恶人谷

Healing a Troubled Mind Takes More Than a Pill

By Charles Barber
Sunday, February 10, 2008; B01

Feeling depressed? No problem, pop a pill.

That's what more and more Americans are doing these days to quell what ails their troubled souls. The use of antidepressants in the United States has exploded in the past couple of decades, and drugs such as Prozac, Paxil and Zoloft, which didn't even exist 20 years ago, are household names, almost household staples.

And why not? The television ads make it seem so easy: An agonized man or woman stares listlessly into space or slumps on a bed or couch, holding their head in their hands. Then they take a pill and suddenly morph into a happily engaged and joyous being, back on the job or walking in a park, awash in sunshine, surrounded by grandchildren, a golden retriever nipping at their heels, while lush music plays in the background.

But recovering from mental illness is rarely that simple. I know.

As an optimistic 18-year-old freshman at Harvard in the 1980s, I found myself afflicted by indescribably disturbing and intrusive thoughts that involved repetitious words and irrational fears that I had harmed others. This assault on my mind -- diagnosed a few years later as obsessive-compulsive disorder -- led me to drop out of two colleges in as many years and made it difficult to hold down a job as a busboy.

That was the low point. After that, I began the long, arduous and at times confused process of emotional recovery. Medication was helpful -- as was cognitive behavioral therapy, particularly early on -- but what ultimately made the difference, what really made me want to get well, was finding a sense of purpose in my new life, a life that had been reconfigured by illness.

The critical moment in my own recovery was my decision -- very unpopular at the time -- to work full-time in a group home for people with severe developmental disabilities, young men my age who could not talk. Having been given all the choices, I gravitated toward a place where there were few options. But I intuitively sensed that I would find a new path there. Indeed, I found I was good at the work, and it was therapeutic for me to "get out of my own head" and serve others.

Ultimately I returned to college, went to graduate school and have spent my career writing about and working with people with serious mental illness in shelters, prisons and halfway houses. Both my work with my clients and my own prolonged and difficult yet ultimately rewarding journey have taught me lessons about what's involved in overcoming true psychological distress -- and what isn't.

In 2006, an astonishing 227 million prescriptions for antidepressants were dispensed in the United States -- up 30 million from 2002. Altogether the United States accounts for about two-thirds of the global market for antidepressants. Other proven and practical approaches to managing milder forms of depression, such as diet changes, exercise or cognitive behavioral therapy, haven't gotten the attention they deserve in our high-tech zeal for the drugs.

Antidepressants can be highly effective, particularly for the more severe forms of depression. But when you speak to people with severe mental illness who have gotten better, you learn about the reality of the recovery process, which is rarely about a pill -- even if that pill is effective. When you interview patients about how they got better, they hardly ever cite Prozac or Zyprexa or lithium. For that matter, they rarely cite a particular doctor or therapist or treatment program. Rather, they talk about a person who was kind to them when they were really down; they talk about the child they wanted to be a good parent to; they talk about God and spirituality; they talk about something that brought them pleasure even when they were cloaked in pain. Many of these reasons to live -- the reasons to seek treatment in the first place -- are highly personal and idiosyncratic, as was mine.

As I've learned, both professionally and personally, social context is critical to recovery. In other words, there's invariably a social reason to get better. This is what has been largely overlooked by the "medical model" of treatment, which proposes that you must stabilize a person with treatment (typically drugs) before they can be put back in their social roles or environment.

Larry Davidson, a Yale researcher on recovery from severe mental illness, has examined the data and found that this model is flawed, at least in the field of mental health. "In the medical model, you take a person with a mental illness, you provide treatment in the hopes of reducing symptoms, and then they're supposed to approximate some notion of normality," he told me. "Our research shows the opposite. You take a person with a mental illness, you then reduce the discrimination and stigma against them, increase their social roles and participation, which provides them a reason to get better in the first place, and then you provide treatment and support. The issue is not so much making them normal but helping them get their lives back."

Davidson's contention is supported by the provocative finding by a number of researchers that schizophrenia outcomes are better in developing countries, where, generally speaking, patients get more support from family and society, and where ill people are less likely to be excised from their natural communities.

Another thing patients will tell you is that recovery exists, or can exist, within the context of illness. In other words, recovery doesn't mean cure. It means living with the illness, managing it and getting better within certain limitations. "I define recovery as the development of new meaning and purpose as one grows beyond the catastrophe of mental illness," says William Anthony, director of Boston University's Center for Psychiatric Rehabilitation. "My feeling is you can have episodic symptoms and still believe and feel you're recovering. It is a matter of moving beyond the debilitating phases of the illness."

The idea that recovery doesn't usually mean the removal of all symptoms is a novel and distinctly un-American way of looking at psychiatric illness, and illness in general. The fact remains, however, that most major psychiatric illnesses are episodic but chronic. Recovery involves both coming to terms with symptoms -- one hopes in the context of their gradual moderation, but that's not always the case -- and finding a meaningful life in their midst.

For many patients, this is a decades-long process of acceptance and resolve. At the end, some patients can actually say they're glad -- within reason -- that they've experienced an illness, because it has greatly enriched their lives and their appreciation of things. We do have to be careful not to romanticize suffering, but this is nonetheless something you commonly hear from those who have found the elusive meaning in the presence of sickness.

This leads us to the final lesson I've learned: Treatment is most effective when the patient is in charge and the ultimate expert in his or her own recovery. There is evidence that when patients feel in control, the results of treatment are better. Treatment works best when the doctor or therapist acts as a kind of expert consultant. As Home Depot puts it: "You can do it, we can help."

That's what I found in my own process. That my journey was a self-directed path, one in which I saw myself as the author of my recovery rather than as a passive recipient of a pill, made all the difference. Ultimately I no longer saw myself as a patient but as a writer, father and husband. Ultimately I found ways to use my obsessive ways adaptively. A little like Monk, the television detective who uses his OCD to solve crimes, I repurposed or redefined my illness to write and research with extra drive.

But these complex lessons about the arduous realities of attaining emotional health, as told not by doctors or companies but by patients, have received little traction in mainstream health care and the mainstream media. The negative reception isn't surprising. Listening to patients cuts against the establishment grain. We live in an age of experts, in which we like to cede control of our bodies and our being to others. Different parts of our bodies go to different experts. The ultimate expert, perhaps, is the pill. Our fervent and simple-minded belief is that the experts, and the pills, will take care of things for us.

The simultaneously inspiring and terrifying reality is that getting better -- the winding, agonizing road to stability -- is a little messier (and a lot more interesting) than we would like it to be.

charles.barber@yale.edu

Charles Barber is a lecturer in psychiatry at the Yale University School of Medicine and the author of the just-published "Comfortably Numb: How Psychiatry Is Medicating a Nation."

The television ads make it seem so easy: An agonized man or woman stares listlessly into space or slumps on a bed or couch, holding their head in their hands. Then they take a pill and suddenly morph into a happily engaged and joyous being, back on the job or walking in a park, awash in sunshine, surrounded by grandchildren, a golden retriever nipping at their heels, while lush music plays in the background.

Prozac Nation?
The returns aren't in.
By Peter D. Kramer
Posted Monday, Feb. 11, 2008, at 7:28 AM ET
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In the waning months of the Carter administration, and of my own brief stint in the Department of Health, Education, and Welfare, I was detailed to develop a document for the signature of the surgeon general, Julius Richmond. A feminist group had asked for an assessment of the "mother's little helper" problem, the tendency of doctors (so went the widely held assumption) to prescribe Valium instead of listening to their patients. This inquiry occurred in the context of a broader discussion about whether America was becoming an overmedicated society―whether we were peculiarly averse to discomfort and enamored of the quick fix. And so I convened experts from the National Institute of Mental Health and other federal agencies to assess what was known about women and the use of prescribed psychotherapeutic medications.

The exercise taught me how difficult it is to find facts that bear on beliefs about drug use. By the 1970s, in any given year, almost one-quarter of all women had used a psychotherapeutic medication, and about 10 percent of men. But women reported more negative life events and responded to them with more symptoms. It was patients with high levels of distress who had received medication, and high distress correlated with diagnosable illness. That was the sort of information we had―indirect, coarse-grained. We did know that the French and the Swedes were prescribed more psychiatric medicines than were Americans, and that many Americans failed to renew their scrips even once. The newer medications, like Valium, were safer than older drugs, like barbiturates, which accounted for six times as many deaths per prescription written. Nor did addiction trends show a clear pattern.

My task force drafted a circumspect letter saying that little in the scientific literature suggested a crisis or even a uniquely American response to anxiety. Later, I helped analyze data that found that general practitioners provided more "therapeutic listening" to women than to men. Prescribing did not replace "quality time"; it supplemented it. Still, the important questions remained unanswerable. No one had done fly-on-the-wall studies to see how doctors assess patients. Even detailed information about diagnosis and prescribing would not resolve the technical and philosophical debates. Some psychiatrists believed that anti-anxiety medications had a justifiable role in the treatment of depression, so that apparent mistaken prescribing might represent "street smarts" on the part of GPs. Meanwhile, public-health advocates were skeptical of the diagnostic system and the related pharmacology research. It did seem that Valium was playing a signal role in the culture. Think of Jill Clayburgh; three of her films in this era―An Unmarried Woman, Starting Over, and I'm Dancing as Fast as I Can―featured Valium.

A quarter century later, the evidence about mother's little helpers is no clearer, but the case can be made that what was at stake had less to do with medication than with society at large. Yes, Valium had its beneficiaries and its victims. But the broad trends now look to have had their own momentum―more conflicting responsibilities for women, less time with patients for doctors, and a loss of cohesion and gravitas throughout the culture. In retrospect, Valium supplied convenient metaphors for change to which it contributed minimally. Two or three decades down the road, will today's widespread concern over antidepressant prescribing have a similar feel?

Charles Barber certainly does not think so. In Comfortably Numb: How Psychiatry Is Medicating a Nation, he makes the case that Prozac and its peers are threats to the health and civility of the nation. Once again, the drug reveals America as it is―commercial and unreflective. Barber writes: "The SSRIs are at the epicenter of emotional entitlement, its ultimate symbol and its ultimate expression." These concerns about the drugs' cultural impact are ones I raised in 1993, in the form of thought experiments, in Listening to Prozac. Effectively, Barber's claim is that my worst fears have come to pass, that America has become a dystopia, through the use of antidepressants.

If nothing else, Barber, a caseworker with the chronically mentally ill who has gone on to teach at Yale, has assembled a handy compendium of evidence for the belief that we are overmedicated. He reports that 33 million Americans took a psychiatric drug in 2004. He finds abundant signs that the stigma of mental illness is decreasing, a change he deems ominous because of the accompanying growth in comfort with medication use. Barber mounts the customary attack on psychiatry's promiscuous diagnosing, the FDA's toothless oversight, Big Pharma's baneful influence, and the society's embrace of reductionistic theories of the mind. Barber does believe that medication, and not psychotherapy, is the best treatment for serious depression; but he says that most antidepressants are prescribed for ill-defined maladies for which drugs are ineffectual. To reverse our self-indulgence, Barber favors cognitive behavior therapy and an increased tolerance for melancholy, emotional pain, and even frank depression.

The problem with this line of argument is that it lacks perspective. Barber dips into history, and he amasses popular references (Oprah, The Sopranos), but his conclusions are ahistorical, his cultural reach is narrow, and his facts are often simply wrong.

Barber trumpets, "To say that we are the most psychiatrically medicated nation on earth is a prodigiously absurd understatement." As regards antidepressants, he buttresses this claim by citing pharmaceutical sales; but paying high prices is not the same as taking more pills. According to a study from the MIT Sloan School of Management, on a per capita basis, by the year 2000 Swedes and Canadians had begun taking more antidepressants than we do.* Greece, Italy, Spain, and (again) Sweden used a larger proportion of new, on-patent antidepressants than did the United States. The authors concluded that on the variables studied, the United States "is often 'in the middle' relative to other countries, and is not an outlier."

Depression goes with latitude. Perhaps the Swedes and Canadians should seek more treatment than we do. But the British and the Portuguese are generally clustered with us, as well. The transatlantic perspective suggests that Oprah, the FDA, and the American Psychiatric Association―never mind the American character―cannot bear the entire burden for our prescribing patterns.

As for a surge in usage, 33 million Americans is 11 percent of the population. Sampling techniques have changed; data from the 1970s excluded children and the elderly, and the populations studied tended to be urban. Even so, any difference between prescribing now and then is not so great as Barber would have us imagine. As in the past, substantial percentages of patients―Barber says one-third―do not refill their scrips. And once again, the newer medications are safer in overdose than older drugs in the same category. The more distance you take, the harder it is to make the case that our current circumstances are unique.

The notion that we embrace too many subclinical conditions as treatable is likewise myopic. In the 1950s and '60s, almost everyone who was not psychotic qualified for a diagnosis of neurosis. Who was not a candidate for psychoanalysis? That treatment carried little stigma. In some circles, cachet was attached to it, as an indulgence for the elite. Medication arouses more controversy, in part because of the broad population that can access it. But it is hard to argue that more people are diagnosable today than in the heyday of Freudianism. And as regards treatment and stigma, if our tolerance has spread to medication, is that change entirely for the worse?

Psychotherapies are effective, and they are underutilized―on these points, doubtless Barber is right. But even here, his pronouncements sound a bit off. Barber writes, "In the high-tech age of Corporate Psychiatry, efforts like CBT don't get the press they should." But in 2007, Newsweek and O gave CBT coverage, and a cognitive therapy book was a best seller―hardly signs that the treatment is off our radar. Nor is psychotherapy research free from the problem of bias that dogs medication testing. In The Great Psychotherapy Debate, Bruce Wampold found that CBT's special contribution has been exaggerated. (One problem: Widely used rating instruments, developed by cognitive therapists, favor CBT by emphasizing change in cognition as a key outcome.) Neutral research finds that most therapies work equally well. A humane view might be less sectarian than Barber's. The bulk of studies find that it's relationship―the therapeutic alliance―that matters, not techniques particular to any one approach.

Too much Prozac? To my mind, the most interesting data appeared in a study by Benjamin Druss and others, published last October. It found that nearly 40 percent of people who received mental-health services, including medications prescribed by a family doctor, did not meet diagnostic criteria for illness. But more than half of those undiagnosed patients had suffered mental illness in the past. Of the remaining 18 percent, more than half had one of three other indicators of need: a prior mental hospitalization, a syndrome one symptom shy of a diagnosis, or a serious recent stressor like divorce or rape. The final 8 percent, those who received services with no explanation, were largely treated outside the medical system, by clergy or self-help groups.

Again, our best analyses are inexact. But they point to the limits of the problem under discussion. Wild prescribing hardly seems to be at issue. Still, we must ask: Should rape victims (and others under stress) who have no clear mood disorder receive mental-health services, and which ones? How effective are antidepressants for patients with four rather than―as the diagnostic manual demands―five depressive symptoms? Are general practitioners sloppy or perspicacious? These questions are serious. They are difficult. They are not uniquely American. They are not new.

The issue that Barber addresses, distinguishing the treatment of disease from what I have called "cosmetic psychopharmacology," remains important. And it's not that Barber is wrong about the culture. Big Pharma wields too much influence. Soft technologies like psychotherapy get short shrift. The world is too much with us; late and soon, getting and spending, we lay waste our powers. But there is a danger in taking a narrow viewpoint―making our time and place out as exceptional and so finding constant crises.

Likewise, there is risk in answering questions prematurely. Finally, how antidepressants interact with capitalism remains uncertain. We may―this concern was at the core of Listening to Prozac―be using medication to achieve the assertiveness and confidence that our society demands. Or, as Barber suggests, we may be numbing ourselves. But two other possibilities remain on the table. We may be doing pretty well with the imperfect medicines we have. Or we may still be failing to reach numbers of people with substantial mental illness.

Correction, Feb. 11, 2008: This article originally misspelled the name of MIT's management school.