“My Best Friend, my doctor, won’t even say what it is I’ve got.”
I recently became aware of a trend, the Modern Medicine Lament, in which American writers struggle to make an uneasy peace with a system from which they feel alienated. And it begs the question: has it always been this way?
Doctors have enjoyed a colorful depiction in books and letters over the years. Kafka’s brilliant short story “A Country Doctor” is still read and taught frequently. Boris Pasternak’s Dr. Zhivago was a man of principle in any language, in any time. Chekhov was a trained physician. I should also mention my favorite doctor in literature, Dr. Livesey, from Robert Louis Stevenson’s Treasure Island. Stevenson, you’ll recall, sketched another doctor, Dr. Jekyll, whose enthusiasm for chemicals took him off the rails (if Jekyll lived in America today he would surely declaim in a basement recovery meeting about the social transgressions committed by his intoxicated self). Mary Shelley’s Frankenstein, written almost 200 years ago, offers a remarkable foreshadowing of the moral and ethical challenges inherent to the practice of medicine, which has always had one ultimate goal: triumph over death. It is telling that we will in passing mistake the name of the title character for that of the monster.
In 1885 Louis Pasteur, a Frenchman, first administered vaccine to a human, a child bitten by a rabid dog. The treatment was successful. It was not an insignificant moment in human history. Giant scientific leaps forward like Pasteur’s continue to inject health and medicine into the lives of everyday people. Vaccines and antibiotics changed the world, though today their administration is practically mundane. In America, where good health has always been considered something of a birthright, we resent doctors. They are a necessary evil, a reminder of the basic infirmity of our bodies and the inevitability of their decline. Sure, Americans love watching fictional doctors treat fictional patients on television, but in reality aren’t doctors society’s consummate whipping boys? After all, that goal – sticking it to death – has never yet been achieved. Good news from a doctor cannot amount to more than “you will live for maybe a few more years, all things being equal.” And anyway, Americans don’t want to live forever, they simply want their life on earth to be pain-free, and believe it should be.
Pills that govern the chemical workings of the brain are now at the forefront of our ever-advancing medical knowledge. They treat disorders like depression, schizophrenia, autism, addiction, panic, mania, and garden-variety anxiety. Neurochemistry remains the least understood field in medicine, but the sales figures of these drugs have exploded in the past twenty years. Pharmaceutical manufacturers employ direct advertising – and also work more quietly through doctors – to encourage the public to treat a psychological condition far enough from bliss as a disorder. Comparatively little attention is paid to the fresh array of stresses and overload of stimuli that burden the modern brain, and how these factors can capitalize on the ease of modern life, where we are at greater leisure to explore exactly how we feel, as opposed to wasting all of our energy on mere survival. Effexor, Wellbutrin, Paxil, Zoloft, Prozac: ugly mash-ups, yes, but also household words. The drugs have brought relief to millions of people suffering from mental duress.
But the rise of Psychotropic Nation has created a cultural preoccupation with pills here in the U.S., one that has in turn given rise to questions about the efficacy of our medical system (actually just one of many aspects of our system that provoke such questions). If you are writing a novel, say, and wish to introduce recreational drug use into the plot (you may want the characters to seem more subversive, irrational, hedonistic, or edgy), you might shy away from the ho-hum world of schedule 1 drugs: your pot, your cocaine and heroin – in favor of those that can be obtained with a doctor’s note: pain pills, sedatives, amphetamines. The irony payoff is just too great, and writers love irony. The companies that make these drugs want you to want them, but as soon as you do, you probably should not have them. And maybe you, the writer (or the characters for that matter), don’t have health insurance, or went through a period when you weren’t covered – that just adds to the irony. Without insurance you’re not seeing a doctor, making it a whole lot easier for you to go schedule 1 than to buy a bottle of valium. And, given the cost of such pills, cheaper too.
Jonathan Franzen wrote extensively on this aspect of American life (see also Ben Kunkel’s Indecision, in which psychopharmacology plays no small roll). In The Corrections the drug is called Aslan, and its effects are somewhere between Prozac and ecstasy. At least two Lamberts use the drug, Chip during an unfortunate weekend sex binge, and Enid, Chip’s mother, whose little helper gets her rather strung out over a longer period. Franzen’s treatment is made more complete as Gary, eldest of the Lambert kids (and hilariously aware of the ebb and flow of his own serotonin and dopamine levels) invests money in the drug company that makes Aslan. Meanwhile, the pill is pushed by a leonine doctor with a creepy, guru-like aspect. And, of course, the one individual who could really use a pick-me-up, the crushingly depressed father Alfred, gets none. Collective dysphoria has never been so amusing.
Life imitates art, but it’s no barrel of laughs. That said, the cover story of this month’s Harper’s, “Manufacturing Depression: A Journey into the Economy of Melancholy”, by Gary Greenberg, does deliver the odd ironic chortle. Mr. Greenberg, a psychotherapist, is writing a book about the “misuses of medical diagnoses,” and if his magazine piece is any indication, it may be worth reading. The piece opens with Mr. Greenberg cataloging the failures and dissatisfactions of his life to a kindly psychiatrist, Dr. George Papakostas, in order to see if he qualifies for an experimental drug study at the Depression Clinical and Research Program of Massachusetts General Hospital. And, after checking some boxes, the doctor delivers his diagnosis: Mr. Greenberg has Major Depression. Would he like to try Celexa, Lexapro, Mirapex, or omega-3 fish oil?
“It was hard to believe that Papakostas really thought I had major depression,” writes Mr. Greenberg. Mr. Greenberg does feel bad sometimes, inadequate, feckless, and yes, his hair is thinning. His life is not blissful. But what is made abundantly clear to him is that the clinical criteria for a diagnosis of Depression, codified in the psychiatrist-developed Structured Clinical Interview, are bunk. Your score on this questionnaire, determined by the doctor, is totally subjective, the questions laughably interpretive. Dr. Papakostas, looking for subjects for a drug study driven by new medicines from Forest Laboratories, Inc. and paid for by the federal government, is predisposed towards a diagnosis of Clinical Depression. That’s really what someone looking to join such a study wants to hear, right? “‘Are you content with the amount of happiness that you get doing things that you like..?'” It is a standardized question asked by the doctor at one of Mr. Greenberg’s weekly follow-ups. “‘I’m not big on contentment,’ I said. Is anyone? I wondered. Is anyone ever convinced that his or her pursuit of happiness has reached its goal? And what would happen to the consumer economy if we began to believe that any amount of happiness is enough?”
The uncomfortable intersection of the consumer economy and medicine is at the heart of an article by Bruce Stutz that appeared in the May 6 issue of the NY Times Magazine. Unlike Mr. Greenberg, who never believes that he is clinically depressed even as he dutifully takes his Mass General fish oil, Mr. Stutz begins from a different point of view: he, like millions of Americans, went through a period of debilitating depression for which he sought medical treatment. Talk therapy and a prescribed selective serotonin reuptake inhibitor, Effexor, worked for him. Three years and a more positive outlook on life later, Mr. Stutz found himself shaking hands with his psychiatrist at the conclusion of his final session. But there was no mention of going off the drug.
“Somehow I couldn’t believe I had to take this pill for the rest of my life,” he writes. How many people taking such medication have had that thought? It’s not just the side effects, the occasional bouts of impotence, the weight gain, the dulled sensory perceptions and emotions, and it’s not just the monetary cost of the pills. It is also living with a stigmatizing reminder that one is sick and will never be well. But Mr. Stutz was well: he felt better; he was able to go one with his life. The stresses that had predicated his mental slide, the death of a parent, the breakup of a marriage, the loss of a job, were in the rearview. So he tapered his meds and hunkered down. Fierce withdrawal symptoms followed: mental torpor, physical discomfort, and the frightening “brain zaps,” blinding, incapacitating insta-headaches. With the help of some experts in clinical biology, Mr. Stutz does an admirable job of elucidating the chemical processes that were at work in his brain, which was, without the help of the meds, running a serotonin deficit. What Mr. Stutz did not experience during that period was a return of his depression symptoms. And so he wonders, “does our long-term reliance on these drugs become more of a convenience than a cure?”
Drug companies and doctors have about as much interest in helping people go off their psych meds as tobacco execs have in helping people quit cigarettes. Still, the medical industry is simply giving us what we want, a quick fix. What happens when the quick fix goes bad? The title of Ann Bauer’s May 18 article on Salon.com, “Psych Meds Drove My Son Crazy”, is inelegant but to the point. Her story is gripping, horrifying, and ultimately infuriating. Mrs. Bauer’s eldest son was born with autism. At the age of 17 this highly functional kid living in Minnesota became depressed, and his mother took him to a psychiatrist who prescribed an anti-depressant, which, she was assured, would not only snap him out of his funk, but also help control some of his autism-related obsessive tendencies. Instead, his condition grew worse. Doctors at a “respected neuropsychology clinic” reevaluated Mrs. Bauer’s son, now 30 pounds heavier and sleeping 16 hours a day, and changed the original diagnosis: in addition to his autism, her son was experiencing “‘psychomotor slowing’ – a form of schizophrenia.” And so a different drug was prescribed, Abilify, which was new (and, Mrs. Bauer notes, had been marketed direct-to-consumer in Time and Newsweek). Still her son’s condition worsened, “humming, shifting foot to foot, screaming if anyone touched him or tried to move him.” He would dialogue with voices that Mrs. Bauer could not hear. She tapered him off the Abilify.
Two days later he “got out of bed and stood in one place for a solid hour.” When Mrs. Bauer placed a hand on him, he beat her up.
Amazingly, the doctors managed to convince Mrs. Bauer to try yet another drug, a powerful anti-psychotic, Geodon. Her son took to living on the street after that. Only by conducting her own research, and getting a lucky referral to the Mayo Clinic from a retired doctor in Stony Brook, N.Y., an expert in a little known condition called autistic catatonia, did Mrs. Bauer find her son proper medical care. It took two years. Five days after checking him into Mayo, Mrs. Bauer read a front-page story in the NY Times “about psychiatrists in Minnesota who were collecting money from drug manufacturers for prescribing atypical antipsychotics, including Abilify and Geodon.” The article cited some hefty payout numbers, and also some serious risk factors for the drugs. It did not mention a fact that the doctors at Mayo confirmed: administered to an individual suffering from autistic catatonia, which they determined was the root cause of her son’s initial decline, neuroleptics like Abilify and Geodon only amplify the effects of the disorder, and they can cause permanent neurological damage.
She doesn’t say so, but I really hope Mrs. Bauer sued the pants off some folks. I would be interested to know.
There will be more Modern Medicine Laments to come. We will read them, and we will also watch with interest TV shows like “The Sopranos”, in which the writers have taken an increasingly critical line on the treatment of depression in America, and films like Michael Moore’s upcoming documentary about the ills of the American health care system. We will see more legal settlements against drug manufacturers like Purdue Pharma (OxyContin) and Pfizer (Celebrex) for misrepresenting the effects of their products to the consumer public. And, of course, we will continue to pop pills. We are a nation of armchair doctors. Sometimes it seems like a prescription pad is the only thing separating us from the real thing.
Update: The Libra in me desires balance. I do not want this post to seem an ad hoc dismissal of the medical profession as a whole. So I would steer folks to a book, Mountains Beyond Mountains, by Tracy Kidder, that had a profound impact on me when I read it. The book is about Dr. Paul Farmer, whose work battling T.B. while bringing basic medical care to corners of the world like Haiti and Peru where none existed before makes him something of a medical superhero. Kidder’s profile of Dr. Farmer proves that modern medicine is still changing the world for the better.