently beats placebos in the alleviation of depressive symptoms, and it seems to be at least as effective as the tricyclic antidepressants to which it has been compared. Many of the studies of the drug, however, were not well structured, and their results may not be entirely reliable. SAMe does not have a long catalog of side effects, but it can trigger mania in patients with bipolar disorder. No one seems to have any concrete idea what SAMe’s mode of action is. It may be implicated in the metabolism of neurotransmitters; long-term use of SAMe in animals increases their brain neurotransmitter levels. It appears to enhance dopamine and serotonin in particular. A deficiency of SAMe may be linked to poor methylation, which would subject the body in general to stress. The elderly tend to have low levels of SAMe, and some researchers have proposed that this deficiency is linked to the lowered function of the aging brain. Many explanations for SAMe’s apparent effectiveness have been proposed, with virtually no evidence to support any of them.
Homeopathy is occasionally used to counter depression: Practitioners administer tiny doses of various substances that might in larger doses give healthy people depressive symptoms. Many forms of non-Western medicine may be useful against depression. One woman who had battled depression all of her life, and who had had little help from antidepressants, found, at the age of sixty, that Qigong, a Chinese system of breathing and body exercises, could eliminate the problem altogether. Acupuncture, which has been gaining more and more adherents in the West—Americans now spend $500 million per year on it—has also had amazing effects for some people. The NIH acknowledges that acupuncture may change brain chemistry. Chinese herbal medicine seems less reliable, but some people have achieved great shifts in their consciousness through the use of herbal remedies.
Many people who use alternative therapies have tried conventional ones. Some prefer the alternative therapies, while others are seeking to supplement conventional treatments. Some are conceptually drawn to means of healing that are less intrusive than medication or ECT. Avoiding the talking therapies seems to be at best naive, but finding variant talking therapies, or using talking therapies with nontraditional forms of treatment, can be preferable for some people to visiting the pharmacologist and ingesting compounds about which we still know perilously little.
Among those I met who had danced any distance down the homeopathy highway, I hold Claudia Weaver in particularly high regard. Claudia Weaver is forcefully herself. Some people change with the situation and become reflections of the people with whom they are in dialogue, but Claudia Weaver has a particular mix of bluntness and eccentricity that knows no masters. It can be unsettling, but there is also something extremely satisfying about it. You know where you stand with Claudia Weaver—not that she isn’t polite, because she in fact has impeccable manners, but because she is quite uninterested in disguising her essential self. Indeed she throws down her personality almost like a gauntlet: you can rise to the challenge and like her and she’ll be pleased, or you can decide that it’s a little bit too difficult, in which case you are welcome to go your merry way. As you get to know her, you find her idiosyncratic mind charming. With her deliberateness go loyalty and measureless integrity. She is a very moral person. “I certainly have my eccentricities, and I just became proud of them,” she says, “because I couldn’t understand how to live without them. I’ve always been very particular and opinionated.”
When I first met Claudia Weaver, she was in her late twenties and was on homeopathic remedies as part of a whole-body treatment that was to control her allergies, her digestive problems, her eczema, and other aspects of her health. She was concurrently using meditation and had changed her diet. She carried with her some thirty-six vials of different substances at different potencies in tablet form (she had a further fifty at home), several oils, and an Ayurvedic tea. She was taking all this on a schedule of dazzling complexity, ingesting the tablets whole in some instances, grinding them up and dissolving them in others, and administering certain ointments topically. Six months earlier, she had put aside once and for all the medication on which she had relied on and off since age sixteen; she had had problems with drugs and was ready to try something else. As had happened on some other occasions when she had stopped, she experienced a temporary high and then began to slip down. A brief go with Saint-John’s-wort had been ineffective for her. The homeopathic remedies had stopped her short of disaster and seemed to be fairly effective.
Her homeopathic practitioner, whom she had never met face-to-face, lived in Santa Fe, where he had treated a friend of hers with excellent results. She called him every day or two to discuss how she was feeling, and he asked her various questions—“Does your tongue feel coated?” or “Do your ears feel runny?” for example—on the basis of which he prescribed remedies, usually about six pills a day. The body, he maintains, is like an orchestra, and remedies are like tuning forks. Claudia is an enthusiast for rituals, and I think that she was somewhat persuaded by the very complexity of her regimen. She liked all the little bottles and the consultations and the protocol of the enterprise. She liked taking the elemental cures—sulfur, gold, arsenic—and the more exotic compounds and mixtures—belladonna, poison nut, squid’s ink. The focus on treatment distracted her from the illness. Her practitioner could usually address an acute situation even if he couldn’t alter the underlying arc of higher and lower spirits.
Claudia has had a lifetime of insight into and discipline concerning her depressions. “I have a lot of trouble remembering positive things when I’m depressed. I go over and over the negative things that people did to me, for which I have an elephant’s memory, and times when I was wronged or shamed or embarrassed, and they escalate and become worse than they were in real life, I’m sure. And once I think of one of those things, I can think of ten and that leads to twenty more. In an alternative-spirituality group to which I belong, I was asked to write down negative things that have hindered my life, which I did for twenty pages; and then I was asked to write down positive things. I couldn’t think of anything positive to say about myself. I also get fascinated with dark subjects, with Auschwitz or with a plane crash, and I can’t stop imagining dying in such situations. My practitioner can usually figure out what to prescribe to alleviate my obsessive fear of disasters.
“I have quite a lot of experience with me. Next month it’ll be twenty-nine years of experience with me. And I know that I can give you a linear story today and that tomorrow it will be a different linear story. My reality changes with my moods so much. One day I can tell you how terrible my depression is and how I’ve been racked with it all my life; and then if it seems to be more under control the next day, I can say that everything’s just fine. I try to think of happy times. I try to do things to prevent me from introspection, which leads to depression fast. I feel ashamed of everything about myself when I am depressed. I can’t take on board the idea that probably everyone else is also a human being and also going through various emotional states. I have humiliating dreams; even in my sleep I can’t get away from this horrendous, weighty feeling of being oppressed, and life being hopeless. Hope is the first thing that goes.”
Claudia Weaver felt oppressed by her parents’ fixity: “What they wanted was for me to be happy in ways that were their ways.” Already in childhood, “I felt very much in my own world. I felt I was different and apart. I felt small, and that I didn’t count, and lost in my thoughts, and almost unaware of other people. If I was out in the backyard, I would just wander around there, not seeing anything.” Her
family was “very stiff upper lip” about the whole thing. In third grade, she began to withdraw physically. “I hated to be touched or hugged or kissed, even by my family. I was so tired all the time at school. I remember teachers saying to me, ‘Claudia, pick your head up off that desk.’ And nobody thought anything of it. I can remember getting to a gymnastics class and just falling asleep on the radiator. I hated my school and didn’t feel like I had any friends. Anything other people said could hurt me, and did. I remember walking the halls by sixth or seventh grade and not being interested in anybody and not feeling like I cared about anything. I’m extremely bitter about my childhood, though at the time I was also strangely prideful of my difference from the rest of the world. The depression? It was always there; it just took a while to name it. I had a very loving family, but it never occurred to them—or to most parents of their generation—that their child could have a mood disorder.”
Her one real pleasure was riding, at which she showed some talent. Her parents bought her a pony. “Riding gave me self-confidence, it gave me happiness, it gave me a window of hope that I didn’t have anywhere else. I was good at it and I was recognized as being good at it and I loved that pony. We clicked together as a team and knew each other as partners. He seemed to know I needed him. It brought me out of my misery.”
The Noonday Demon Page 21