Autodidact: self-taught

Dec
12
2012

IV

by V. L. Craven

-0170- …it seemed as though the air around me was setting, the way glue sets, into a weird rigidity, so that people’s voices all seemed to be breaking and cracking through the solid air, and that cracking noise made it hard to hear what I they were saying. I had to break through just to lift my fork. I ordered the salmon and began to be aware that my odd situation was showing. I was slightly mortified but didn’t know what to do about it. Those situations are embarrassing, no matter how many people you know who have taken Prozac, no matter how wonderfully at ease everyone is supposed to be with depression. Everyone at the table knew I was writing a book on the subject and most of them had read my articles. It didn’t help. I mumbled and apologised my way through dinner like a Cold War diplomat. ‘So sorry if I seem a bit unfocused, but you know I’ve just been having another go-around with depression,’ I might had said, but then everyone would have felt obliged to ask about specific symptoms and causes to attempt to reassure me, and those reassurances would in fact have exacerbated the depression. Or, ‘I’m afraid I can’t actually follow what you’re saying because I’ve been taking five milligrammes of Xanax every day, though I’m of course not addicted, and have also just began a new anti-psychotic which I believe has strong sedative properties. Is your salad good?’ On the other hand, I had a feeling that if I went on saying nothing, people were going to notice how peculiar I was being.
-0171- And then I found that the air was getting so hard and brittle that the words were coming through in staccato noises that i couldn’t quite string together. Perhaps you have had the experience of attending a lecture and realising that in order to follow the main points you need to keep paying attention; but your mind wanders a bit and then you can’t quite make sense of what is being said when you return to it. The logic is missing. So it was for me, but on a sentence-by-sentence basis. I felt the logic disappearing right out from under me. Someone had said something about China, but I wasn’t sure what. I thought someone else had mentioned ivory, but I didn’t know whether it was the same person who’d been talking about China, though I did remember that the Chinese had made ivory things. Someone was asking me something about a fish, perhaps my fish? Whether I ordered fish? Whether I liked fishing? Was there something about Chinese fish? i heard someone repeat a question (I recognised the sentence pattern from the time before), and then I felt my eyes close and I thought quietly, it is not polite to fall asleep when someone asks you a question for the second time. i must wake up. So I pulled my head up from my chest and smiled in what was meant to be an I-didn’t-quite-catch-that way. I saw puzzled faces looking at me. ‘Are you okay?’ someone asked again, and I said, ‘Possibly not,’ and some friends who were there took me by the arms and led me outside.
-0172- ‘So sorry,’ I kept saying, dimly aware that I had left everyone at the table thinking I was probably strung out on drugs, and wishing that I had simply said that i was depressed, hyper-medicated, and unsure of how well I’d get through the evening. ‘So sorry,’ and everyone kept saying that there was nothing to be sorry about. And the friends who had saved me got me home and up to my bed. I took out my contact lenses and then tried to chat a few minutes, to reassure myself. “So how are you?” i said, but when my friend started to answer me, he became rather faint, like the Cheshire cat. … My God, I had forgotten the intensity of depression.
-0173- We are determined by sets of norms that are quite beyond us. The norms to which I was brought up and which I established for myself are quite high by world standards; if I do not feel able to write books, I feel something is wrong with me. Some people’s norms are much lower; those of other people are much higher. … But some people feel that they’re okay as long as they can feed themselves and keep on living.
-0174- …the research I had been doing for this book, whether it was to be of value to anyone else or not, was terrifically useful to me. I had been sad for a few months for a variety of reasons and was under considerable stress, coping with everything, but not easily. Because I had learned so much about depression, I recognised the crossover point immediately for what it was.
-0175- Remission from mental illness requires maintenance: all of us periodically encounter physical and psychological trauma, and chances are pretty good that those of us with a significant vulnerability will all have moments of relapse in the face of problems. A life time of relative freedom can unfold best with careful and responsible attention to medication, balanced with steadying, insight-producing talk. Most people with severe depression require a combination of drugs, sometimes at unorthodox doses. They also require an understanding of their shifting selves, one that a professional can facilitate.
-0176- There is an old fable that used to be told in my family about a poor family, a sage, and a goat. The poor family lived in misery and squalor, nine of them sharing one room, and no one had enough to eat and everyone’s clothes were in rags and their life was one of utter, unrelenting misery. Finally one day the man of the house set off to visit the sage and said to him, “Great sage, we are so miserable that we can barely stay alive. The noise is terrible, and the filth is awful, and the lack of privacy could kill a person, and we never have enough to eat, and we are all beginning to hate one another, and it is just horrendous. What should we do?” To which the sage replied simply, “You must get a goat and have the goat live inside the house with you for one month. Then your problems will be solved.” The man looked at the sage in astonishment. “A goat? To live with a goat?” But the sage insisted, and since he was a very wise sage, the man did as he had been told. For the next month, the hellish life of the man’s family was beyond intolerable. The noise was worse; the filth was worse; there was nothing remotely resembling privacy; there was nothing to eat since the goat kept eating everything; and there were no clothes because the goat ate everyone’s clothes as well. The rancour in the house became explosive. At the end of the month, the man returned to the sage in a fury. “We have lived for one month with a goat in our hut,’ he said. ‘It has been horrendous. How could you have given us such ludicrous advice?’ The sage nodded sagely and said, ‘Now get rid of the goat and you will see how peaceful and sublime your lives are.’
It’s that way with depression. If you can knock out your depression, you can live in wonderful peace with the real-world problems you may have to confront, which always seem minimal by comparison. I called one of the people I was interviewing for this book and politely began the conversation by asking how he was. ‘Well,” he said, “my back hurts; I’ve sprained an ankle; the children are mad at me; it’s pouring rain; the cat died; and I’m facing bankruptcy. On the other hand, I’m psychologically asymptomatic at present, so I’d say all in all that things are fabulous.”
-0177- I have done pretty well for side effects. My current psycho-pharmacologist is expert in side-effect management. I have had some sexual side effects from my medications-a slightly decreased libido and the universal problem of much-delayed orgasm. A few years ago, I added Wellbutrin to my regimen; it seemed to get my libido running again, though things have never come up to old standards. My psycho-pharmacologist has also given me Viagro, just in case I get that side effect and has since added dexamphetamine, which is supposed to increase sexual drive. I think it does but it also made me twitchy. My body seems to go through shifts beyond my ability to discern, and what works just splendidly one night may be a bit tricky the next. Zyprexa is sedating and I mostly sleep to much, about ten hours a night, but I have Xanax around for the occasional night when I am assaulted by sensation and cannot get my eyes closed.
-0178- There is a curious intimacy that comes of swapping breakdown stories. Laura Anderson and I have communicated with each other almost daily for more than three years, and during my third breakdown, she was extraordinarily attentive. [She came from nowhere into my life and we developed a friendship of strange and sudden intimacy:] with a few months of her first letter to me, ]I felt as though I had known her forever, and though our contact–mostly by E-mail but sometimes by letter or postcard, very occasionally by phone, and once in person–remained separate from the rest of my life, it was nonetheless so habitual as to become, very soon, addictive. It took on the shape of a love story, running through discovery, ecstasy, tiredness, rebirth, habit, and profundity.] At times, Laura was too much too soon, and in the early stages of our contact I sometimes rebelled against her or tried to contain the contact between us–but soon I came to feel on the rare days when I didn’t hear from Laura as though I’d missed a meal or a night’s sleep. Though Laura Anderson is bipolar, her manic episodes are much less pronounced than her depressive ones, and they are more easily controlled–a condition that is with increasing frequency called bipolar two. She’s one of the many people for whom, no matter how carefully medications and treatments and behaviours are regulated, depression always lies waiting–some days she’s free of it and other days she’s not, and there’s nothing she can do to keep it at bay.
[Writing notes: epigraph]
-0179- [Personal account = Laura Anderson] “I am frustrated because these diseases seem to me so blatantly multi polar in many instances–it makes me wish Levi-Strauss had never brought our attention to binary opposition. Bicycle is about as far as I’ll go with the prefix. I am convinced there are forty different shades of black, and I don’t like looking at this on a linear scale–i see it more as a circle and a cycle where the wheel is spinning too quickly and a desire for death can enter through any spoke. I though of checking myself into the hospital this week, but I have been there enough to know that I would not be allowed a stereo even with headphones, or scissors to make Valentine’s Day cards, and that I would miss my dogs, and that I would be terrified without and would miss terribly Peter, my boyfriend, who loves me through all the vomit and anger and unrest and no sex and that I would have to sleep in the hall by the nurses’ station or be locked in a room on suicide watch and so on–well, no thank you. I’m fairly confident that with the meds keeping me equatorial–between the two poles–I’ll be okay.”
-0180- [Personal account = Laura Anderson] ‘…I have changed doctors and medicine–from Depakote to Tegretol, with some Zyprexa thrown in to expedite the effects of Tegretol. Zyprexa really slows me down. Physical side effects for mental illness seem such an insult! I think with all the stuff I’ve taken I now qualify for Advanced Depression. Still-I get this strange amnesia–it becomes impossible to remember, when an hour is an honest hour, just how dreadful depression is–eking one’s way through endless minutes.
-0181- [Laura Anderson] A few days later she wrote, “The self-consciousness gets in the way of offering much depth of personality to people–as a result, most friends I’ve made in the past eight or nine years are fairly casual. This grows lonely, and leaves me feeling idiotic. I just called, for example, a very dear (and demanding) friend in West Virginia, who wants an explanation for my not coming to visit her and her new baby. What to say? That I would have loved to make the trip but was busy staying out of the mental hospital? It’s so humiliating–so degrading. If I knew I wouldn’t get caught, I’d love the lie about it–invent an acceptable cancer, that recurs and vanishes, that people could understand–that wouldn’t make them frightened and uncomfortable.”
-0182- Laura is constantly hindered; every part of her life is defined around her illness. “As for dating: I need people I date to be a little able to take care of themselves, because me taking care of me takes a lot of energy, and I can’t be responsible for every little hurt feeling someone has. Isn’t that a terrible way to feel about love? It’s hard to manage professionally too–the short-lived jobs, the gaps in between them. Who wants to hear about your hopes for your medication? How can you ask that anyone understand? …”
-0183- [Laura Anderson] “When my regular appetites are diminished by depression–my needs for laughter, sex, food–the dogs provide me with my only really numinous moments.”
-0184- [Laura Anderson] “…The whole day thus far has been an exercise in FORCING myself to do the tiniest things and trying to evaluate how serious my situation is–Am I really depressed? Am I just lazy? Is this anxiety from too much coffee or from too much anti-depressant? The self-assessment process itself made me start to weep. What bothers everyone is that they can’t DO anything to help other than be present. I rely on E-mail to keep me sane! Exclamation points are little lies.”
-0185- [Laura Anderson] ‘…I just feel like I’m draining people right now, yourself included. There is only so much I can ask for while giving nothing back…”
-0186- [Laura Anderson] “i look at old photos today, and they seem like they are snapshots of someone else’s life. What a series of trade-offs medication mandates.” But soon she was at least getting up. “Today I had a few good moments,” she wrote at the end of the month. “More of those, please, from whoever doles them out. I was able to walk in a crowd and not feel self-conscious.” The next day she had a little relapse. “I was feeling better and hoped it was the start of something wonderful, but today I have a lot of anxiety, of the falling-over-backward, drawstring-in-the-sternum variety. But I still have some hope, which helps” The next day, things were worse. “My mood continues to be grim. Morning terror and abject helplessness by late afternoon.”
-0187- [Laura Anderson] “…Depression takes away whatever I really, really like about myself (which is not so much in the first place). Feeling hopeless and full of despair is just a slower way of being dead. I try to work through these large blocks of horror in the meantime. I can see why they call it ‘mean.’ ”
-0188- [Laura Anderson] In December she had an adverse reaction to lithium; it made her skin intolerably dry. She lowered her dose and went on Neurontin. It seemed to work. “Shifting back to the centre, a centre, known as ME feels good and real,” she wrote.
The following October, we finally me. She was staying with her mother in Waterford, Virginia, a beautiful old town outside Washington, the place where she had grown up. {I had become so fond of her by then that I couldn’t believe we had never met.}
-0189- [Laura Anderson] But the time with her family was stirring too many memories and she was not doing well. She was desperately anxious, so anxious that she was having troubling speaking.
-0190- Laura and I had a conversation that drifted in and out of coherence; she seemed to be speaking from some faraway place. And then as we were looking at some photos, she suddenly got stuck. It was like nothing I’d ever seen or imagined. She was telling me who was who in the photos and she began repeating herself. “That’s Geraldine,” she said, and then she winced and began again, pointing, “That’s Geraldine,” and then again, ‘That’s Geraldine,’ each time taking longer to pronounce the syllables. Her face was frozen and she seemed to be having trouble moving her lips. I called her mother and her brother, Michael. Michael put his hands on Laura’s shoulders and said, ‘It’s okay, Laura. It’s okay.” We eventually managed to get her upstairs; she was still saying over and over, “That’s Geraldine.”
-0191- [Laura Anderson] As it turned out, some of her medications were having a bad interaction that had caused this seizure; indeed they were the reason for the strange stiffness in the afternoon, for the loss of speech, for the hyper-anxiety. By the end of the day, she had come through the worst, but ‘all the colour had drained out of my soul, all the me of me I loved; I was a little doll-shell of what I had been.’ She was soon put on a new regimen. Not until Christmas did she began to feel like herself again; and then in March 2000, just as things were looking up, she had the seizures once more. ‘I am so frightened,’ she wrote to me. ‘And so humiliated. It’s pretty pathetic when the best news you can share is that you’re not convulsing.’ Six months later, they hit again. ‘I can’t keep picking up my life again,’ she said to me. ‘I’m so afraid of the seizures I get anxiety…My doctor wants me to take Valium, but that makes me pass out. This is my life now. This will always be my life, these terrible plummeting descents into hell. The awful memories. Can I stand to live this way?’
-0192- Can I stand to live the way I do? Well, can any of us stand to live with our own difficulties? In the end, most of us do. We march forward. The voices of past time come back like voices of the dead to sympathise about mutability and the passage of the years. When I am sad, I remember too much, too well: always my mother and who I was when we sat in the kitchen and talked, from the time I was five until her death when I was twenty-seven; how my grandmother’s Christmas cactus bloomed every year until she died when I was twenty-five; that time in Paris in the mid-eighties when my mother’s friend Sandy, who wanted to give her green sun hat to Joan of Arc, Sandy who died two years later; my great-uncle Don and great-aunt Betty and the chocolates in their top drawer; my father’s cousins Helen and Alan, my aunt Dorothy, and all the others who are gone. I hear the voices of the dead all the time. It is at night that these people and my own past selves come to visit me, and when I wake up and realise that they are not in the same world as I, I feel that strange despair, something beyond ordinary sadness and closely akin, for a moment, to the anguish of depression. {PN: At night is when my loops of humiliations return, as well. Sometimes I get pangs over how easy life was when i was eight–always eight–and wish I’d paid closer attention. Then we’re off to every awful thing ever said or done to me.}
-0193- Or is it just a part of life, to keep living in all the ways we cannot stand?
I find the fact of the past, the reality of time’s passage, incredibly difficult. My house is full of books i can’t read and records to which i can’t listen and photos at which i can’t look because they are too strongly associated with the past. When I see friends from college, I try not to talk about college too much much because I was so happy then–not necessarily happier than i am now, but with a happiness that was particular and specific in its moods and that will never come again. Those days of young splendour eat at me. i hit walls of past pleasure all the time, and for me past pleasure is much harder to process than past pain. … The pleasures of the past, however, are tough. The memory of the good times with people who are no longer alive, or who are no longer the people they were: that is where i find the worst current pain. Don’t make me remember, I say to the detritus of past pleasures. Depression can as easily be the consequence of too much that was joyful as of too much that was horrible. There is such a thing as post-joy stress too. The worst of depression lies in a present moment that cannot escape the past it idealises or deplores.
-0194- There are two major modalities of treatment for depression: talking therapies, which trade in words, and physical intervention, which includes both pharmacological care and ECT. …
Medication and therapy should not compete for a limited population of depressives; they should be complementary therapies that can be used together or separately depending on the situation of the patient.
-0195- It is striking that patients who recover from depression by means of psychotherapy show the same biological changes–in, for example, sleep electroencephalogram (EEG)–as those who receive medication.
-0196- While traditional psychiatrists see depression as an integral part of the person who suffers from it and attempts to bring about change in that person’s character structure, psycho-pharmacology in its purest form sees the illness as an externally determined imbalance that can be corrected without reference to the rest of a personality.
-0197- The conflict between psycho-dynamic therapy and medication is ultimately a conflict on moral grounds; we tend categorically to assume that it the problem is responsive to psycho-therapeutic dialogue, it is a problem you should be able to overcome with simple rigour, what a problem responsive to the ingestion of chemicals is not your fault and requires no rigour of you. It is true both that very little depression is entirely the fault of the sufferer, and that almost all depression can be ameliorated with rigour. Antidepressants help those who help themselves. If you push yourself too hard, you will make yourself worse, but you must push hard enough if you really want to get out. Medication and therapy are tools to be used as necessary.
-0198- Talking therapies come out of psychoanalysis, which in turn comes out of the ritual disclosure of dangerous thoughts first formalised in the Church confessional. Psychoanalysis is a form of treatment in which specific techniques are used to unearth the early trauma that has occasioned neurosis. It usually requires a great deal of time–four to five hours a week is standard–and it focuses on bringing the content of the unconscious mind to light. It has become fashionable to bash Freud and the psycho-dynamic theories that have come down to us from him, but in fact the Freudian model, through flawed, is an excellent one.
-0199- The psycho-dynamic therapies that have grown out of psychoanalysis, however, do have a crucial role to play. The unexamined life can seldom be repaired without some close examination, and the lesson of psychoanalysis is that such examination is almost always revealing. The schools of talking therapy that have the most currency are the ones in which a client talks to a doctor about his current feelings and experiences. For many years, talking about depression was considered the best cure for it. It is still a cure. “Take notes,” wrote Virginia Woolf in The Years , “and the pain goes away.”
-0200- Most psycho-dynamic therapies are based on the principle that naming something is a good way to subdue it, and that knowing the source of a problem is useful in solving that problem. Such therapies do not, however, stop with knowledge: they teach strategies for harnessing knowledge to ameliorate use.
-0201- Martin Keller, of Brown University’s Department of Psychology, working with a multi-university team, found in a recent study of depressives that less than half experienced significant improvement with just medication; that less than half experienced significant improvement with cognitive behavioural analysis; and that more than 80 percent experienced significant improvement after being treated with both.
-0202- What calms you down? What exacerbates your symptoms? There is no particular difference, from the chemical standpoint, between depression that has been triggered by the death of family members and the depression occasioned by the demise of a two-week affair. Though extreme responses seem more rational in the first instance than in the second, the clinical experience is nearly identical.
-0203- The two kinds of talking therapy that have the best record for the treatment of depression are cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT). CBT is a form of psycho-dynamic therapy–base on emotional and mental responses to external events, in the present and in childhood–that is tightly focused on objectives. The system was developed by Aaron Beck of the University of Pennsylvania and is now in use throughout the United States and most of Western Europe. Beck proposes that one’s thoughts about oneself are frequently destructive, and that by forcing the mind to think in certain ways one can actually change one’s reality–it’s a program that one of his collaborators has called “learned optimism.” He believes depression is the consequence of false logic, and that by correcting negative reasoning one may achieve better mental health. CBT teaches objectivity.
The therapist begins by helping the patient make up a list of “life history data,’ the sequence of difficulties that have led him to his current position. The therapist then charts responses to these difficulties and attempts to identify characteristic patterns of overreaction. The patient learns why he finds certain events so depressing and tries to free himself of inappropriate responses. This macroscopic part of CBT is followed by the microscopic, in which the patient learns to neutralise his ‘automatic thoughts.’ Feelings are not direct responses to the world: what happens in the world affects our cognition, and cognition in turn affects feelings. if the patient can alter the cognition, then he can alter the concomitant mood states.
-0204- i have never been in CBT, but I have learned certain lessons from it. If you feel the giggles coming on in a conversation, you can somethings step yourself from laughing by forcing your mind to some sad subject. If you are in a situation in which you are expected to have sexual feelings you do not in fact have, you can push your mind into a world of fantasy quite remote from the reality you are experiencing, and your actions and the actions of your body can take place within that artifice rather than in the present reality. This is the underlying strategy of cognitive therapy.
-0205- Just think lovely thoughts, lovely, wonderful thoughts and they will sap the pain. Think what you do not feel like thinking. It may be fake and self-delusional in some ways, but it does work. Force out of your mine the people associated with your loss; forbid them entrance to your consciousness.
-0206- Once the cycle is broken, the patient can begin to achieve some self-control. The patient learns to distinguish between what actually happens and her ideas about what happens.
CBT functions according to specific rules. The therapist assigns lots of homework: lists of positive experiences and lists of negative experiences must be made, and sometimes they are put on graphs. The therapist presents an agenda for each session, continues in a structured fashion, and ends with a summary of what has been accomplished. Facts and advice are specifically excluded from the therapist’s conversation. Pleasurable moments in the patient’s day are identified, and the patient is instructed in the art of including emotional pleasure in his life. The patient should become alert to his cognition so that he can stop himself when he ventures toward a negative pattern and shift his processing to a less harmful system. All this activity is patterned into exercises. CBT teaches the art of self-awareness.
-0207- [A Holocaust survivor] ‘This gave my mind a focus on something over which I could exercise some control, and it filled my mind so that I could close myself off from the reality of what was happening to me, and it got me through.’ This is how the principle of CBT might be carried to an extreme under extreme circumstance. If you can force your thoughts in certain patterns, that can save you.
-0208- CBT is broadly used today, and it seems to show some significant effect on depression. There seem also to be extremely good results from interpersonal therapy, the treatment regimen formulated by Gerald Klerman, at Cornell, and his wife, Myrna Weissman, at Columbia. IPT focuses on the immediate reality of current day-to-day life., Rather than working on an overarching schema for an entire personal history, it fixes up things in the present. It is not about changing the patient into a deeper person, but rather about teaching the patient how to make the most of whoever he is. It is a short-term therapy with definite boundaries and limits. It assumes that many people who are depressed have had life stressors as the trigger or consequence of their depression, and that there can be cleaned up through well-advised interaction with others. Treatment is in two stages. In the first, the patient is taught to understand his depression as an external affliction and is informed about the prevalence of the disorder. His symptoms are sorted out and named. He takes on the role of the sick one and identifies a process of getting better. The patient makes up catalogues of all his current relationships, and with the therapist defined what he gets from each one and what he wants from each one. The therapist works with the patient to figure out what the best strategies are for eliciting what is needed in his life. Problems are sorted into four categories; grief; difference about rold with close friends, and family (what you give and what you expect in return, for example);states of stressful transition in personal or professional life (divorce or loss of job; for example); and isolation. The therapist and the patient then establish a few attainable goals and decide how long they will work toward them. IPT lays out your life in even, clear terms.
-0209- [James Ballenger of the Medical University of South Carolina] “Psychotherapy changes biology. Behaviour therapy changes the biology of the brain–probably in the same way the medicines do.’ Certain cognitive therapies that are effective for anxiety lower levels of brain metabolism while, in mirror image, pharmaceutical therapies lower levels of anxiety. This is the principle of antidepressant medication, which by modifying the levels of certain substances in the brain changes the way a patient feels and acts.
-0210- Since scientists know that lowering the levels of certain neurotransmitters can cause depression, they work on the assumption that raising levels of these same neurotransmitters can alleviate depression–and indeed drugs that raise levels of neurotransmitters are in many instances effective antidepressants. It is comforting to think that we know the relationship between neurotransmitters and mood, but we don’t. It appears to be an indirect mechanism. People with lots of neurotransmitters bumping around in their heads are not happier than people with few neurotransmitters. Depressed people do not in general have low neurotransmitter levels in the first place. Putting extra serotonin in the brain does no immediate good at all; if you get people to eat more tryptophan (it is found in a number of foodstuffs, including turkey, bananas, and dates), which raises serotonin levels, that doesn’t help immediately, though there is evidence that reducing dietary tryptophan may exacerbate depression.
-0211- Under ordinary circumstances, serotonin is discharged by neurons and then reabsorbed to be discharged again. The SSRIs (selective serotonin re-uptake inhibitors) block the re-absorption process, thus increasing the level of free-floating serotonin in the brain. Serotonin is one of nature’s through lines in the development of species: it can be found in plants, in lower animals, and in human beings. It appears to serve multiple functions, which vary from one species to the next. In human beings, it is one of several mechanisms that control constriction and dilation of blood vessels. It helps form scabs, causing the clotting necessary to control bleeding. It is involved in inflammatory responses. It also affects digestion. It is immediately involved in regulation of sleep, depression, aggression and suicide.
-0212- Does it matter than most antidepressants suppress REM sleep, or is that an irrelevant side effect? Is it important that antidepressants usually lower brain temperature, which, in depression, tends too go up at night?
-0213- Four classes of antidepressant medication are currently available. The most popular are the SSRIs, which bring about higher levels of serotonin. Prozac, Luvox, Paxil, Zoloft, and Celexa are all SSRIs. There are also two older kinds of antidepressants. The tricyclics, named for their chemical structure, affect serotonin and dopamine. Elavil, Anafranil, Norpramin, Tofranil, and Pamelor are all tricyclics. The monoamine oxidase inhibitors (MAOIs) inhibit the breakdown of serotonin, dopamine and norepinephrine. Nardil and Parnate are both MAOIs. Another category, atypical antidepressants, includes drugs that operate on multiple neurotransmitter systems. Asendin, Wellbutrin, Serzone, and Effexor are all atypical antidepressants.
-0214- …if you have a special subtype of depression, atypical depression, where you overeat and oversleep, you’ll do better on an MAOI than on a tricyclic, though most clinicians use the newer drugs in these patients anyway. Aside from that–you choose a drug that appears to have a low side-effect profile as the first line of action. You can decide on a more activating drug such as Wellbutrin for someone who is very withdrawn, or a deactivating drug for someone who is agitated, but beyond that–it’s just trial and error with the individual patient.
-0215- Less than 25 percent of patient who take antidepressants continue the treatment for six months, and a large proportion of those who stop do so because of sexual and sleep-related side effects.
-0216- The tricyclic antidepressants work on several neurotransmitter systems, including acetylcholine, serotonin, norepinephrine, and dopamine. The tricyclics are particularly useful in severe or delusional depression.
-0217- The MAOIs are particularly useful when depression carries acute physical symptoms such as pain, decreased energy, and interrupted sleep. These drugs block the enzyme that breaks down adrenaline and serotonin, thus increasing the level of these substances. MAOIs are excellent drugs but have many side effects. Patient taking them have to avoid a range of foodstuffs with which they have troubling interactions. They can also affect bodily function. One patient I interviewed got total urinary retention from MAOIs: ‘I pretty much needed to go to the hospital when I had to pee, which was not convenient.’
-0218- The atypical antidepressants are just that: atypical. Each has its own novel mode of action. Effexor affects both serotonin and norepinephrine. Wellbutrin acts on dopamine and norepinephrine. Asendin and Serzone work on all the systems. It is popular at the moment to try for so-called clean drugs, drugs that have highly specific effects. Clean drugs are not necessarily more effective than dirty ones; specificity may to some degree be connected to the control of side effects, but it seems that the more things you muck around with in the human brain, the more effective the treatment is likely to be for depression. Clean drugs are developed by the pharmaceutical companies, which are enthusiastic about the tidiness of chemical sophistication; but such drugs are not particularly distinguished for therapeutic purposes.
-0219- After some routine blood work, a cardiogram, often a chest x-ray and some anaesthesia-related checks, patients who are deemed fit for ECT sign consent forms, which are also presented to their family. The night before the treatment, the patient fasts and has an IV put in place. In the morning, he is taken to the ECT room. After the patient has been hooked up to monitors, medical attendants put gel on his temples and then apply electrodes for either unilateral ECT to the non-dominant side of the brain only–which is the preferred starting strategy, usually to the right brain–or bilateral ECT. Unilateral ECT has fewer side effects, and recent research shows that high-dose unilateral ECT is as effective as bi-hemisphere treatment. The administering doctor also chooses between sine-wave stimulus, which gives more sustained stimulation, and brief-pulse square-wave stimulus, which induces seizures with fewer side-effects. A short-acting IV general anaesthetic is given, which will put the patient out completely for about ten minutes, and a muscle relaxant is also given to prevent physical spasms (the only movement during the treatment is a slight wiggling of the toes–unlike ECT of the 1950s, in which people thrashed around and injured themselves). The patient is connected to an EEG machine and an electrocardiogram (EKG) machine so that a brain scan and a heart scan are running at all times. Then a one-second shock causes a temporal and vertex seizure in the brain that usually goes on for some thirty seconds–long enough to change brain chemistry, not long enough to fry up the grey matter. The shuck is usually about two hundred joules, which is equivalent to the output of a hundred-watt bulb; most of this is absorbed by the soft tissue and skull, and only a tiny fraction of it reaches the brain. Within ten or fifteen minutes, the patient wakes up in the recovery room. Most people who receive ECT have ten or twelve treatments over about six weeks. ECT is being administered increasingly on an outpatient basis.
-0220- Martha Manning has described her depression and ECT in a beautiful and surprisingly hilarious book called Undercurrents.
-0221- ECT does result in disruption of short-term memory and can affect long-term memory. The disruptions are usually temporary, but some patients have had permanent memory deficits. One woman I met, who had been a practising lawyer, came out of ECT minus any recollection of law school. She could not remember anything she’d studied, nor where she had studied, nor whom she had known during her studies. This is extreme and rare, but it does happen. ECT has also bee associated with the death or about one in ten thousand patients, according to one study, usually because of cardiac problems after the treatment.
-0222- Is it crazy to avoid the behaviours that make you crazy? Or is it crazy to medicate so that you can sustain a life that makes you crazy? I could downgrade my life and do fewer things, travel less, know fewer people, and avoid writing books on depression–and perhaps if I made all those changes, I would not need medications.
-0223- “Imagine a society that subjects people to conditions that make them terribly unhappy, then gives them the drugs to take away their unhappiness. Science fiction? It is already happening…In effect, antidepressants are a means of modifying an individual’s internal state in such a way as to enable him to tolerate social conditions that he would otherwise find intolerable.
-0224- Maggie seemed awfully withdrawn. I had no idea how hard Maggie was trying, not the slightest inkling of what she was pushing herself through.
-0225- I had been through depression, and I wanted to help, but she could not talk on the phone and she did not want visitors, and her parents knew enough to give her leeway for silence. I have felt more closely in touch with the dead.
-0226- [Maggie] “You don’t think in depression that you’ve put on a grey veil and are seeing the world through the haze of a bad mood. You think that the veil has been taken away, the veil of happiness, and that now you’re seeing truly. You try to pin the truth down and take it apart, and you think that truth is a fixed thing, but the truth is alive and it runs around. You can exorcise the demons of schizophrenics who perceive that there’ something foreign inside them. But it’s much harder with depressed people because we believe we are seeing the truth. But the truth lies.
-0227- Nonetheless, religious belief is one of the primary ways that people accommodate depression. Religion provides answers to unanswerable questions. It cannot usually pull people out of depression; indeed, even the most religious people find that their faith things or vanished during the depths of depression…Much religion allows us to see suffering as laudable. It grants us dignity and purpose in our helplessness.
-0228- …religion did little to help Maggie Robbins. “As I got better I remembered, “Oh yeah, religion–why didn’t I use that to help me?’ But it couldn’t help me at the low points.” Nothing could.
-0229- In some ways this seems pragmatic: it is not about belief but about scheduling and could be accomplished equally well with an aerobics class.
-0230- People think that Christianity is against pleasure; as it sometimes is; but it’s very, very pro-hoc. You’re aiming for joy that will never go away, no matter what kind of pain you’re in. But of course you still go through the pain. I asked my priest, when I wanted to kill myself. ‘What’s the purpose of this suffering?’ and he said, ‘I hate sentences that have the word suffering and the word purpose in them. Suffering is just suffering…
-0231- Most people cannot emerge from really serious depression just by fighting; a really serious depression has to be treated, or it has to pass. But while you are being treated or waiting for it to pass, you have to keep up the fighting. To take medication as part of the battle is to battle fiercely, and to refuse it would be as ludicrously self-destructive as entering a modern war on horseback. It is not weak to take medications, it does not mean that you can’t cope with your personal life; it is courageous.
-0232- You cannot wait to be cured. ‘Labour must be the cure, not sympathy–Labour is the only radical cure for rooted sorrow,’ wrote Charlotte Bronte; it is not the whole cure, but it is, still, the only one. Happiness itself can be a grand labour.
-0233- For the time being, we must accept that fate has given some of us a strong vulnerability to depression, and that among those who carry such a vulnerability, some have treatment-responsible brains and some have treatment-resistant brains. Those of us who can’t get substantially better in any way must count ourselves, no matter how dire our breakdowns may have been, among the lucky ones. We must, further, treat those for whom there can be no recovery with forbearance.
-0234- “If many remedies are prescribed for an illness,” Anton Chekhov one wrote, “you may be certain that the illness has no cure.”
-0235- Since depression is a cyclical illness that will go into temporary remission without any treatment, one might credit any sustained useless or useful activity with its eventual amelioration. It is my absolute belief that in the field of depression, there is no such thing as a placebo. If you have cancer and try an exotic treatment and then you think you are better, you may well be wrong. If you have depression and try an exotic treatment and think you are better, then you are better. Depression is a disease of thought process and emotions, and if something changes your thought process and emotion in the correct direction, that qualifies as a recovery.
-0236- “Exercise produces endorphins. Endorphins are endogenous morphine, and they make you feel great if you’re feeling normal. They make you feel better if you’re feeling awful. You have to get those endorphins up and running–after all, they’re upstream of the neurotransmitters too, and so exercise is going to work to raise your neurotransmitter levels.”
-0237- Sugar and carbohydrates appear to raise the absorption of tryptophan in the brain, which in turn raises serotonin levels. Vitamin B6, which is found in whole grains and shellfish, is important to serotonin synthesis; low levels of B6 may precipitate a depression. Low cholesterol has been linked to depressive symptoms. The studies aren’t in, but a good diet of lobster and chocolate mousse may do much toward improving one’s state of mind.
-0238- The evidence for beneficial mood effect from omega-3 fatty acids is the strongest of all.
-0239- …other foodstuffs may cause depression. ‘Many Europeans have wheat allergies, and many Americans have corn allergies’… ‘These common substances become brain toxins which precipitate all kinds of mental distress.’ Many people develop depressive symptoms as part of a syndrome of adrenal exhaustion, a consequence of excessive indulgence in sugars and carbohydrates.
-0240- Many people have seasonal changes of mood and develop recurrent winter depression; the changes of season–what one patient called “the crossfire between summer and winter:–are a difficult time for everyone.
-0241- Light stimulates the hypothalamus, where many of the systems–sleeping, eating, temperature, sex drive–that depression deregulates are based. Light also influences serotonin synthesis in the retina. A sunny day offers about three hundred times as much light as the average household interior.
-0242- Sleep is the primary determinant of circadian body patterns, and altering sleep disrupts the timing of neurotransmitter and endocrine release.
-0243- many depressed people have substantially reduced sleep altogether, and that insomnia during depression is a predictor of suicidality.

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