Coming of Age on Zoloft (8 page)

The second unique feature of the DSM definition of depression, they write, is that DSM attempts to make depression into an absolute category. Many historical models of depression posited not a binary distinction between sick and well, but a long continuum between melancholy illness and complete health. The ancient Greeks, from whom we get our oldest descriptions of depressive illness, had such a system. They defined melancholic illness as an excess of black bile, one of the four bodily substances or “humors” that were thought to be responsible for illness and ordinary temperament alike. People with a melancholic disposition were moody and self-deprecating, but as long as these traits didn’t get out of hand, the people who had them weren’t considered to be ill. Pathological sadness wasn’t different from ordinary sadness in kind, only in degree. But the modern DSM doesn’t deal in shades of gray. It was designed to create clarity, filtering out people who do have a disorder from those who don’t.

It is an understandable desire. And yet, Horwitz and Wakefield argue that in striving for clarity and consistency, the modern DSM has thrown out clinical accuracy to a worrying degree. They claim that there are any number of life events, like a romantic breakup or the loss of one’s job, that could cause a person to meet the DSM criteria for major depression for two weeks or more. Such people are not suffering from a mental disorder, but DSM’s lack of attention to context means that they are often erroneously classified as cases of depression. (The two-week cutoff for diagnosing a major depressive episode itself appears to be arbitrary, born more from a wish for standardization than from any scientific principle. An earlier document from which the DSM-III team drew heavily for its work placed the diagnostic cutoff for depression at one month instead.) This doesn’t mean that people who are feeling very sad don’t want or need aid, only that a depression diagnosis might not be the most accurate or helpful response.

All in all, Horwitz and Wakefield conclude that the modern DSM is incapable of distinguishing between ordinary and disordered sadness. As such, they say, it has greatly expanded the number of people who are seen as having depressive illness—and the number of people who are treated with antidepressants. Recently they’ve had a glint of agreement from an unlikely source: Robert Spitzer, the psychiatrist in charge of the committee that wrote DSM-III, who once claimed that the new manual was meant to be “a defense of the medical model as applied to psychiatric problems,”
44
went on the record on a BBC documentary in 2007 admitting that he too saw a problem in the DSM’s decontextualized approach:

SPITZER:
“What happened is that we made estimates of prevalence of mental disorders totally descriptively, without considering that many of these conditions might be normal reactions, which are not really disorders. That’s the problem. We were not looking at the context in which those conditions developed.”

INTERVIEWER:
“So you have effectively medicalized much of ordinary human sadness, fear—ordinary experiences, you’ve medicalized them.”

SPITZER:
“I think we have, to some extent.”
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But never mind the problems, or the simplifications. Every age has placed its spin on depression’s mystery. The Greeks used the idea of the four humors; people in the Middle Ages described melancholy as a loss of faith in God’s love; Freud saw Oedipal conflict at the heart of everything. And almost within my lifetime, my society has come up with its own explanation—neither more nor less implausible, in its own way, than any of these earlier ones. Chemical imbalance is a powerful metaphor. It is easy to understand. There’s something that can even seem intuitive about it. (Discussing his own antidepressant use in
Newsweek
in 1997, the novelist Walter Kirn wrote that after years on medication, he had started to visualize his own serotonin levels moving up and down “according to the weather, the time of year, and what I’ve had for lunch.”
46
) The serotonin idea has the appeal of a totalizing theory, a simple explanation for something complex. It assails us at once with the authority of science and with the ease of something you imagine you can almost feel yourself.

To have a mood disorder in the 1990s meant grappling with the idea of having a real biological disease. Where somebody in the 1960s would have been prompted by the dogmas of the day to pick over their life history and look for deep inner conflicts or subconscious losses, people in our time had to encounter the idea of what it meant to have a malfunctioning brain. And that shift made a difference, not just in terms of which medications people took but also in terms of the way they understood themselves and their experiences. Chemical imbalance wasn’t just a theory; it was a story that all of us who took antidepressants had to hold up against our own life story, to fit into it somehow or to consciously reject.

3
| Starting Out

D
uring the first few months after I started taking Zoloft, I kept catching myself thinking back to my childhood. I was replaying my earliest memories and, I realized, trying to distill from them some image of the kind of kid I’d been.

It was hard to picture myself from the outside, but when I tried I saw a child who was dreamy, thoughtful, and often worried. I remembered feeling confident and happy at home. My mother told me I’d been bossy and lively as a toddler, a diminutive, redheaded autocrat, and I could believe her. Outside of the house, I hadn’t felt nearly so sure of myself. A lot of my early memories seemed tinged with fear, or just an all-purpose eeriness. I remembered wanting to feel connected to the other kids in preschool and kindergarten, but not always knowing how. They seemed so carefree, so thoughtless, so loud. Sometimes I forgot myself and blended with them. But at other times, the feeling that my dad called anxiety would descend for days or weeks, and nothing would feel right. That feeling clenched my stomach, pinched my breath, kept me awake in the dark while the red glowing numbers of the digital clock marched on and on toward morning.

It had been a while since I’d returned to these memories. But the idea of being a depressed person brought them back from deep storage; it seemed to demand that I reevaluate the past in light of the present, searching for patterns. If what I’d just been through was depression, then what about those times back then? Seen from this new perspective, they seemed like evidence toward the conclusion that Sam had been right—that there really
was
something wrong with me, and that I had always been this way.

Medical anthropologists speak of something called “illness identity,” the sense of oneself as sick that parallels the actual experience of being unwell. Without meaning to, I was combing back over my life and revising it into a slightly new story, one that incorporated the idea of my being at least a little bit afflicted. I found that not only was this kind of editing not hard to do, but it was also almost irresistible.

Taking antidepressants is a complicated activity because it takes place on at least two levels. There’s the literal level of feelings and actions: we suffer; we see doctors; we receive treatment and feel better, or don’t. But there is also an invisible level on which we assign meaning to these experiences. We develop theories about why we felt bad in the first place, why we have chosen the treatments we did, and why they help. Along the way we subtly adjust our self-understanding to incorporate what we’ve been through.

David Karp is a sociologist who has pointed out that in every experience of depression and treatment, the patient moves through a series of predictable stages—from a vague sense that something is wrong; through a crisis; to the recognition that he has a real problem that must be defined, explained, and managed. Each stage, says Karp, invites revisions to one’s sense of self.
1
Talking to people about their own antidepressant stories made me appreciate the simple brilliance of Karp’s idea. Dividing the experience into steps allows us both to see what every antidepressant experience has in common and appreciate the variety that is possible at every turn. In this chapter I’ll use a collection of my interviewees’ voices to talk about how other people got started on antidepressants and began to modify their own identities in response.

WHEN I BEGAN
to conduct interviews for this book, I realized I was far from the only antidepressant user who described feeling different from a young age. Christine was in her mid-thirties when we spoke. She had grown up in Denmark, attended graduate school in the United States, and returned to Europe to live before her children were born. I reached her one afternoon on a grainy video-Skype connection that revealed, with a transatlantic time lag, a pretty woman with dark hair, whose slight Scandinavian accent only seemed to make her speech more expressive.

“I’ve been battling with anxiety my whole life,” she told me, “all the way through childhood.” Christine felt that her difference was both rewarding and troubling.

I was very emotional, and sensitive I guess, to everything. To life in general. More sensitive than other kids. I always pictured myself as this person in black and white, who was almost see-through. Everyone else was like colorful and alive, and I was just this black-and-white, fragile person. But I could feel everything; I could feel everyone around me, all their ups and downs.

—Christine, age thirty-six

Others expressed a similar idea:

Some of my earliest memories are of being afraid of things. With a lot of fear and anxiety around what I would think are pretty common activities for a child. And all I really knew was that my mom was frustrated with it and that other kids around me didn’t understand it; I got teased a lot about being afraid and being sad.

—Ben, age thirty-nine

My entire life I was always kind of the shy one. I wasn’t very social, and that’s just kind of the person that I’ve always been. And as I got into high school, I tried to push myself out of that comfort zone, and tried to be social, but it was still very difficult for me. So I was awkward, and I did outrageous things to get attention, like I colored my hair pink. I started getting the rep for being the weird person, and that never bothered me.

—Shannon, age twenty-six

Many of those who described a sense of apprehension, difference, or awkwardness in childhood referred to their feelings as an “it.” They were aware of these feelings but didn’t yet conceive of them as a specific problem. “I know when I was forced to give it a name, when I felt like I had to contend with it as something ‘other,’ ” wrote Anne, a twenty-five-year-old, looking back on the experiences that had led her to start using antidepressants five years earlier. “But if I get to reflecting, then it starts to seem like there isn’t really a starting point. Like my life has always been informed by the presence of melancholy and anxiety, and only the intensity has changed.” In other people’s stories, as in my own, “it” takes on a name and a meaning after a crisis event nudges them into the mental health care system.

Functionally, crisis events are all the same: they mark the point at which someone decides that the problem is serious and requires help. But they come in all shapes and intensities. Some may be recognized as such only in hindsight. Others, like Heather’s, are unequivocal.

Heather grew up in a wealthy suburb of Atlanta. Both her parents worked corporate jobs, and Heather and her brothers lived in a comfortable house. Heather is bipolar, with depressions that have been more pronounced than her mania. One afternoon while we sat around her kitchen table in Brooklyn over a snack of crackers and baba ghanoush, she told me the story of her especially spectacular crisis. The year she was fifteen, she explained,

my brother and I went to ski camp in Italy. And when I was there, I was the only girl and there were a million guys, so I think that had something to do with it. I was a little bit manic, and then when I came home, my mom just sort of barked out that this kid in my class was killed in a car accident, was run down by a truck, and that just set off this horrible reaction of depression. I was beside myself, kind of. That was the summer I was fifteen. I started drawing all these depressing things and I started writing poetry. Just totally withdrawing, and I feel like everything changed drastically.

Heather didn’t know what was happening to her or even whether the things she was feeling were out of the ordinary, but she did know she was miserable. By fall, she said, “I used to go to a cemetery far away from my house, so I used to walk miles to a cemetery, and I used to sit there, and I used to cut my wrists.”

I had my head all shaved, and I shaved off my eyebrows at one point, I just made my mom cry so many times. Or I’d bang my head on a wall. I was like, “I’m
so
miserable, I can’t feel anything!” I think that’s why people do that to begin with, you’re just so numb.

The cutting?

Yeah. Cutting’s just like, “Do I feel this? I don’t even feel this.” And the fact that I can do this to myself is horrifying. And it’s also like, “Please fucking help me! This isn’t normal behavior.” You’re not supposed to self-destruct. You’re supposed to keep trying to survive, not trying to like kill yourself.

Within a few months, Heather reached a breaking point. “I was totally depressed,” she said.

I was just a zombie. And in December, I overdosed on [the anti-anxiety medication] Klonopin. I took them all, and I remember thinking “Okay, I’m going to die now.” I remember lying down on my bed. I was like, “I don’t really want to die, I’m just so unhappy, I don’t want my life to be like this.” So I called Poison Control, and I said, “What happens when you take a whole bottle of Klonopin?” And she was like, “You’re going to have seizures and heart failure.” She said, “Do you want me to call the ambulance?” And I said “No, I can get a ride.” So I went downstairs and I asked my mom, like, “Can you take me to the hospital, I just took all my pills.”