In 1999, ten years after the appearance of Prozac in Britain, she describes her drug regime as consisting of two Prozac capsules in the morning, followed by lithium. Lithium is the salt that, because it was found in the nineteenth century to dissolve urate stones, was used to treat gout and was drunk as waters in spas and at first in the soft drink 7-UP. It produced a sense of well-being and by the 1880s it had been found to have a beneficial effect on manic patients in asylums. Then forgotten, it found its way back in the 1950s in one of the first randomized controlled trials in psychiatry. However, the American Food and Drug Administration didn’t license it for use in mania until 1970. It is now regularly prescribed to keep the mood swings of manic depression on an even keel, so that the mania in the cycle doesn’t result in the dangerous activity that can have sufferers from bipolar disorder sectioned in psychiatric wards.
Alongside lithium, Wurtzel recounts that she also takes a pink caplet called Depakote, the trade name for valproic acid, an anticonvulsive drug once prescribed for epilepsy, but now used to control mood. Then comes the blood pressure medication atenolol, which alleviates the shakiness in her hands that the other drugs produce. With dinner, she takes one of the older tricyclic antidepressants that act on the dopamine and norepinephrine systems of the brain, alongside the evening doses of the other drugs. Lethargic all day, she can’t sleep at night, so she also takes a sleeping tablet that has a blackout effect.
In the memoir Prozac Diary, psychologist Lauren Slater describes her own troubled trajectory. Daughter to a mother whose intensity had manic dimensions, Slater, as a child, starts hearing voices–a blue baby who cries, a girl in a glass case. She has a history of self-harm and has undergone five hospitalizations for depression twinned with anxiety which, when the book opens, manifests itself in an obsessive and compulsive need to ‘touch, count, check and tap over and over again’. The man she describes as the Prozac Doctor gives her what is in 1988 the recently licensed wonder drug. He tells her how ‘Prozac marked a revolution in psychopharmacology because of its selectivity on the serotonin system; it was a drug with the precision of a Scud missile, launched miles away from its target only to land, with a proud flare, right on the enemy’s roof.’
Slater is one of Prozac’s earliest recipients. She wonders whether the Prozac Doctor has displaced her subjectivity, her history, with a series of biochemical equations. Since illness, as she says, is part of the self and something one gets attached to, there is a struggle before she begins to take the prescribed pills.
This resistance to taking the drug the psychiatrist offers is telling. It is oddly reminiscent of Freud’s own, sometimes disputed, contention that a patient resists interpretations and is unwilling to give up the accumulated habits and conflicts of the self, for which illness has provided some kind of solution. Kay Redfield Jamison echoes this in her memoir An Unquiet Mind, charting the course of her own manic depression. After years of just about containable mania, she finally goes, in the midst of a psychotic flight, to see a psychiatrist. She is ambivalent about his diagnosis, both relieved and resistant. Nor does she want the prescribed lithium which will remove her symptoms and which she knows she will have to take indefinitely.
Recognizing oneself in the straitjacket of a diagnosis, accepting an interpretation or a prescription, means giving up the self one knows. There is a double fear here, common in bipolar disorder, that the brilliance, the speeded-up activity, the elation, which accompany the milder forms of mania, will go with the drug.
In Slater’s case, through Prozac she is effectively born into the youth she never experienced. Better than well, she walks around arcades, is alive to sound, people and colour; goes to rock concerts unafraid, gets a job, a place at Harvard; completes a PhD in record time and eventually goes on to become a therapist and edit a book on women’s mental health. Along the way, there are the side-effects: a certain intensity which is also creative goes from the world. She misses her ‘illness identity’–a factor that Wurtzel also explores, noting that suicide attempts most often come when the pills have eased the worst of depression and the young woman no longer knows who she is. After a while Slater’s sexual pleasure wanes, the bleakness of depression re-emerges; the drugs have to be adjusted. But the Diary, written ten years after her first contact with the drug, is undoubtedly a Prozac success story.
Jamison is clear in retrospect that she needs both her lithium and her psychotherapy: lithium prevents her ‘seductive but disastrous flights’, diminishes depression, ‘clears out the wool and webbing from my disordered thinking’, keeps her out of hospital and makes psychotherapy possible. The latter heals, ‘makes some sense of the confusion, reins in the terrifying thoughts and feelings, returns some control and hope and possibility of learning from it all’.
It is interesting that these depression narratives still broach childhood and history in old quasi-psychoanalytic terms. Freud provided the twentieth century with the best story of the self available and the one which carries the most meanings–though sex, desire and becoming woman have become less important now than the quality of parenting and the upbringing that grow the child’s identifications and illness. This is the case even when the depression or other condition has a possible inherited factor. But this psychoanalytic shaping of the family is now overlain with a version of ‘cure’ which is biochemical and neural, the dominant psy language of our turn of the century.
Today Big Science is called upon to lend authority to descriptions which may be as old as the hills in their actual content. For example, to say, as is the pattern now, that brain chemistry is implicated in mood or depression may be little more than to say that humans have bodies. To say, as Slater does in an article, that ‘touching, talking, feeding, rocking, smiling, giggling’ with one’s baby are expressions of love or neural messages which have an impact on the limbic system, or the emotional brain, and imprint themselves on the child is to repeat Winnicottian injunctions in what today counts as a scientific register. All this is fine and well. But what the pharmaceutical industry does with such neural and biochemical language is to feed it back to us as a medicalization of feeling and behaviour for which, when things go ‘wrong’, it can provide the drugs that cure. The fact that we may need or want the cure does not necessarily make the supposed scientific legitimacy or power of the drug prescribed any greater than sipping the (lithium) waters at the nineteenth-century spa or than a session with the hypnotist.
In its Global Burden of Disease, 2000, the WHO ranked depression as the fourth ‘leading cause of burden’ amongst all diseases; and the one most affecting productive life, resulting in 11.9 per cent of years lost from life’s span due to disability. Predictions are that worldwide, depression will soon be second only to heart disease in its seriousness, while in the developed world it will rise to be the highest cause of the burden of disease. These are astonishing figures. They can be read to say that either the contemporary world (war, poverty, politics, terror, inequality) or biology (genetic inheritance, population rise) increasingly inflicts on people what are now called ‘mood disorders’. They could also be read to say that we are measuring something we never measured before. Sadness, even disabling sadness, has only recently become a classified illness that swallowing a pill can cure.
Once, sadness and its accompanying inactivity might have been linked to sloth, the sin of accidie, the torpor of ennui, that mental prostration which was a lingering suicide and that some attributed to the spiritual aridity attendant on God’s grace departing from the individual. Discipline might be recommended as a cure. Melancholy, the early term most usually linked to today’s medicalized depression, described a profound sadness, due, according to humoral theory, to an excess of black bile in the body. The OED gives ‘ill-temper, sullenness, brooding anger’ as definitions, and also points out that in the Elizabethan period and for a long time afterwards ‘sadness, dejection, esp. of a pensive nature; gloominess…introspection…perturbation’ formed a ‘fashionable mark of intellectual or a
esthetic refinement’. Hamlet suffered from it; George Cheyne recognized it. In Charles Lamb’s time, the sadness was subsumed under ‘hypochondriasis’ (which became the illness of suffering from imagined illness).
Jean-Paul, the early German Romantic, whose Hesperus (1795) was the most popular novel there since Goethe’s The Sorrows of Young Werther had led to a wave of suicide amongst the young, gave melancholy the inflection of ‘world weariness’ or Weltschmerz–a term the post-punk Goth subculture picked up as emblematic of the eighties, when ‘death rock’ also emerged. Harking back to humoral resonances, Baudelaire called his utter lassitude, that dejected weariness of ‘limping days’, spleen, the very site of black bile’s production. Spleen transformed him into ‘the bored prince of a rainy country, rich, but impotent, young and yet very old’, his memories straining over some thousand years. For him as for Coleridge, it now seems clear that the condition was linked to repeated use of opium, then a legal substance and often used as a sedative, though whether the condition or the drug use came first remains, even today, an open question. In the second half of the nineteenth century, depression was often subsumed under neurasthenia, or an attack of nerves. As such, it was both plague and affectation, a fashionable attribute which might also savagely debilitate.
Esquirol and the developing French psychiatry–seeing a disease of the emotions where melancholy with its popularly understood attributes of sadness had been–described a condition named lypémanie (from the Greek lype, or sadness), a partial madness which was attended by chronic delusions and an overwhelming tristesse. Esquirol, whose asylum population came largely from the poorer classes, found rates of the condition increased from May to August; that it was most prevalent in twenty-five-to forty-five-year-olds; and that while heredity played a role, domestic crises, disturbed relations and grief precipitated the condition. In Germany and Britain, the term ‘melancholia’ was maintained by the nascent alienists. Sir William Gull used it in 1868 as part of his description of ‘hypochondriasis’: ‘its principal feature is mental depression, occurring without adequate cause’.
The word ‘depression’ itself, to describe a condition rather than a sharp drop in the landscape or of vigour in trade, only gradually came into the English language. Always a good indicator of the mood of the times, George Eliot was one of the first to use the term as a noun to refer to an emotional condition: Daniel Deronda finds the beautiful Gwendolyn after she has been betrayed and widowed ‘in a state of deep depression, overmastered by those distasteful miserable memories’. G.E. Berrios notes that by the end of the nineteenth century, depression came to be defined as ‘a condition characterized by a sinking of the spirits, lack of courage or initiative and a tendency to gloomy thoughts’. The term migrated into Kraepelin’s nomenclature. Importantly, Kraepelin broke down the large, generalized category of psychosis to classify a pattern of symptoms as manic depression, now more commonly known as bipolar disorder. Kraepelin’s genius lay in stressing the cyclical nature of an illness which most often presented itself to doctors in its depressed state: when sufferers were high, they rarely thought anything was wrong with them–though, of course, their relatives might.
For Freud, common depression is of no substantive interest in itself: he mentions it several times in passing, either as an accepted and usual part of everyday life or as part of a larger condition such as hysteria, where it can be linked with anxious excitation. In the Psychopathology of Everyday Life, he talks of a man ‘overburdened with worries and subject to occasional depressions’. Only when he compares mourning to melancholia do the kind of obsessional states of depression which characterize melancholia take on a dynamic interest for him: a pattern links these to a loss about which the subject is ambivalent and so sadistically attacks herself.
The self-tormenting in melancholia, which is without doubt enjoyable, signifies, just like the corresponding phenomenon in obsessional neurosis, a satisfaction of trends of sadism and hate which relate to an object, and which have been turned round upon the subject’s own self…It is this sadism alone that solves the riddle of the tendency to suicide which makes melancholia so interesting–and so dangerous.
This sadistic attack on the self is in full play in many of today’s depression memoirs, though they are rarely Freudian. Freud also links this severe kind of melancholia to a manic high, a cyclical rhythm which makes him consider the possibility that certain unknown ‘toxins’ are in play here, linking the physiological to the psychogenic.
By the time we arrive in 1962 when pills are on the market in a handy form, the Oxford English Dictionary suggests that the physiological or chemical has altogether taken over from the psychogenic. Depression has become so medicalized that it usurps the place of experience. The Lancet of 2 June notes: ‘events at the onset of depression…must be interpreted with caution for failure at work…or in a love affair may be early symptoms, rather than causes’. Failure has slipped from being a cause of misery or even a precipitating factor of a psychological condition into becoming a symptom underlying a disorder called depression.
Since then, depression has often enough become ‘tantamount to dysphoria, meaning unhappiness, in combination with loss of appetite and difficulty sleeping’. The shift in emphasis from depressed mood to visible symptoms marks the objectivizing psychiatrist’s victory: there is hardly a need for subjective states of mind at all in the diagnosis. In 1991, just three years after the launch of Prozac by Eli Lilley, Edward Shorter notes in his History of Psychiatry, the NIMH began a ‘National Depression Screening Day’ as part of its mental health awareness programme. Athough the intentions were worthy–to inform family doctors how to diagnose depression in their patients in order to refer them to psychiatrists, since a missed major depression might result in suicide–the ultimate effect was ‘psychiatric empire-building’ against other kinds of care. As a consequence of this emphasis on depression, it became the ‘single commonest disorder seen in psychiatric practice, accounting for 28 percent of all patient visits’. The existence of Prozac has moved hand in hand with the process of spreading depression: ‘Physicians prefer to diagnose conditions they can treat rather than those they can’t.’
On its official website, the British Royal College of Physicians notes that there are some thirty different kinds of antidepressant available today. Their use began in the fifties and they are divided into four main types: the older tricyclics, which are dangerous in overdose; the MAOIs (monoamine oxidase inhibitors), now hardly used because of their serious side-effect of high blood pressure; the preferred SSRIs (selective serotonin re-uptake inhibitors), amongst which is the famous Prozac, better known since its patent ended in 2001 as Fluoxetine; and the trickier SNRIs (serotonin and noradrenaline re-uptake inhibitors), prescribed only when the others don’t work. The Royal College admits quite openly that there is no complete certainty about how these medications function, ‘but we think that antidepressants work by increasing the activity of certain chemicals in our brains called neurotransmitters. They pass signals from one brain cell to another. The chemicals most involved in depression are thought to be Serotonin and Noradrenaline.’ There is more certainty about what these antidepressants are used for, as well as what the disorders they work on might be:
Moderate to severe depressive illness (not mild depression)
Severe anxiety and panic attacks
Obsessive-compulsive disorders
Chronic pain
Eating disorders
Post-traumatic stress disorder.
If women seem to get depressed more than men do, the website states pragmatically, ‘this is possibly because men are less likely to admit their feelings; [they] bottle them up or express them in aggression or through drinking heavily’. It adds, perhaps less helpfully, ‘Women may be more likely to have the double stress of having to work and, at the same time, look after children.’ True enough, though the underlying suggestion that there is a free choice in the offing here, that women could either have the men look af
ter the children or look after them rather than go out to work in a mere snap of the fingers, is insidious. There is also an implication that working and mothering together–something surely that most women have done through most of Western history–marks the downward path to depression. One might say with as much ‘truth’, that when men both work and father, there is a downward path to war.
GENERALIZING DIAGNOSES
The admirable certainty that all websites and handbooks now display about the nature of the above ‘disorders’ reminds us that we are once more in an age of Kraepelinian classifications. Illness descriptions and categories produced by the American DSM and its international kin, the International Classification of Diseases, govern the medical and psychiatric worlds. Such manuals, which bear the accolade of science, are useful for unifying practice vis-a-vis insurance providers, bureaucrats and statistics gatherers. They may also help sufferers who want the ‘liberation’ that a diagnosis can give together with the attendant and sometimes helpful medication. But the way in which such illnesses come into being and the function of description should not be forgotten.
A psychoanalytically trained psychiatric graduate and member of the Columbia University Psychiatry Department in the 1960s, Robert Spitzer in 1966 took over the task of chairing the DSM-III task force. Psychiatrists at the time in America seemed to agree on little: one might name a patient ‘a textbook hysteric’, while the same patient might be labelled a ‘hypochondriac depressive’ by another. Psychiatric diagnoses did not have what the period’s scientists understood as ‘reliability’–that is, they failed to produce results that were both consistent and replicable. And if psychiatrists disagreed about diagnosis, they would inevitably also disagree about treatment and cure. Underlying this emphasis on reliability are the needs of Big Pharma, as the massive combined weight of the international pharmaceutical industry is known: ‘How can you test the effectiveness of a new drug to treat depression if you can’t be sure that the person you’re testing is suffering from that disorder?’ The answer of course might well be–and sometimes became–that if the patient responds to the drug, then there is a disorder and it’s called depression; but that’s to get ahead of oneself and the period in which the new, more authoritative, DSMs came into being.
Mad, Bad, and Sad: A History of Women and the Mind Doctors Page 55