It was dawning on the seriously suicidal patients among us that a fire in the building held unspeakable possibilities. (“With any luck, I’ll succumb to smoke inhalation.”) Some dragged their feet and held back, hoping to get lost in the patient shuffle: “No, no, that’s okay, you just go along without me,” or “You go on ahead, I’ll be along in a minute.” The staff stiff-armed the last of the holdouts, like a high school coach forcing his least able players onto the football field.
Taken individually, we were strange fruit; collectively, we were partners in suffering unleashed from confinement and eager for a little diversion, no matter that it entailed the possibility of being trapped in a burning building. We became as giddy as a kindergarten class on a trip to the insect museum, as our caretakers hustled us out into the soupy September night.
Once we hit the street and everyone was accounted for, we jostled and poked each other, making dark jokes about the staff’s efforts to coax the Mood Disorders wing out of harm’s way. Marooned in the parking lot—some of us still attired in sleepwear, some in street clothes—the gathering took on a carnival atmosphere. (Lights! Sirens! Action!)
Two or three fire engines roared to a stop in front of the building and began unfurling pythonlike hoses. We stood in chaotic, agitated clusters, like fireflies in a jar, and sucked on air as sticky as cotton candy. A couple of my fellow unit-mates body-slammed the vending machines fortifying the fence of the gas station. Lo and behold, the reluctant coolers gave up multiple cans of soda. Someone had even managed to tote a boom box, despite the admonition to drop everything and exit the building.
Under the yellow sodium vapor lights of the gas station, we cranked up the music. The smokers smoked and the rest of us swayed. Given the hour, there was next to no traffic on Wisconsin Avenue; we had the city to ourselves.
Out of the corner of my eye, I noticed Eleanor, the psychotherapist cum patient, standing by herself, smoking and smiling wistfully at the scene, as if she had seen something like this before but couldn’t quite place it. Her platinum-blond wig was askew; I assumed that in the rush to leave her room, the towering hairpiece had failed to connect with her center of gravity.
“Eleanor, your wig’s turned around—it’s on backwards.” Surely this proud, stately woman did not mean to appear in public so radically out of alignment.
She looked at me and winked. “I know.” She smiled before taking another long drag on her cigarette. The wig stayed right where it was. Party hats all around!
Soon enough the “all clear” sounded. False alarm. We were never in any real danger. Cigarettes were grudgingly stubbed out and we dragged ourselves back into the building. But for me the minuscule slice of time we shared outside the walls of the Mood Disorders Unit that night was as precious as it was surreal.
I returned to my narrow bed, fell deeply asleep, and dreamed we were standing under the gas station’s sodium vapor lights: everyone on the unit was mysteriously and gloriously encrusted in an outer casing of multicolored glitter. No one was tragic or sick.
I was discharged after five weeks—Dr. Salerian had pushed my insurance as far as it would go, but they were ready to cut off any further inpatient care. I was not yet feeling any relief from the medication—it would be two months before I noticed a lift—so I retreated to home, at odds with myself and with everything around me, adrift in a backwash of recovery.
In November I flew out to visit my sister Suzy in California for a couple of weeks by myself; the kids stayed home with Bob. Suzy’s keen wit and empathy always soothed me, and she possesses an esthetic sensibility that makes all things shabby seem lovely and valuable. At some point during the two-week stay, I awoke one morning and sensed a subtle shift. I felt as though I had been relieved of a heavy physical load carried so long that I forgot it was attached until the tonnage lifted.
I experienced a cluster of physical sensations—colors grew brighter, noises and language connected with their origins—and an undeniable feeling of lightness. “Aha! So this is what it feels like to be well again.” It was my first glimmer of recovery and I prayed it was the real thing.
Complete recovery was a long, hard slog, like climbing out of a slippery ravine. Wellness returned in pieces: first came a willingness to venture out of the house; next, a more natural cadence to my speech; finally, laughter and an appreciation for the small everyday things, the fun things. And the compulsive rocking ceased. I still had to confront some major problems: At home, Bob and I had to sort out whether or not we would remain together, and I had to face the fact that I was in an untenable and unpleasant work environment. Above all, I needed to try to restore a sense of normalcy to our household for the children’s sake. But after a year, I had fully recovered from depression and the episode became a veiled memory.
It is easier to deal with a second episode of depression—easier to define the onset and easier to accept that it runs its course. When I was struck in 1996 with yet another episode of major depression, I complained bitterly to Dr. Salerian: “I am devastated that this keeps coming back. I can’t believe I have this shitty recurring illness!” I wept with exasperation. Balls of sodden Kleenex made shapes in my lap, as I sat disconsolate and ragged in his downtown office.
“For Heaven’s sake, Gail, you don’t have a recurring illness!” he reprimanded me. “You have a chronic illness. But you don’t have AIDS, you’re not schizophrenic, you have depression. Now learn to deal with it!”
Over time, I learned the markers to watch for (the onset of confused speech and a struggle to find the correct word; a propensity for misplacing familiar objects; persistent and uncontrollable rocking) and the triggers (stress and anxiety; lack of sleep and exercise; too little sunlight or outdoor exposure). And I learned that absent a cure for clinical depression, the illness can be managed.
Most people can obtain relief by taking antidepressants and/or engaging in talk therapy. Some people achieve immediate relief from depression with antidepressants alone; others see little relief from medication but, over time, derive benefit from cognitive behavior therapy, or CBT, as it’s known.
Cognitive behavior therapy trains patients to recognize negative thoughts and behaviors and helps them erect mental barriers to these thoughts and actions. Recent research suggests that both antidepressants and CBT can be effective, but that the two treatments work in very different ways.
A recent study reported in the Archives of General Psychiatry6 suggests that CBT effects a change in the functioning of the cortex, the region of the brain charged with thinking and reasoning; drugs, on the other hand work on areas of the limbic system that govern emotion, sensation, and memory. The two regions of the brain play distinctly different roles in depression.
Some clinicians who treat depression believe that either talk therapy without medication or medication without talk therapy can provide relief from most depressions; but most psychiatrists recommend both medication and some form of psychotherapy taken together for their severely depressed adult patients. Recent findings underscore that attacking the illness from two different angles, utilizing a combination of antidepressants with therapy, is more effective than either treatment on its own.7
This approach has proven to benefit adolescents as well as adults. The results of a study funded by the National Institute of Mental Health and made public in August 2004 demonstrated significant improvement in teen patients diagnosed with moderate to severe depression, who were treated for twelve weeks with a regime that included fluoxetine and cognitive behavioral therapy.8
I understand the impulse to shun the medication and rely solely on psychotherapy; people often reject the notion that the brain, like any other organ of the body, can be “fixed” by taking a pill, or that a person needs to take medicine for a disease whose roots are in the mind of the sufferer. But Dr. Robert Sapolsky, professor of biology and neurology at Stanford University, speaking on the public radio broadcast The Infinite Mind, summed it up best: “Depression is as real a biological disorder as is diabetes, and
you don’t sit down a diabetic and say, ‘Oh, come on. What’s with this insulin stuff? Stop babying yourself.’”9 As long as you are willing to experiment until you get the dosage and formula right, and put up with minor side effects, antidepressants can be a godsend.
It is important to bear in mind, however, that all drugs are toxic and should be prescribed by competent physicians who closely monitor their patients. A leading authority on psychiatric drugs, Dr. Samuel H. Barondes, a self-proclaimed fan of antidepressant medication, admits that the drugs don’t always achieve their intended results and that “even the best of them are blunt instruments that have a large number of effects on the brain, only some of which can be considered therapeutic.”10 And, because of differences in the way our bodies process the drugs, there is always the chance that a patient may experience an “idiosyncratic” response to the antidepressant.11
In more than a handful of instances, an idiosyncratic response has resulted in tragedy: suicide, homicide, or inexplicably harmful behavior. The history of antidepressants is replete with cases demonstrating the adverse effects of the drugs, and the controversy over their use has spilled out of the medical establishment and into the media, generating widespread anxiety. I will have more to say about the controversy regarding antidepressant medication and adolescents in a subsequent chapter. But it bears repeating: these are powerful, potent drugs. Anyone prescribed an antidepressant, be it an adult or a child, must be closely monitored for adverse reactions.
Antidepressant medication has been around since the middle of the last century. In the 1960s, tricyclic antidepressants (TCAs) were the first to be used to treat depression,12 adjusting brain chemistry by addressing a deficit of chemicals called neurotransmitters, which act to relay messages in the brain. The three neurotransmitters known to be at play in depression are serotonin, norepinephrine, and dopamine. The more recent class of antidepressants, serotonin selective reuptake inhibitors (SSRIs), which came into widespread use in the 1990s, are more finely tuned to act upon the individual neurotransmitter—hence patients experience fewer side effects than before. But the scientific community’s understanding of the precise way these drugs work is limited.13
It is impossible to predict which antidepressant will work for a given patient, or why some individuals require combination therapies—two or more drugs taken in tandem—before they see results. Nor is it clear why it takes several weeks of continuous use for the drugs to take effect. Dr. Barondes explains, “The influence of these drugs on neurotransmission is apparent within minutes…” [but the] “immediate changes in neurotransmission are just the first step in a multi-step process that relieves depression by gradually changing the brain.”14 Clearly, we are in an era akin to the pioneering days of aviation when it comes to deciphering how the brain works.
For half a dozen years after my diagnosis, I experimented with the medication, tapering off antidepressants to see if I could control the illness without psychotropic drugs. I even tried a yearlong course of St. John’s wort, a popular herbal remedy widely used to treat depression in Europe, though its claims of efficacy have been disputed by recent trial data.
According to Dr. Salerian, in his experience it takes his patients who suffer from chronic depression approximately five years to come to terms with the notion that they may be better off taking a sustained low dosage of medication, rather than starting and stopping medication as their depression mushrooms and wanes. I was no exception to his rule; five or six years after my first suicidal depression, I finally came to accept that I needed a pharmacological regimen to sustain my mental health. And there may be lasting benefits.
In the past few years, startling evidence has emerged that proves patients with chronic depression suffer reduced brain function. For the one out of ten Americans who suffer from depression, Listening to Prozac’s Dr. Peter Kramer says the evidence makes “diagnosis and treatment all the more urgent.”15
Specifically, studies utilizing magnetic imaging scans show “statistically significant” reduction in the size of the hippocampus—the area of the brain responsible for learning and memory—when measured against the brains of nondepressed subjects.16 In the neuroimaging study cited, patients with depression showed a nineteen percent reduction in hippocampal volume. Theorizing that depression was the root cause of the brain shrinkage, the study took pains to eliminate overall brain size, alcohol exposure, age, and education as variables, so what you see is a picture of a brain in distress as a result of the illness.
Further study by Dr. Yvette Sheline, a professor of psychiatry and radiology at Washington University, showed not only that there was a decrease in hippocampal volume, but that the effects of depression were cumulative over the lifetime of a person’s illness. The research indicated that the length of time a patient had been depressed—the total number of days a person suffered from depression during his or her lifetime—predicted the size of the hippocampus. The longer the person suffered without treatment, the smaller the hippocampus. The study concluded, “Antidepressants may have a neuroprotective effect during depression.”17
These findings, if they bear out in further clinical tests, will come as a shock to persons who suffer from chronic depression, but there is a silver lining: Recent studies suggest that neurons in the hippocampus, unlike neurons in other parts of the brain, have the ability to regenerate, suggesting that pharmacological intervention may be critical to the long-term health of the brain.
Looking at yet another critical part of the brain, evidence shows that “depressed patients suffer significant loss of cells in the prefrontal cortex, the part of the brain involved in ‘discerning reward versus punishment,’ altering moods and risk taking,”18 which may help explain the anatomical and chemical differences scientists observe in brains of persons who committed suicide when compared to the brains of individuals who died from other causes.19
In the coming years, we will gain much more knowledge about the brain and behavior and how these very complex chemicals work. Meanwhile, I continue to take antidepressant medication prophylactically, and every few years, when I feel I no longer derive the same benefit or sense the onset of major depression, we rejigger the pharmaceuticals, adjusting for newer and more targeted medications as they come on the market. And if the pharmaceuticals were to fail me, there is always electroshock therapy (ECT).
Electroshock therapy is the ultimate boogeyman of therapeutic treatment, because of the perception that “the treatment actually alters the brain, changing a person’s personality and character,”20 a misperception founded in medical lore and surrounded in myth since its introduction sixty-five years ago. No one knows why or how ECT works precisely, but its efficacy is well founded as an “effective and safe treatment for those with severe mental illness,”21 especially in cases of major depression where no pharmacological interventions proved effective.
There is ongoing research on “brain pacemakers,” which in the future may obviate the need for pharmacological solutions to depression and other psychiatric illnesses, but thus far, the pioneering ventures have stumbled over FDA approval or been too costly to benefit the general patient population.
I am not happy to be a depression sufferer, but no one escapes life without a personal crucible. This one is mine.
5
LETHAL SECRETS
If you don’t have anything nice to say about your former spouse, don’t say anything at all—at least, not in front of the children.
As I said, there can be no “good” divorce for children. But some are better than others. So why are so many divorces fought in the green zone that should provide a cordon sanitaire around the sanctity and safety of children? Most divorces make most people temporarily crazy. But the lengths to which you go to protect your children from the fallout of the divorce will help them heal faster and leave fewer scars.
In the immediate aftermath of our separation, during the summer of 1992, Bob and I worked out an accommodation: we kept the children in the house and
shared responsibility for caring for them. I moved temporarily to live with a friend, who lived around the corner from the boys’ school. After school I retrieved the kids, and Bob and I spent most evenings and weekends at the house together with them, eating dinner and sharing chores, attending soccer matches, and shuttling the kids to various outings.
Although it was awkward at first, the routine soothed us all over time, and a year into our separation, I moved back into the house and we shared the residence. Bob and I reached an easy accord in which we took turns—one week on, one week off—assuming responsibility for staying home evenings and weekends with the kids. Holidays remained the same, just as they had in the past, everyone on both sides of the family gathered; relatives graciously accepted that if Bob and I could handle the situation, then they could make accommodations, too. There was a surfeit of caring adults in the boys’ lives, family and friends, who supported our children. It does indeed “take a village.”
The logistics became more complicated when Bob relocated to California for a job in 1995. It was a challenge to keep the village intact once it traversed state lines. Bob was offered a dream job, one he had coveted for several months with a publishing offshoot of Time Warner. Unfortunately, the offer came shortly after I too had changed jobs—also a plum job, with a humanitarian organization that suited my skills and my interests, working to advance the campaign to ban land mines and address the needs of innocent victims of war and conflict.
Bob and I had often talked about wanting to move back to our roots—all of us together; our families were California natives and the kids were close to their cousins, aunts, uncles, and grandparents. But the timing was all wrong: I felt I was just reassembling my life and I did not want to be uprooted.
Will was still in elementary school and Max had two years to go before high school, so we decided that when Max was ready for high school, the boys would join Bob in California, where, we hoped, we could take advantage of better public schools than the District of Columbia offered. In the interim, I assumed the mantle of single mom. Bob spoke to the kids every evening by phone and commuted cross-country once a month for a long weekend with them.
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