By Charles Barber
Sunday, February 10, 2008
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 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."