Prozac Nation (37 page)

You associate madness with Zelda Fitzgerald in all her rich, gorgeous, cerebral disturbedness, or maybe you think of it as something that members of Aurehano Buendía's family sank into at the incestuous end of
One Hundred Years of Solitude.
Madness is something of the fiery hot tempers of Latin America or the Deep South, of Borges and Cortázar or William Faulkner and Tennessee Williams. Madness is delightful to the beholder, scary in its way, but still fun to watch, a sport for spectators and rubberneckers who can't avert their eyes from the awfulness that they know they shouldn't be seeing. Madness is Jim Morrison swinging suggestively out of the fifteenth-floor window of his suite in the Chateau Marmont; it's Elizabeth Taylor and Richard Burton duking it out through the cramped camera angles of
Who's Afraid of Virginia Woolf?;
it's Edie Sedgwick in all her anemic, anorexic beauty, trying to do herself in with amphetamines and pearls while dancing on the table at Ondine and posing for
Vogue
as a youthquaker; it's Kurt Cobain, in every one of those Nirvana videos, looking like a man who is sick, deeply sick, who needs help badly and wears his desperation like a badge of cool; it's Robert Mitchum, with his tattooed knuckles, preaching and ranting in
The Night of the Hunter;
it's Pete Townshend smashing his perfectly good guitar to bits and pieces; it's every great moment in rock and roll, and it's probably every great moment in popular culture.

But
depression
is pure dullness, tedium straight up.
Depression
is, especially these days, an overused term to be sure, but never one associated with anything wild, anything about dancing all night with a lampshade on your head and then going home and killing yourself. The elegance and beauty and romance of Cio-Cio-San as she bleeds to death in
Madame Butterfly, or
of the double suicide in
Romeo and Juliet:
That is the domain of madness alone. The word
madness
allows its users to celebrate the pain of its sufferers, to forget that underneath all the acting-out and quests for fabulousness and fine poetry, there is a person in huge amounts of dull, ugly agony.

Why must every literary examination of Robert Lowell, of John Berryman, of Anne Sexton, of Jean Stafford, of so many writers and artists, keep perpetuating the notion that their individual pieces of genius were the result of madness! While it may be true that a great deal of art finds its inspirational wellspring in sorrow, let's not kid ourselves about how much time each of those people wasted and lost by being mired in misery. So many productive hours slipped by as paralyzing despair took over. None of these people wrote during depressive episodes. If they were manic-depressives, they worked during hypomania, the productive precursor to a manic phase which allows a peak of creative energy to flow; if they were garden-variety, unipolar depressives, they created during their periods of reprieve. This is not to say that we should deny sadness its rightful place among the muses of poetry and of all art forms, but let's stop calling it
madness,
let's stop pretending that the feeling itself is interesting. Let's call it
depression
and admit that it is very bleak. Sure, madness draws crowds, sells tickets, keeps
The National Enquirer
in business. Yet so many depressives suffer in silence, without anyone knowing, their plight somehow invisible until they adopt the antics of madness which are impossible to ignore. Depression is such an uncharismatic disease, so much the opposite of the lively vibrance that one associates with madness.

Forget about the scant hours in her brief life when Sylvia Plath was able to produce the works in
Ariel.
Forget about that tiny bit of time and just remember the days that spanned into years when she could not move, couldn't think straight, could only lie in wait in a hospital bed, hoping for the relief that electroconvulsive therapy would bring. Don't think of the striking on-screen picture, the mental movie you create of the pretty young woman being wheeled on the gurney to get her shock treatments, and don't think of the psychedelic, photonegative image of this same woman at the moment she receives that bolt of electricity. Think, instead, of the girl herself, of the way she must have felt right then, of the way no amount of great poetry and fascination and fame could make the pain she felt at that moment worth suffering. Remember that when you're at the point at which you're doing something as desperate and violent as sticking your head in an oven, it is only because the life that preceded this act felt even worse. Think about living in depression from moment to moment, and know it is not worth any of the great art that comes as its by-product.

 

The first order of business, when Dr. Sterling comes to see me at Stillman, is finding a drug that will work. Clearly, the whole Mellaril experiment has been something of a failure, perhaps not a colossal failure, but considering the condition I'm in and its progression while I've been under the influence of this exhausting neuroleptic, it might be safe to say that Mellaril is not for me.

Before I left for England, I had a consultation at the Affective Disorders Clinic at McLean, and the evaluating physicians were completely gung ho about a new pill called fluoxetine hydrochloride, brand name Prozac. They thought I was the perfect candidate for the drug, and they were all set to enroll me in a study that would have allowed me free treatment and medical care. But I was leaving for London, and besides, Dr. Sterling is a bit more conservative; she doesn't think that just because something is new or that all the radical psychopharmacologists at McLean are hyped up about it means it's the right thing to take. Fluoxetine had been virtually untried beyond the confines of McLean and other similarly progressive meccas of pharmaceutical research and treatment.

Dr. Sterling wants me to know what other drugs are available. Even if she ends up opting for fluoxetine, she thinks it's important that I understand the process she has gone through in making that decision. First, there are the standard tricyclic antidepressants, formulated and introduced in the fifties, drugs like Tofranil, Elavil, and Norpramin, which are, at this point, available quite cheaply in their generic forms as, respectively, imipramine, amitriptyline, and desipramine. These drugs mainly act on the production of norepinephrine and serotonin, two chemicals—scientifically known as neurotransmitters—that the brains of depressives are either lacking or not using efficiently. Essentially, these drugs prevent secreting cells from reabsorbing these neurotransmitters, thus allowing them to circulate and stimulate the next nerve cell into production Psychiatrists have had a fair amount of luck treating depression with these drugs over the years but they have some annoying side effects—drowsiness weight gain dry mouth constipation blurred vision—and have mostly been used by people incapacitated by depression.

Then there are the monoamine oxidase inhibitors (MAOIs) like Nardil and Parnate, another type of antidepressant that works by preventing the breakdown of surplus neurotransmitters, thus creating larger reservoirs within the nerve synapse. The MAOIs work on norepinephrine, serotonin, and dopamine—the most commonly implicated chemicals in mood disorders—but the lack of specificity has its disadvantages. MAOIs require some very rigid dietary restrictions that can be too taxing for a psychologically unstable person to observe. People taking MAOIs can't eat certain cheeses, pickles, vinegar, or drink rich red wines, for instance, a fact that was discovered by doctors only after patients taking the drug consumed these substances and died. (In a famous legal and medical scandal, the lawyer and author Sidney Zion's daughter Libby died in a hospital after a doctor's error had resulted in her taking a dangerous combination of drugs. Nardil was one of the substances believed to have precipitated her death.) With MAOIs the fear is that a suicidal patient might take advantage of this fatal opportunity to try a comparatively pleasant, and frankly gourmet, method of death which might only involve chowing down on some Stilton or imbibing a goblet of Chianti.

Then there's Prozac. It is so new at this point that Dr. Sterling still refers to it as fluoxetine. Prozac, like Zoloft, Paxil, and other drugs of its type which were not yet available as I lay in Stillman in 1988, acts only on serotonin. It is very pure in its chemical objectives. Its drug family will come to be known as selective serotonin reuptake inhibitors (SSRIs), and it can act very powerfully and directly within its narrow domain. Since fluoxetine's aims are less scattershot than that of its predecessors, it tends to have fewer side effects.

The McLean people recommend fluoxetine because they have diagnosed me with
atypical depression.
This diagnosis was not easy for them, or for Dr. Sterling, to come by, as the occasional appearance of manic-like episodes (for instance, during my energetic first month in Dallas) might indicate that I suffer from either manic-depressive illness or cyclothymia, a milder type of mood-swing disease. But in the end, the diagnosticians conclude that I've been too persistently down and not florid enough in my manic periods to be bipolar. Atypical depression is long-term and chronic, but the sufferer's mood can occasionally be elevated in response to outside stimulus. This diagnosis seems a better way to explain the periodic occasions when I seemed happy or productive, but would always return to my normally depressed state in perfect boomerang fashion. Apparently—and this is news to me, because I assumed that most depressions went on for years like mine—the natural history of a “typical” depression involves a person becoming despondent in response to some situation or turning point in life, then going to therapy, working it through, perhaps taking some drug, and recovering in a certain amount of time. Another typical depression would be much more extreme: A person goes completely nuts, ends up in a mental hospital or attempts suicide, and recovers in time through intensive treatment. But in both scenarios, the symptoms achieve some sort of apex and logical conclusion.

The atypically depressed are more likely to be the walking wounded, people like me who are quite functional, whose lives proceed almost as usual, except that they're depressed
all
the time, almost constantly embroiled in thoughts of suicide even as they go through their paces. Atypical depression is not just a mild malaise—which is known diagnostically as
dysthymia—
but one that is quite severe and yet still somehow allows an appearance of normalcy because it becomes, over time, a part of life. The trouble is that as the years pass, if untreated, atypical depression gets worse and worse, and its sufferers are likely to commit suicide out of sheer frustration with living a life that is simultaneously productive
and
clouded by constant despair.

It is the cognitive dissonance that is deadly. Because atypical depression doesn't have a peak—or, more accurately, a nadir—like normal depression, because it follows no logical curve but instead accumulates over time, it can drive its victim to dismal despair so suddenly that one might not have bothered to attend to treatment until the patient has already, and seemingly very abruptly, attempted suicide.

Dr. Sterling, everyone at McLean, and every psychiatrist I've met since has admitted ignorance about why the specifically serotonergic action of fluoxetine seems to work for atypical depression in ways that the tricyclics don't. Dr. Sterling could have prescribed something like imipramine for me months ago, but all the case histories seemed to indicate that it would have done no good. Since the MAOIs are highly toxic when mixed with the wrong foods, there was no way Dr. Sterling would administer one of them to me in my precarious state. Besides, the conventional wisdom has always held that the best treatment for atypical depression is therapy alone. But now that fluoxetine is on the market as Prozac, there is a sense that at long last there is a chemical antidote for this disease.

It is interesting what happens to me as I lie in my bed in Stillman and listen to Dr. Sterling explain my diagnosis and my options. Having my situation boiled down to these scientific terms, to a disease I can look up in the American Psychiatric Association manual, gives me some kind of renewed sense of hope. It's not just depression—it's
atypical
depression. Who would have thought they have a name to describe what is happening to me, and one that pinpoints my symptoms so precisely? In the book
Understanding Depression,
Donald F. Klein, M.D., and Paul H. Wender, M.D., characterize atypical depressives as people who “respond positively to good things that happen to them, are able to enjoy simple pleasures like food and sex, and tend to oversleep and overeat. Their depression, which is chronic rather than periodic and which usually dates from adolescence, largely shows itself in lack of energy and interest, lack of initiative, and a great sensitivity to periodic—particularly romantic—rejection.” Those sentences perfectly delineate my symptoms. I feel suddenly so much less lonely. For so many years I wondered what was wrong with me, why I felt so awful but still, somehow, didn't completely fall apart. For years I thought there would be no help for me until I got progressively worse, rather like someone who would like to be employed but knows she can't possibly earn as much at a job as she receives from a welfare check, and so flounders deep into poverty in order to receive public assistance.

Dr. Sterling tells me that she has suspected from the start that the cache of feelings and behaviors that characterize atypical depression described my situation exactly. But she's never bothered to mention it because there isn't any reason to draw the symptoms of a depression into a particular category unless a therapist is about to prescribe an antidepressant. Enter Prozac, and suddenly I have a diagnosis. It seems oddly illogical: Rather than defining my disease as a way to lead us to fluoxetine, the invention of this drug has brought us to my disease. Which seems backward, but much less so later on, when I find that this is a typical course of events in psychiatry, that the discovery of a drug to treat, say, schizophrenia, will tend to result in many more patients being diagnosed as schizophrenics. This is strictly Marxian psychopharmacology, where the material—or rather, pharmaceutical—means determine the way an individual's case history is interpreted. But right now, lying in Stillman, I am in no position to do this kind of critical thinking. I am simply reminded of the way I've always felt that the onslaught of my depression occurred gradually and then suddenly—an ostensible paradox, but that's why it's atypical.