Mental Illness as Biology?
In the fall of 1991, for a brief period, I experienced what I believe to be advanced clinical depression. For a variety of reasons, and assisted by an initiating incident, I slipped into a state which might be called "nothingness."In this state, I felt detached from the world around me, even from my most intimate environments. In my own cheerfully decorated bedroom, I felt no emotion. Not even plain old boredom, which would have been pleasant by comparison. All emotions -- love, affection, anger, sorrow -- were gone.Actually, I cannot say I had no emotions. I did. But they all seemed desperately negative. Most involved fear. Fear that I would never escape the condition. Once I actually did escape the condition, I developed a persistent fear of my own mind. Fear that my mind could produce such a place. Truly, a hell on earth. I remember thinking, stuck in that hell, that if I were to remain there, it would be best if I killed myself. I thought that if I worked as a psychiatric nurse in a hospital in which all the patients felt as I did, the most humane thing I could do would be to quietly put them out of their misery, extinguishing their awful lives, one by one, like a merciful candle snuffer going down the rows. Certainly, if I had a pill to take that would relieve the enormous emptiness I felt, I would take it -- and give it, happily, to everyone else."This is a disease I've been challenged with by God," says Mike. Mike is 30, a successful trader on the Pacific Stock Exchange. He is likable, well-read, educated, witty, engaging and sweet -- if at times detached and noncommittal. Mike suffers from depression, a condition he has treated for three years with antidepressants such as Paxil and Serzone. "It's like a diabetic taking insulin. I may have to do it for the rest of my life," he explains.Mike's view of his depression as a disease to be kept at bay reflects the thundering message of our times, that conditions ranging from anorexia and obesity to panic disorder to alcoholism to manic-depression are the result of chemical malfunctions -- probably genetically inherited -- in the brain. In books like Listening to Prozac, The Broken Brain and The New View of Self, in Time and Newsweek, on talk shows and news shows, American society is fed the mantra: You are what your brain chemicals make you.Americans, their doctors and the pharmaceutical companies which produce medications to treat our "chemical imbalances" are sailing off on a buoyant, if somewhat leaky, ship of neurobiological destiny. Many of the estimated 15 million in the U.S. suffering from chronic depression are resigning themselves to a lifetime of medication. Buoyed by the successes and overwhelming popularity of the new SSRIs (selective serotonin reuptake inhibitors, including Prozac and drugs like Serzone and Zoloft), neuropsychiatry has embarked on a massively funded exploration of mental illness as biology. But as this raucous ship sails into uncertain horizons, quieter voices, including those of the formerly depressed, call it back.They argue that people can and do overcome depression through willed change, that mental illness has its balance -- mental health -- and humans are not condemned to live as slaves to their brains.Despite millions of dollars of research funding, there are still no studies proving mental illness is a result of malicious brain chemicals or that "diseases" such as alcoholism are genetic. The medical model of mental illness has alleviated stigma and guilt for suffering patients and their families, yet it may also threaten to steer us from more profound solutions to depression and mental illness.By the BookMike, like millions of depression sufferers, has read his copy of "Depression: What You Need to Know," a slim brochure proffered by the government's National Institute of Mental Health and produced "as a public service" by Eli Lilly and Company, manufacturer of Prozac. The brochure refers to "depressive illness" and states that such an illness is a "whole-body" illness. This illness affects "the way you eat and sleep, the way you think about yourself, and the way you think about things" -- rather than the other way around, for instance. "It is evident that individuals with major depressive illness often have too little or too much of certain neurochemicals."The pamphlet is a potent symbol of the enormous influence pharmaceutical companies like Eli Lilly have on the national dialogue over mental illness. As psychology author Alfie Kohn noted in American Health magazine: "Most of the research at the National Institute of Mental Health is biological in nature ... Nurture receives lip service while nature receives enormous grants."Pharmo-companies such as SmithKline Beecham now own their own health maintenance organizations (HMOs), and Beecham, Lilly and Merck together own the five largest "pharmacy benefit managers" in the country -- companies which control the drugs that health plans and HMOs pay for. Some HMOs, in turn, resist paying for anything other than medication to treat depression. Antidepressants have become an economy unto themselves. Greg Critser, writer and antidepressant consumer, has given a name to the hydra: "pharmo-capitalism."Pharm SurplusIn the world of pharmo-capitalism, pharmo-companies skip middlemen and market to consumers. An ongoing campaign by Bristol-Myers Squibb in newspapers asks people to diagnose their own "persistent anxiety" by taking a simple quiz."Most antidepressants are now being prescribed by family physicians," says Peter Breggin, a medical doctor and author of Talking Back to Prozac. "The doctor will see a lady for 10 minutes and then prescribe Prozac. That's what direct advertising has pushed."According to a March report in Barron's, the unstoppable rise of the Dow Jones average parallels almost exactly the rise in sales of three of the top-selling SSRI antidepressants: Prozac, Zoloft and Paxil. According to various sources, anywhere from 18 million to 43 million people in the U.S. are taking SSRIs. Prozac's $2.3 billion in 1996 sales represented approximately a third of Lilly's $7.3 billion top line, and nearly as much as the entire company's sales when the product was introduced ten years ago. In the drug maker's 1996 annual report, CEO Randall Tobias calls Prozac "a true breakthrough product with a revolutionary impact on its market and on its maker." Tobias calls Prozac "our flagship" and credits it with "the dawn of this new age."The media appear to worship the new science. In May, a Time cover on the "biological basis" of addiction included a story on depression in which Time described the brains of those suffering from "hereditary depression," failing to note that, to date, there has been no confirmation of such a thing.There are studies which suggest some people have a genetic vulnerability to depression, and yet the picture shifts dramatically when environment and family and thinking are introduced. Time quoted a brain researcher saying, "When it [the brain] does not function properly, abnormal mood swings may occur." Which sounds, in our tech-driven, post-Darwinian society, quite rational. But the subtle shift of language implies a dramatic shift of philosophy. Rather than the brain not functioning "properly" when a person goes through mood swings, the brain now causes mood swings. We, as thinking human beings, are no longer in control of our minds.For about two years after my 'depression,' I continued to be mildly depressed. My world view had shifted. No longer was the universe a loving, benign universe. Dark pits pocked it, living hells one could fall into for no good reason. Occasionally, I felt myself slipping back into a state of blankness. With the help of my partner, I could distract myself enough not to slip completely. But the world seemed a much gloomier, much colder place. If before I was embraced by the universe, now I merely existed in it for no reason. Life had lost its meaning.Pill for All ReasonsTo the millions of patients who have taken the new SSRIs and felt the dense fog of depression lifted from their shoulders, the biomedical model of depression feels right.To them, depression feels concretely physical and also random, as though it's come from nowhere and invaded their minds like a virus. "I feel ill at ease, nervous, agitated, blocked. It feels like there's a chemical running through my whole body and I feel fuzzy and different," says Mike, who, after Paxil began to "wear off," switched to Serzone and has since increased his dose from 300 to 700 milligrams daily.Mike seems willing to continue to experiment with drugs, despite negative effects on his sex life. For him, depression is terrifying: "I'm terribly fearful of my depression. Depression is depressing. It affects every area of my life. I would be so thrilled and happy just to live like I do when I'm 'happy' -- just normal. That's what the drugs help me do."Because the SSRIs are effective at alleviating depressive episodes, as well as the symptoms of obsessive compulsive disorder and now, apparently, social phobia, chronic fatigue syndrome, irritability, bulimia and anxiety, they are prescribed for everything from smoking cessation to PMS. Last summer, the FDA approved SSRIs for the treatment of obesity. And the FDA may approve marketing to children this year. Increasingly, the SSRIs are permeating both the way we treat mental problems and the way we see them. Altered StateFlippant criticisms of the use of Prozac and other medications to treat a burgeoning spectrum of mental ailments threaten to trivialize the topic of depression itself. There is nothing trivial about it. One in five patients suffering from intractable depression seeks and receives the final cure: death. "When I was depressed, a good day was if I could get out of bed and do one thing," says "Roberta," a San Jose-based drug and alcohol counselor who has -- through medication and a new therapeutic model -- recovered almost completely from her own chronic depression. "There are a lot of people out in the world really hurting inside," she says. Many find relief in the form of tablets of white, green and yellow.The disease model stimulates discussion on the topic of mental illness, but it also implies a limit to psychological change. The biomedical view has altered the way patients see themselves, encouraging both relief (if they find drugs helpful) and a new fatalism. Patients now request antidepressants on their first therapy visit. "They're starting to say things they've read, like 'It's chronic, it's a lifelong disease.' The literature is more pessimistic and people are more scared," says Gordon Trockman, an associate professor of psychiatry at the University of Hawaii.Breggin believes the new model does more damage than good. "Depression is about being hopeless. If you tell a person they have a genetic, biochemical disorder, you've encouraged their very worst fears -- that they're worthless and flawed. The fact that something 'feels chemical' does not make it chemical," he asserts. "The metaphor of disease is the religion of the modern patient."Secret Brain"I can't help feeling that anything that works so effectively, that's so transformative, has got to be hurting me at another end, maybe sometime further down the road." -- Elizabeth Wurtzel, Prozac NationBeyond the parallels to Aldous Huxley's Brave New World -- in which the awful and wonderful existential states of humanity are ironed over through "infant conditioning" and the drug soma -- purely physical questions about antidepressants persist. Precious little is known about the brain, an organ involving over 100 billion interlaced neurons. Some researchers compare the complexity of the brain to that of the universe. Even researchers at Eli Lilly are not sure how Prozac and other antidepressants work. In its own literature, Lilly explains that Prozac's effects are "presumed to be linked to its inhibition of ... neuronal uptake of serotonin." The brain transmits information between nerve cells called neurons in the form of electrical signals and chemicals called neurotransmitters (including serotonin). The space between neurons is called a synapse. Prozac and related SSRIs purport to work by blocking the action of a serotonin feedback, or "reuptake," pump which operates between neurons, allowing more serotonin to remain in the synapse.People with mental illness possess brains which differ chemically and structurally from those of "happy" people. Certain parts of their brains may hyperfunction or fail to function. These differences are known as the biological "markers" of mental illness.Because antidepressants seem to work, researchers hypothesize backward that if a medicine which acts to maintain serotonin in the synapse makes someone feel better, that person's problem was a lack of serotonin to begin with.No one really knows."The brain is totally dynamic -- more dynamic than we thought. I certainly don't understand it," says Jeffrey DePaulo, psychiatrist and researcher at the Johns Hopkins University School of Medicine and one champion of the biomedical model and treatment through medication. According to critics of antidepressants like Breggin, our ignorance of what's actually happening in the brain during depression and also during the use of medications, combined with the stampede of prescriptions for drugs like Prozac, is a prescription for disaster. No one knows what the continued long-term use of an SSRI does -- if it causes cellular damage or what Breggin calls "severe rebound depression," or withdrawal.Ditching ProzacProzac has received more adverse-reaction complaints at the FDA than any other regulated drug. The Prozac Survivors Support Group -- founded by a man whose fiancee killed her own mother, he claims, while suffering an adverse reaction to Prozac -- reports receiving seven to 10 calls a day from people experiencing "catastrophic" reactions to SSRIs. But most psychiatrists consider semi-psychotic side effects a normal course of events for a patient population which borders on psychosis already.DePaulo observes that the wreckage of depression might weigh more heavily than the side effects of new drugs. According to him, chronic depression may be "the No. 1" impairing disease in the country. "Only aggravated heart disease is more impairing," he says. "And 70 percent of depressed patients are not getting treatment. We can't wait for all these answers to be practical doctors. We're for what works."And antidepressants do work. Sort of.For patients like Mike, SSRIs deliver them from the grips of mind-numbing depression. "Nina," a 32-year-old software company employee in Silicon Valley, became ill on Prozac. But Paxil allowed her to finish graduate school. For Roberta, "Sarah" and Suzanne, all of whom suffer or have suffered from depression, antidepressants are a lifeline to maintaining jobs and relationships. A lifeline to life. "I think I really need to be on it," says Nina, who recently upped her Paxil dose to 60 milligrams a day. "It scares me that I'm going up and up, but all the doctors tell me to take it."Like the experience of Charlie in Flowers for Algernon, a gradual "wearing off" or tolerance to the drugs seems ubiquitous. Doctors call this "Prozac poop out." Patients who experience miraculous changes on the SSRIs, who are able to enjoy life again, find themselves in a panic when their lifelines begin to unravel. "Sarah," also a Silicon Valley software company employee, has been through the older tricyclics as well as Prozac, Paxil and Zoloft, she says. "We would throw in Effexor and lithium sometimes, too. All the doctors want to do [when drugs wear off] is get you off your current meds and get you onto something new."Talk Isn't Cheap"After six years on Prozac, I know that it is not the end, but the beginning." -- Elizabeth Wurtzel, Prozac NationMost scientists and therapists agree that, while antidepressants alleviate symptoms of depression, they are not a cure. Patients who stop taking medications without having undergone a deeper psychological change generally end up where they started. Evidence shows talk therapy is at least as effective for depression as medication. Medication and talk therapy are more effective than medication alone. The changes brought about by medication are quicker and more dramatic, while changes brought about by some forms of therapy are more permanent.But in the face of the new "wonder drugs," talk therapy is withering. In this decade, talk therapists report a 20 to 50 percent drop in business.Of course, talk therapy was never a miracle cure to begin with. Many therapists themselves seem depressed. If there were an effective model for happiness, wouldn't we all be happy by now?"A lot of these guys, Jesus, it'd be depressing just to walk into their office," says Breggin of his colleagues, "Our training, and I hate to say it, but our training is to see people as defective objects. And my colleagues are, in many cases, the least warm, friendly and caring group of any, including lawyers."When patients find medicines that work, they are quick to latch onto the disease model and dispense with therapy. "Therapy started to get old. All my therapists would say, 'Wow, you've had a really hard life, no wonder you're so depressed,' " says Suzanne, 30. "I was telling them the same old sad story and finally I just decided, there's no sense in upsetting myself. I know what's wrong. I suffer from depression." Most of her therapists, she says, ended up prescribing meds anyway.Psychologist Abraham Maslow once said: "It is tempting, if the only tool you have is a hammer, to treat everything as if it were a nail." Psychiatrists and therapists want patients to get better. When medications work, medications are prescribed. Yet the work of psychiatrists exploring the biomedical model inspires a feeling of imbalance. Psychiatrists tend to deal exclusively with those who come into their offices because they are unhappy. Without effective therapy, patients often get worse. Who, however, is researching happy people, and how happy people become happy?Eventually, I discovered that if I felt myself slipping into "depression," I could concentrate my focus on someone else, on friends who were talking to me about their life, their feelings, their thoughts. I began to see that whenever I felt threatened by depression, it was because I had an initial thought about it -- a remembering -- followed by a feeling of fear, and suddenly I stood at the edge of a great precipice looking into an enormous spiraling tunnel, knowing fully the horror that tunnel contained. Yes, my thoughts could take me there.But if I distracted myself, my thoughts could lead me away from the precipice.Like, yes, Virginia, there is a hell. Hell is what you imagine it to be. Create it in your mind and you can go there -- you might even get stuck for a while. Certainly if you decide you're stuck, you are.The biomedical model of depression as disease implies a similar one-way action in the brain: that genes or biochemistry create our thinking and our mood. That the chemical comes first, and then the thought. This model leaves out free will and can create despair in patients who have run through the gamut of medications.The truth -- as far as scientists testing humans, monkeys and rats know it -- is that while there is a genetic tendency toward depression, this tendency can be overridden through loving parenting. Without loving parenting, the brain can get stuck in ruts of negative thinking; those ruts can become deeper and begin, eventually, to affect the body. Grooves and patterns are thus created. Physical parts of the brain become more or less electrically active and may change their structure. All this, and at the same time the brain also changes more than a million times per second. There is almost nothing more fast or fluid, perhaps only light.A neurology term, "long-term potentiation," means, simply, that a thought or action that is new takes more "brain energy" at first but becomes, with repetition, easier. This is basic learning. A yogic word, samskara, has a similar meaning: You tend to do what you've done. While negative thought patterns and chemical levels may get "set" in a person's brain, they can also be reversed. Positive thought patterns can be learned -- with effort at first, but then new patterns are set. (Positive -- or at least creative -- thinking utilizes more areas of the brain, with greater elegance and efficiency.)In a study of obsessive-compulsive patients at UCLA, "cognitive, bio-behavioral" therapy produced the same brain changes, recorded on PET scans, as an SSRI. Patients, through "mindful awareness" and willed changes in behavior, were able to change their own brains. The study's author, Jeffrey Schwartz, writes in Brain Lock, "We can literally make a new brain groove."Even placebo pills create positive change in depressed patients nearly 40 percent of the time, rivaling antidepressant effects. Last fall, a study on children with "genetic vulnerability" to depression in adoptive families showed only those children who were exposed to "psychiatrically disturbed" parents began exhibiting signs of depression themselves. Even then, not all of these children became depressed.At the very least, change in the brain is a two-way street. Even the elusive genes dictating mental illness seem malleable, and may lose or gain influence through human thought and behavior. Depressed patients with nearly psychotic parents have recovered through exposure to knowledge outside the family, and their own realizations.Transpersonal psychiatrist Mark Kasprow, who helped start the Transpersonal Care Clinic at the San Francisco Veterans Administration Medical Center, sees the debate as somewhat irrelevant. "There's a circular relationship [between biology and human action] and you can enter at any point in the circle and intervene. People tend to fall in one camp or another, nature or nurture, drugs or no drugs. But the polarization isn't helpful." Labeling patients as "chronic," as biologically doomed to depression without medication, may not be helpful either.Soul Survivors"Does modern psychology give you any reason for being? And isn't that what we're all asking, all our lives?" -- James Hillman, author of The Soul's CodeIf we assume the spectrum of the human mind ranges from the deeply psychotic or schizophrenic to the contented, self-realized and perhaps enlightened, then psychotherapy has seemingly spent 99.9 percent of its time exploring only one side of the spectrum.We know how we sink and drop and tumble. We can name each queer variation of pathology. But how do we elevate and stretch and "break out" and love and transcend ourselves? In the language of science, there has been little room for such ephemeral notions as the soul. But some therapies which have demonstrated success equal to the medications approach come back to a central mystery of human existence: the consciousness behind the brain.Before the ballyhooed sailing of the neuropharmocologic cruise ship, psychology was beginning to tap ancient veins of spiritual traditions. Studies on "attentional control" training -- watching and shifting thought -- in groups of people suffering from depression and anxiety disorder show "long-term beneficial effects." Psychologists like Laura Pauly, in 1991, were calling for "a convergence of paradigms of religion and science and the necessity for a synergic understanding of depression." Their voices seem to have drowned in the wake of the SSRIs.Mental illness can be understood within the framework of Buddhist and even Christian and other mystical traditions. According to transpersonal therapists, mental illness is equivalent to the Buddhist experience of narrowed focus on self, on the ego or personality, and separation from a divine source. The brilliant manic sees himself, alone, as the creator of all wonders. Depressives become trapped in the "I," isolated and disconnected even from friends and family.The opposite of this "I" trap is connection with the universe, they say. The Oneness. The Allness, in which the self merges with the Absolute. The Christ consciousness. The Krishna.Love Is the Drug"I need love. I need the thing that happens when your brain shuts off and your heart turns on." -- Elizabeth Wurtzel, Prozac NationFor those who suffered from depression before antidepressants or even therapy became popular, shifts in thinking and newfound spirituality produced change. Bay Area novelist Blair Fuller has said he conquered a lifetime of "paralyzing" depressive episodes: first through a mediated LSD therapy session in 1963, when LSD was legal; then through recovery from life-threatening heart surgery. On LSD, Fuller realized he was giving more power to family figures, such as his domineering father, than they deserved. "A big weight was lifted off me," he says. "After that I was more cheerful, more peaceful." After coronary bypass surgery in 1989, the process of preparing to die -- and then recovering -- made the world new again. Reinvigorated, Fuller no longer suffers from depression, but chooses to live according to the dictates of his own inner wisdom. He explains, "This above all, To thine own Self be true. I was always oriented toward accomplishment, and people's reactions to me. In the end, you don't know who you are until you open your heart."Mike, struggling with depression's rearing head as his Serzone "wears off," reports an inner shift of his own. He is thinking about taking Wellbutrin -- but notices that this time the onset of his depression is different. He has begun regularly attending an unconventional Episcopalian church, where members sing and pray and hug a lot. Mike has been reading the Bible and other spiritual texts, and two months ago he fell deeply in love. He now prays regularly. And for the first time in his life, he told his parents -- always unphysical and unaffectionate -- that he loves them both."I'm trying to lean on God, I'm trying to be more objective, to have more consciousness. I talk to God and that seems to help."You know what I hear when I listen to God? ... Just, Love." Mike tears up. "Love keeps on coming at me, and I feel like a colander, like it's draining out, but it also just keeps pouring in."Eventually, my partner stopped talking me through my minor fits of depression. One stressful night, I once again felt I was "losing it." I lay in bed, my mind swirling. All my thoughts were negative; each spiraled into the next, an endless loop.In the midst of all this, I had a thought, a positive thought -- something like "Forgive yourself." This thought was tied into faith. Faith that there was something beyond just me -- my creator. For I did not create my soul.Suddenly, I shifted out of my bleak mental state. The terrible chatter in my mind stopped and I was transported -- not into normalcy, but into a different state of mind altogether. First, I had a vision. An eye, like an Egyptian hieroglyph, seemed to come at me from beyond, and it passed through me. Or I passed through it. The eye was like my "I," my self, my name, Ami Chen Mills, my personality. And once I got beyond it, I was in a state of what I named Christ consciousness. I thought, "This is where we are all One." It was a state of the deepest tranquillity, the deepest, impersonal Love.This experience initiated the restoration of my faith in the universe. And my life has only gotten better since then.