Ian Hacking tells the story of a doctor in Ontario who, when a patient arrives and announces that she has multiple personality disorder, promptly asks to be shown her health insurance card, which contains a photograph and a name, and then says, ‘This is the person I am treating, no one else.’ There are many meanings that can be drawn from this story, but one, surely, is that diagnoses have the hypnotic power of master words. In a rampantly medicalized age, the classification of depression or borderline carries not stigma but the hope of cure.
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DRUGS
I start to get the feeling that something is really wrong. Like all the drugs put together–the lithium, the Prozac, the desipiramine and Desyrel that I take to sleep at night–can no longer combat whatever it is that was wrong with me in the first place. I feel like a defective model…I start to think that there really is no cure for depression, that happiness is an ongoing battle, and I wonder if it isn’t one I’ll have to fight for as long as I live.
Elizabeth Wurtzel, Prozac Nation
In 1963 Karl Menninger, one of the most important figures in American postwar psychiatry, wrote: ‘We tend today to think of all mental illness as being essentially the same in quality, although differing quantitatively and in external appearance.’ For Menninger, with his psychoanalytic orientation, symptoms were expressions or conversions of an underlying inner conflict. This conflict produced anxiety which could manifest itself in everyday or exaggerated neuroses at one end of the spectrum, or at its other extreme in the severe disintegrations of schizophrenia. Psychotherapy, the dominant mode of treatment and explanation, could work with all of these. In its principal understanding and treatment of mental illness, America was then arguably the least biologically oriented of the Western nations. Nowhere else, neither in Britain nor in France, where they played their important cultural, though less medical, part, did the psychodynamic and talk therapies have such prominence, even with disorders that might need hospitalization. European psychiatry had remained what it had been from its origins, primarily hospital-based, while in America the private or office model of psychiatry, which lent itself to the talking cure, had grown to have great importance.
Then, while in Europe through the seventies the talk therapies rose up the popularity scale both in treatment and theoretical value, in America there was a radical turn towards a biochemical model of mental disorder. Apart from attacks by homosexual, feminist and anti-psychiatry critics and the detrimental presiding sense that the talking therapies, from the wildest encounter groups to the most conservative ‘Freudian’, were somehow one, several key factors played into each other to determine this shift.
One was the rise and rise of the pharmaceutical industry and its bopping, hip-hopping shadow, the street drugs trade. Arm in arm came the making of a transformed Diagnostic and Statistical Manual under the aegis of Robert Spitzer, who wanted above all to give the psychiatric profession a reliable medical look. From its earlier psychoanalytical imprecision, in its 150 spiral-bound pages, the DSM grew into that internationally used 900-page bible, which listed and described more varieties of mental disorder than even that arch-classifier Kraepelin had been able to dream of as he piled up his patient records and coded them into illness descriptions. A substantial proportion of these disorders, often characterized by behaviour, mention an associated ‘recommended’ drug treatment. In about 50–70 per cent of mood or anxiety disorders, there is also mention of a co-occurring ‘substance abuse’, though not the alcohol which plagued the populations of turn-of-the-nineteenth-century asylums, but more often a street drug or another prescription drug.
Announcing the new scientific trend, Time in April 1979 put old-fashioned psychiatry on the couch and diagnosed depression and an identity crisis:
Patient’s name: Psychiatry.
Age: In middle years.
History: European born. After sickly youth in the U.S., travelled to Vienna and returned as Dr. Freud’s Wunderkind. Amazing social success for one so young. Strong influence on such older associates as Education, Government, Child Rearing and the Arts, and a few raffish friends like Advertising and Criminology.
Complaint: Speaks of overwork, loss of confidence and inability to get provable results. Hears conflicting inner voices and insists that former friends are laughing behind his back. Patient agrees with Norman Mailer: ‘It’s hard to get to the top in America, but it’s even harder to stay there.’ Diagnosis: Standard conflictual anxiety and maturational variations, complicated by acute depression. Identity crisis accompanied by compensatory delusions of grandeur and a declining ability to cope. Patient averse to the therapeutic alliance and shows incipient overreliance on drugs.
Unlike their psychoanalytic kin, medical researchers working on brain biochemistry were already optimistically predicting wonder drugs.
People with titles like biochemist, psychobiologist, neurophysiologist and psychopharmacologist are attracting scarce federal funds and replacing traditional psychiatrists as chairmen of hospital psychiatry departments. The field offers what psychiatry seems to have been yearning for all through the 1970s: scientific expertise, medical underpinnings and an escape from the troublesome subjectivity of the human mind.
At about the same time as Time ran this article, a Dr Rafael Osheroff was admitted to the famous Chestnut Lodge, where he spent seven months being treated for the symptoms of ‘psychotic depression’ by intensive psychotherapy. He requested medication but apparently it was denied him, in favour of a ‘regression’ to childhood, so that he could build himself up anew from there. Osheroff obtained a transfer to another clinic where he was treated with phenothiazines and antidepressants. Within three months, he had returned to his old life. Sadly, in the interim, that life had changed: his wife had left him and he had been ousted from his medical practice. Osheroff sued Chestnut Lodge for malpractice and received $250,000 in an out-of-court settlement. Ways of curing him had been available and had not been used.
The case had major repercussions for psychoanalysis in the context of American psychiatry: it now seemed that not to use drugs on patients could constitute malpractice. Young doctors, already hesitating between psychiatry and better-paying specializations, chose to go into less contested areas. Soon, to make up for the growing lack of medics, psychoanalysis in America would open its doors wider and wider to the ranks of lay analysts–from psychologists to social workers. In tandem, psychiatry became a more firmly biochemical practice.
That ‘troublesome subjectivity’ that was the human mind and its messy emotions had hardly been drug-free throughout the twentieth century, nor even the nineteenth. Chloral hydrate, the first of the popular sedatives, and ‘the first rehearsal of the “Prozac” scenario’, was synthesized in 1832 and by the 1870s had a great public following as a drug that could relieve common symptoms from insomnia to anxiety and the vapours–or ‘melancholia’. Virginia Woolf amongst many others was prescribed it for home use.
Various other drugs–such as apomorphine, a derivative of the opium that held sway in the seamy ‘dens’ of nineteenth-century cities–were enlisted to still mania. Potassium bromide, with its bitter taste, was used in ‘hysterical epilepsy’: in 1891 the Paris asylums were employing a thousand kilos of potassium bromide a year as a sedative. Barbiturates, synthesized in 1864, modified into Barbital by Emil Fischer and Joseph von Mehring in 1903 for hypnotic and sedative use, then named and marketed in 1904 by Bayer as Veronal and by the Schering firm as Medinal, soon became the drug of choice in private asylums and nervous clinics. It had few side-effects and the working dose was far lower than the toxic dose, always a concern for doctors with patients who might be suicidally inclined. Its offshoot, phenobarbital, marketed as Luminal by Bayer in 1912, became for a time the pink elixir of asylum psychiatry and the housewife’s calming friend, though it had a longer life as an anticonvulsant successful in epilepsy treatments.
The post-Second World War psychiatric pharmaceuticals story has two main avenues. One leads through the w
ork with antihistamines–anti-allergy drugs–to the discovery of their sedative side-effects, and thence to chlorpromazine, used as an anaesthetic, then as an antipsychotic in France, Eastern Europe, Britain, Canada and finally America. Technically a neuroleptic, chlorpromazine could both quieten delirium, such as in the manic phase of bipolar disorder, and reduce confused states. It also had a startling impact on long-term psychotics and schizophrenics, waking them from the deep sleep of madness and emptying the mid-century asylums. It quickly outdistanced insulin and electro-shock treatment for such patients, and all but put an end to lobotomies and leucotomies. SmithKline & French (now GlaxoSmithKline), who bought the drug from its developers Rhône-Poulenc and licensed it in America in 1954, made some $75 million from it in the first year of its sale. Now displaced by what are called the atypical antipsychotics such as risperidone, which have far fewer side-effects, chlorpromazine was one of the great psychiatric drug successes, despite the ‘tardive dyskinesia’ it eventually produced in patients–that is, those Parkinsonian-like involuntary and repetitive movements from the sticking out of tongue to blinking, to piano-playing finger exercises and leg or arm thrusts. Though there have been many splendid speculations, no one has altogether agreed on exactly what it is that makes these newer drugs work.
The second wing of the pharmaceutical story perhaps begins with Frank Berger, a Jewish Czech refugee from Hitler’s Europe, who landed in America in 1947. At once a doctor and a bacteriologist interested in the physiological basis of nervousness, overexcitability and irritability, Berger went to work for Wallace Laboratories. Soon, Meprobamate was proven to calm anxious monkeys and went on the market as Miltown and Equanil. At the American Psychiatric Association meeting of 1955, there was a buzz that doubled as a whispering campaign. The axiolytic (anti-anxiety drug) Miltown was said to be terrific. A few months later, pharmacists were routinely running out of supplies. ‘Happy pills’ were up and away, the first of America’s long list of mood enhancers, in this case lesser in side-effects than alcohol.
Following in Miltown’s footsteps came Benzodiazepine and its derivatives, first the powerful Librium, then the Diazepams, the best known of which is Valium, child of another refugee chemist, Leo Sternbach, who worked for Hoffmann-La Roche. Stronger than Miltown, in the sixties Valium became the world’s favourite and seemingly least toxic tranquillizer, making it on to the World Health Organization’s essential drug list. Between 1969 and 1982, Valium was America’s bestselling pharmaceutical. In a good year for the drug, immortalized by the Rolling Stones in 1966 as ‘Mother’s Little Helper’, some 2.3 billion little yellow pills were sold. Famously, the Stones linked the pill to the constitutional right to the pursuit of happiness. But too many ‘little helpers’ made that pursuit seem ‘a bore’, and soon the ‘shelter’ they provided ‘was no more’.
Not technically addictive–though the difference between what is called addiction and dependence may have more to do with social control than chemistry in this druggy world–Valium users could nonetheless develop a ‘dependency’ which was hard to break. In 1975 the Food and Drug Administration imposed special reporting requirements to control refills of both Valium and Miltown. In Prozac Nation, Elizabeth Wurtzel describes how her father slept through her childhood and their ‘quality time together’, a prisoner ‘of nerves and Valium, Librium, and Miltown and whatever else too’.
Usually, in the stories and in the statistics, it is women who are the pill-swallowers, tranquillized into the stupor of Stepford Wives and depressed to the point of suicide, without–and sometimes even with–the magic of the nineties’ Generation X prescription drug of choice, Prozac.
Women are, indeed, deeply enmeshed in this saga of everyday drug use, depression and anxiety. The question needs to be addressed: why do women figure in so much greater numbers and percentages on all the statistical indicators, particularly in the category now called ‘mixed depression and anxiety’? The Psychiatric Morbidity Survey published in 2000, listing the main conditions suffered by gender, shows that whereas women suffer only marginally more than men from the main categories of mental disorder, they suffer in significantly greater numbers from that everyday mixture of depression and anxiety.
The question of why more women suffer from depression than men has received a variety of answers, none of them singly suitable for all circumstances. It’s a fact, as the old adage has it, that women go to doctors where men go to the pub–or to deviance and crime. When they feel low or disturbed or perturbed, women do pharmaceuticals where men in far greater numbers do booze and street drugs. Even though, with greater equality and changing cultural habits the figures are creeping up, in Britain only 19 per cent of known street drug offences are committed by women. Women, however, consult physicians more regularly and frequently than men, outstripping them by some 5–6 per cent–a figure more or less equal to the greater statistically recorded proportion of anxiety and depression amongst women.
FIGURE 1 Percentage suffering from mental illness
Source: Psychiatric Morbidity Survey, 2000, as cited in The Layard Report on Depression, 2004. Adults aged 16–75; more than one condition [in the same patient] is possible.
In part, women are drawn into the medical habit by the very nature of reproductive physiology. In the West and in all countries where a welfare system of medicine presides, women go to doctors from the age of menstruation, when conception or contraception becomes a question, onwards. Pregnancy and birth are medical issues where state surveillance and self-care coincide. Once the child is born, it is most often women who will take it to the doctor or nurse. Talking to doctors, taking advice, seeing professionals who may make you feel better–indeed, swallowing pills–is part of being a woman in the modern world. Women’s larger showing in the statistics of mental disorders may therefore be as much a matter of self-reporting and a tendency to consult, as of any particularly greater incidence of depression and anxiety than men.
Even should a susceptibility be posited, then it may well be related to the starts and stops of women’s hormones in relation to the reproductive process. As long ago as Pinel, women’s menstrual, pregnancy and birth cycles were linked to various mental, emotional, and what we now call ‘mood’ or ‘affective’ disorders. Social and cultural factors which produce malaise inevitably play into this, but it isn’t as clear as we once thought that equality, however unequal, would erase the misery that topples women either towards anorexia or what our times understand as ‘depression’.
FIGURE 2 Percentage of males and females consulting an NHS GP in the 14 days before interview: Great Britain 1971 to 2001
Source: http://www.statistics.gov.uk/lib2001/Section3533.html
If this risks sounding like a reactionary stance towards older feminist readings of women’s condition or towards the very many social gains that Western women have achieved over the last forty years, it isn’t. What needs to be emphasized in this continuing debate is that–despite the many volumes of depression or breakdown or anorexia memoirs that line the shelves–the greatest percentage of both men and women who consult doctors, old age apart, are those who have no regular work or those engaged in manual labour. Although in Britain the 2004 Layard report–which looked into the scale of mental illness in relation to overall disability and its costs–found depression and anxiety disorders were higher predictors of unhappiness than poverty, it is nonetheless the case that an impoverishment of potential, together with life on the most deprived estates or streets, does much to enmesh people in the mental health or its neighbouring prison system.
DEPRESSION
Elizabeth Wurtzel’s streetwise and lippy Prozac Nation powerfully captures the frenzied spirit of nineties youth, the so-called Generation X, whose drug-charged highs too often descended into the terrifying and recurring lows of depression, which themselves became the target of more drugs–this time, prescribed. The confessional presents a portrait of an intelligent, sensitive New York child trapped and pulled apart by vocal divorcing pare
nts whose differences are acted out over the expense, management and love of her, though it’s sometimes hard in the midst of this to catch their attention.
By the age of twelve, Elizabeth is cutting herself at school. Talk therapy with a doctor who postures about his fame never quite seems to make enough difference. The psychiatrist feels more like the referee in her parents’ battles than someone who is there for a sensitive child. She spends much of her time in a state of distress encased in earmuff size headphones listening to Bruce Springsteen, a friend in the desolate emptiness of despair, in which life has no meaning despite sex, more drugs and the kind of high-octane education that gets you to Harvard. Then, after still more drugs–cocaine, Ecstasy–troubled loves and a manically fuelled summer of writing for a Texas newspaper, comes a major down and a suicide attempt. In what increasingly emerges as a portrait of the artist as a young, depressive, often self-destructive woman, aka Sylvia Plath, Wurtzel begins to see a woman psychiatrist, Dr Sterling, who tries to help. Despite this, she finds herself hospitalized first at Stillmans Hospital, then like Plath at McLean’s in Belmont, Massachusetts, and eventually, with the appearance of Prozac, diagnosed as suffering from ‘atypical depression’.
The ‘atypically depressed’ are the ‘walking wounded, people like me who are quite functional, whose lives proceed almost as usual, except that they’re depressed all the time, almost constantly embroiled in thoughts of suicide even as they go through their paces’. The condition, though severe, allows an ‘appearance of normalcy’. Wurtzel is simultaneously productive and living in constant despair, pursued by the ‘cognitive dissonance’ of the two side by side. If untreated, her condition gets worse. Wurtzel is treated. She is given Prozac. It helps. She is also, over the years, given much else.
Mad, Bad, and Sad: A History of Women and the Mind Doctors Page 54