Is Depression a Medical Condition?
By Justin E. H. Smith
In Harlem, ten years or so ago, I overheard two elderly ladies waiting for a bus underneath a billboard that read: "Depressed? It's Chemistry, Not Character." This slogan was followed by a 1-800 number which would put the caller in touch with a medical professional able to write a prescription for antidepressants, that is, to set the chemistry right by preventing the reuptake of serotonin. The one lady said to the other: "I went to my doctor and he told me that's what I got. Depression. I always knew it was something."
I confess I feel tremendous inhibition at the prospect of taking up the topic of reuptake inhibitors. This is because it is, unlike my usual preoccupations (God, animals, language), by no means just an intellectual exercise for me. Over the past 18 years I have been on at least six different kinds of SSRI, each one bearing a brand name that sounds more like a Lexus model than the last. (Could I have been taking something called 'Selexa', or did I just see one parked outside of Starbuck's?) In the long run, they never quite do the trick, or if they do, then they do that plus a whole lot more one would rather avoid. And so invariably I wind up back where I started: lucid yet burdened, supremely sane yet stalked by a particularly dark demon, my constant companion, my familiar.
I have chosen to write about this condition not out of desperation --no, the drama of it was all played out years ago, and now I am nothing if not stable--, but rather out of a sort of calling, rare for me, to enter into identity politics. I am tired of all the stupid things I hear said about my fellow depressives. It was not so long ago that Jesse Helms, or perhaps Strom Thurmond, described Jean-Bertrand Aristide as a confirmed 'psychotic' when he learned of the Haitian president's Prozac prescription. My fellow philosophy professors thoughtlessly invoke 'happiness pills' as the easy way out for the philosophically lazy, while the general public seems to perceive antidepressants as a crutch for the frivolous, as a Hollywood indulgence, as a symptom of privileged frailty. This moralistic condemnation is usually counterbalanced only be the equally unsubtle medicalistic reduction of our emotional lives to chemical imbalances. I am neither crazy, nor lazy, nor is my state entirely explicable in terms of a certain disequilibrium of fluids. I am a depressive, which is to say a person who experiences the world in a certain way. Now I am every bit as materialist as the cynical doctors who paid for that billboard, yet I dare say that when I talk about my depression what I am talking about is nothing other than my 'character'.
There I go philosophizing again. I had set out to tell a little something about myself, and before I know it I'm talking about the mind-body problem. I will not claim that to know that black dog, as Churchill put it, in itself gives one insight into this deep and intractable riddle. What I will claim is that reflection upon the nature of depression, and upon the actual (as opposed to commercial) virtues of antidepressants is for me a central part of the Socratic project of self-knowledge. Some people take paper-making classes, others learn the ancient art of retreating to weekend wellness spas. And some heed the oracle. Chacun son passe-temps.
My particular diagnosis has generally been depression with obsessive-compulsive symptoms, a mixture often found, they say, in 'high achievers'. When I was an undergraduate I was so obsessed with obtaining top grades that I found myself symbolically swallowing every letter A I came across, and symbolically spitting out every B, C, D, and F. If I accidentally swallowed while looking in the direction of a C or a D, I would have to quickly go in search of compensatory A's to ingest. I cannot describe the deep sense of dread that such a mistake was able to bring about. There were times when I would inadvertently swallow looking at the wrong part of a sign along the freeway, and I was thereby compelled to exit at the next off-ramp, drive back to a point before the sign, turn around again, and drive back past, swallowing up the A's, if there were any, or spitting out the low marks that I had inadvertently ingested on my first pass. In reading books, if I came across a sentence with too many bad letters in it, I was compelled to look away from the book and to mouth any one of a stock of sentences containing no bad letters and plenty of A's. "That's not great, lovely man," was for some reason the most therapeutic sentence I could conjure. It was (I think?) meaningless, but phonetically very satisfying. The 'l' sound was also very satisfying, and sometimes I would add it in where it did not belong just to make sure to get the needed relief: "That's not great-l, lovely man-l."
My compulsions were not just orthographic and phonetic, but numerological as well. I could not tolerate odd numbers, and if when walking along my head was grazed by a leaf hanging from a tree, I was often compelled to turn back around and let it touch me a second time. At times I could not resist breaking pencils in half in order that one would become two, and each half, now a whole, would have its other.
I do not do these things anymore. Today, I do other things, generally so subtle as to go unnoticed even by me. I am one of the fortunate ones: I've learned to channel my possession into socially acceptable, because socially invisible, directions. One channels, but one never exorcises. The symptoms mutate, but the state causing the symptoms remains, one single and monolithic constant, a lifetime's fellow traveller, a Lebensgefährtin. The woman always knew it was something. It always was something.
**
I am a materialist who nonetheless would be frightened in a graveyard by myself at night, and I am a good and intelligent reader of statistics who nonetheless gets sick with fear every time I am obliged to get into a goddamned airplane. I believe in what Ernest Gellner described as "the world of regular, morally neutral, magically unmanipulable fact," yet I go about my life as though the world were some sentient agent ready to take its vengeance upon me should I fail to follow its harsh and arbitrary commands. This condition has led me to believe that the stupid things we do generally have nothing to do with false beliefs. Would that it were that simple! Superstition bubbles up from the unperceived depths, and enlightenment is no cure. My beliefs are just fine, yet I am sick.
Perhaps we focus on false belief as the root of our problems simply because it is relatively easy to correct. Ever since the Stoics, cognitive therapy has stood out as a promising path towards feeling good about one's lot in life: belief modification, it has been thought, coming to live in the light of the truth, could free one from fearful superstition and thereby lead to emotional well-being. And all without chemicals! But I have been insisting that superstition is independent of belief, and that one's character, the general way one fits with the world, has little to do with the descriptions one gives of it, with the list of things and forces in one's ontology.
Once one has solid first-person evidence of the futility of belief modification in the quest for happiness, chemical modification starts to seem like the best option. If the eradication of false ideas changes nothing, then perhaps the simple accumulation of serotonin will help to make the universe a more charming place. The genie of the future will not have to give a choice of wishes, for now we know that all of that stuff about finding love or treasure or gaining power was really just about stimulating the pleasure centers in the brain, and any scientifically literate wisher would do better to just wish for that directly: constant and intense neural euphoria. I can remember being on a new SSRI at a conference in Rome or New Orleans, or somewhere else one is supposed to want to go, and thinking: I'm just going to lie down there on that hotel bed and enjoy my brain. Everything else --the Colosseum, the French Quarter, the entire world beyond my neurons-- was superfluous. My happiness, such as it was, did not come from making my thoughts fit the world, as the Stoics had counseled, but by cutting the world altogether out of the picture.
**
Jede Krankheit ist eine Geisteskrankheit, said Novalis: Every illness is a mental illness. This inverts the billboard's message, according to which every mental illness is an illness plain and simple. For Novalis, it is not that the soul should be assimilated to the pancreas, but vice versa: that diseases of the body, like depression, have their meaning only in the way they are experienced. This is not to say that your illness is your own damned fault and that you are simply being punished for your failure, as was vividly imagined in Samuel Butler's Erewhon. It is to say that any illness, 'physical' or 'mental', is an illness at all only insofar as it is experienced by some subject. A rusting bar does not suffer from the metallic equivalent of cancer.
**
Whether we are going to speak about a tortured soul or about a defective brain seems to depend mostly on the rhetorical purpose at hand. Students hoping to be excused from some responsibility or other have learned to talk the medical talk very skillfully: how can a mere Ph.D. in philosophy, they seem to be saying to me, possibly argue with a medical note from a real doctor? We're talking about an illness here, not some fleeting mood. Doctors take on the social role of magicians, able to transfigure any procrastinating or hard-partying adolescent into a special kind of creature --a depressive, a manic-depressive, an obsessive compulsive, a sufferer from attention deficit disorder-- usually with nothing more than the most perfunctory speech act. I am not saying these categories do not exist (at least as far as the first three are concerned). Indeed, I have claimed some of them for myself. But I doubt that their reduction to medical conditions like any other is what best helps us to understand them, or to live with them.
In the past several decades we have witnessed the encroachment of medical talk into nearly all domains of social life. The refusal of some drivers to wear seatbelts is spoken of as a 'public health problem'. Of course, a smashed skull is truly a medical condition, but must that mean that every course of action that could lead to its smashing is also medical? Similarly, is the undeniable existence of a chemical substratum to our conscious experience sufficient reason to conceptualize unpleasant or burdensome mental states as medical?
I do not want to take this line of questioning too far. I have cited Novalis's idealist motto as a counterbalance to the prevailing view that every illness, including mental ones, is a medical condition. But I am not an idealist, as I believe the body is its own thing and there are plenty of context-independent facts about it. I am willing to concede that chemotheraphy works on cancer cells in the same way whether one takes cancer to be the consequence of witchcraft or of environmental pollution; and an insulin shot will do the same good in a superstitious diabetic as in a scientistic one. But SSRI's have turned out to function in society rather less like medical insulin than like herbal infusions, yoga, or the cocaine that Freud once thought, not too long ago, would bring about a revolution in the treatment of mental illness: that is, they have vastly different effects depending on what is expected of them. And this only shows that the well-being of the soul is something not nearly as easy to control with medicine as is blood-sugar level.
Somewhere Lévi-Strauss discusses the magic-mushroom habit of the berserkers-- i.e., those medieval Scandinavian warriors who put on the 'bear shirt' and were thereby transformed into bears during battle, giving them full license to rape and kill with extra ursine vigor. Now, those of you who have dabbled with psylocibin will probably agree that raping and killing were not foremost among your desires during your trip. The trip was all-natural, indeed, as shroomers never tire of pointing out, yet it was strongly mediated by culture. And this is why your reaction to mushrooms was different from that of a Viking warrior. I can imagine, similarly, a culture that takes Zoloft before raiding coastal villages, and another that reserves it for monks in an ascetic order dedicated to knowing God, and perhaps another culture still, a tightly controlled millenarian sect, that distributes it to its initiates in preparation for mass suicide. (This last case is not so far from reality, as antidepressants have been shown to increase the risk of suicide-- a fact that should cause any thinking person to doubt the simple, reductionist belief in a cause-and-effect relation between the inhibition of serotonin reuptake and the qualitative experience of well-being.)
Why is the experience of antidepressants so variable? Medical anthropologists have known for a long time that medicines are not just taken by bodies; they are incorporated into cultures, that is to say into preexisting cosmologies that permit certain reponses to things ingested, encourage some, and exclude others. There may be a single, context-neutral fact about what St. John's Wort does in the body (as it happens, probably nothing); but there is no such fact about the role that said wort will play in a culture. In our bodies, it brings about its minor effects and passes through; in our culture's fantasies --and in our culture's economy-- it does a good deal more: it contributes to that nebulous condition we call 'wellness'; it cleanses its consumer of vaguely defined toxins; it purges 'free radicals', whatever the hell those might be; it signals 'consciousness' to other consumers. It is not to be mixed with gin or Diet Dr. Pepper. Now of course consumers of St. John's Wort are likely to be suspicious of chemical antidepressants, but many of the same considerations may be brought to bear in the one case as in the other. For both, success in our culture depends upon the substance's symbolic role in a system of oppositions. Better living through mere chemistry is never enough; the pharmaceutical companies understand that it is principally through marketing --that is, positioning some chemical or other in the desired social role-- that that chemical comes to be perceived as a means to better living.
**
It should not be controversial for me to say that the reason for the existence of antidepressants is the profit of the pharmaceutical companies that produce them. This is not to say they don't work. People who are made happy by new products, who can invest their hopes in wellness accessories available for purchase in Skymall catalogs, people who get a wellness charge from St. John's Wort or from hot stones strategically placed on the back, might also be made happy by the opportunity to take a new antidepressant (one of these, 'Wellbutrin,' has explicitly incorporated 'wellness' --a term that only caught on because those who stood to profit from it were unable to gain permission to make explicit health claims on their product labels-- into its name.) Things are rather more complicated for those of us who live under le soleil noir, as Julia Kristeva called it, but are nonetheless perfectly clear-sighted about our plights, and about the real prospects for escaping them.
Berlin, August 17, 2007
