Anatomy of an Epidemic (22 page)

As the personal stories of Geraldine, Hal, and Jill attest, benzodiazepines continue to be a pathway to disability for many. These three are part of the surge of people with an “affective disorder” who have swelled the SSI and SSDI rolls in the past twenty years. Although the Social Security Administration doesn’t detail the number of disabled mentally ill who have anxiety as a primary diagnosis, a 2006 report by the U.S. General Accountability Office provides a proxy for estimating that number. It noted that 8 percent of the younger adults (eighteen to twenty-six years old) on the SSI and SSDI rolls were disabled by anxiety, and if that percentage holds true for all ages, then there were more than 300,000 adults in the United States who received government support in 2006 due to an anxiety disorder.
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That is roughly sixty times the number of psychoneurotics hospitalized in 1955.

Although it was thirty years ago that governmental review panels in the United States and the United Kingdom concluded that the benzodiazepines shouldn’t be prescribed long-term, with dozens of studies subsequently confirming the wisdom of that advice, the prescribing of benzodiazepines for continual use goes on. Indeed, a 2005 study of anxious patients in the New England area found that more than half regularly took a benzodiazepine, and many bipolar patients now take a benzodiazepine as part of a drug cocktail.
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The scientific evidence simply doesn’t seem to affect the prescribing habits of many doctors. “The lesson has either never been learned, or it has passed people by,” Malcolm Lader said.
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M-Power in Boston is a peer-run advocacy group for the mentally ill, and while I was at one of their meetings in April 2008, a young, quiet woman came up to me and whispered, “I’d be willing to talk to you.” Red hair fell about her shoulders, and she seemed so shy as to almost be frightened. Yet when Melissa Sances told me her story a few days later, she spoke in the most candid manner possible, her shyness transformed into an introspective honesty so intense that when she was recounting her struggles growing up in Sandwich on Cape Cod, she suddenly stopped and said: “I was unhappy, but I didn’t have an awareness that I was depressed.” It was important that I understood the difference between those two emotions.

Her unhappiness as a child was comprised of familiar ingredients. She felt socially awkward and “different” from other kids at school, and after her parents divorced when she was eight, she and her brothers lived with their mother, who struggled with depression. In middle school, Melissa began to come out of her shell, making friends and feeling “more normal,” only then she ran head-on into the torments of puberty. “When I was fourteen, I was overweight, I had acne. I felt like a social outcast, and the kids at high school were very cruel. I was called a freak and ugly. I would sit at my desk with
my head down, and my hair pulled over my face, trying to hide from the world. Every day I woke up feeling like I wanted to die.”

Today, Melissa is an attractive woman, and so it is a bit surprising to learn of this ugly-duckling moment from her past. But with her schoolmates taunting her, her childhood unhappiness metamorphosed into a deep depression, and when she was sixteen, she tried to commit suicide by gulping down handfuls of Benadryl and Valium. She woke up in the hospital, where she was told that she had a mental illness and was prescribed an antidepressant. “The psychiatrist tells me that it adjusts serotonin levels, and that I will probably have to be on it for the rest of my life. I cried when I heard that.”

For a time, Zoloft worked great. “I was like a new person,” Melissa recalls. “I became open to people, and I made a lot of friends. I was the pitcher on the softball team.” During her senior year, she began making plans to attend Emerson College in Boston, thinking that she would study creative writing. Only then, slowly but surely, Zoloft’s magic started to fade. Melissa began to take higher doses to keep her depression at bay, and eventually her psychiatrist switched her to a very high dose of Paxil, which left her feeling like a zombie. “I was out of it. During a softball game, someone hit a ground ball to me and I just held the ball. I didn’t know what to do with it. I told my team I was sorry.”

Melissa has struggled with depression ever since. It followed her to college, first to Emerson and then to UMass Dartmouth, and although it did lift somewhat when she became immersed in writing for the UMass newspaper, it never entirely went away. She tried this drug and that drug, but none brought any lasting relief. After graduating, she found a job as an editorial assistant at a magazine, but depression caught up with her there, too, and in late 2007, the government deemed her eligible to receive SSDI because of her illness.

“I have always been told that a person has to accept that the illness is chronic,” she says, at the end of our interview. “You can be ‘in recovery,’ but you can never be ‘recovered.’ But I don’t want to be on disability forever, and I have started to question whether depression is really a chemical thing. What are the origins of my despair? How can I really help myself? I want to honor the other parts of me, other than the sick part that I’m always thinking about.
I think that depression is like a weed that I have been watering, and I want to pull up that weed, and I am starting to look to people for solutions. I really don’t know what the drugs did for me all these years, but I do know that I am disappointed in how things have turned out.”

Such is Melissa Sances’s story. Today it is a fairly common one. A distressed teenager is diagnosed with depression and put on an antidepressant, and years later he or she is still struggling with the condition. But if we return to the 1950s, we will discover that depression rarely struck someone as young as Melissa, and it rarely turned into the chronic suffering that she has experienced. Her course of illness is, for the most part, unique to our times.

Melancholy, of course, visits nearly everyone now and then. “I am a man, and that is reason enough to be miserable,” wrote the Greek poet Menander in the fourth century
B
.
C
., a sentiment that has been echoed by writers and philosophers ever since.
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In his seventeenth-century tome
Anatomy of Melancholy
, English physician Robert Burton advised that everyone “feels the smart of it … it is most absurd and ridiculous for any mortal man to look for a perpetual tenure of happiness in this life.” It was only when such gloomy states became a “habit,” Burton said, that they became a “dis-ease.”
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This was the same distinction that Hippocrates had made more than two thousand years earlier, when he identified persistent melancholy as an illness, attributing it to an excess of black bile (
melaina chole
in Greek). Symptoms included “sadness, anxiety, moral dejection, [and] tendency to suicide” accompanied by “prolonged fear.” To curb the excess of black bile and bring the four humors of the body back into balance, Hippocrates recommended the administration of mandrake and hellebore, changes in diet, and the use of cathartic and emetic herbs.
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During the Middle Ages, the deeply melancholic person was seen
as possessed by demons. Priests and exorcists would be called upon to drive out the devils. With the arrival of the Renaissance in the fifteenth century, the teachings of the Greeks were rediscovered, and physicians once again offered medical explanations for persistent melancholy. After William Harvey discovered in 1628 that blood circulated throughout the body, many European doctors reasoned that this illness arose from a lack of blood to the brain.

Psychiatry’s modern conception of depression has its roots in Emil Kraepelin’s work. In his 1899 book,
Lehrbuch der Psychiatrie
, Kraepelin divided psychotic disorders into two broad categories—dementia praecox and manic-depressive psychosis. The latter category was mostly comprised of three subtypes—depressive episode only, manic episode only, and episodes of both kinds. But whereas dementia praecox patients deteriorated over time, the manic-depressive group had fairly good long-term outcomes. “Usually all morbid manifestations completely disappear; but where that is exceptionally not the case, only a rather slight, peculiar psychic weakness develops,” Kraepelin explained in a 1921 text.
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Today, Kraepelin’s depression-only group would be diagnosed with unipolar depression, and in the 1960s and early 1970s, prominent psychiatrists at academic medical centers and at the NIMH described this disorder as fairly rare and having a good long-term course. In her 1968 book,
The Epidemiology of Depression
, Charlotte Silverman, who directed epidemiology studies for the NIMH, noted that community surveys in the 1930s and 1940s had found that fewer than one in a thousand adults suffered an episode of clinical depression each year. Furthermore, most who were struck did not need to be hospitalized. In 1955, there were only 7,250 “first admissions” for depression in state and county mental hospitals. The total number of depressed patients in the nation’s mental hospitals that year was around 38,200, a disability rate of one in every 4,345 people.
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Depression, Silverman and others noted, was primarily an “ailment of middle aged and older persons.” In 1956, 90 percent of the first-admissions to public and private hospitals for depression were thirty-five years and older.
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Depressive episodes, explained Baltimore psychiatrist Frank Ayd Jr., in his 1962 book,
Recognizing the
Depressed Patient
, “occur most often after age thirty, have a peak incidence between age 40 and 60, and taper off sharply thereafter.”
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Although the manic-depressive patients that Kraepelin studied were severely ill, as their minds were also buffeted by psychotic symptoms, their long-term outcomes were pretty good. Sixty percent of Kraepelin’s 450 “depressed-only” patients experienced but a single episode of depression, and only 13 percent had three or more episodes.
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Other investigators in the first half of the twentieth century reported similar outcomes. In 1931, Horatio Pollock, of the New York State Department of Mental Hygiene, in a long-term study of 2,700 depressed patients hospitalized from 1909 to 1920, reported that more than half of those admitted for a first episode had but a single attack, and only 17 percent had three or more episodes.
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Thomas Rennie, who investigated the fate of 142 depressives admitted to Johns Hopkins Hospital from 1913 to 1916, determined that 39 percent had “lasting recoveries” of five years or more.
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A Swedish physician, Gunnar Lundquist, followed 216 patients treated for depression for eighteen years, and he determined that 49 percent never experienced a second attack, and that another 21 percent had only one other episode. In total, 76 percent of the 216 patients became “socially healthy” and resumed their usual work. After a person has recovered from a depressive episode, Lundquist wrote, he “has the same capacity for work and prospects of getting on in life as before the onset of the disease.”
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These good outcomes spilled over into the first years of the anti-depressant era. In 1972, Samuel Guze and Eli Robins at Washington University Medical School in St. Louis reviewed the scientific literature and determined that in follow-up studies that lasted ten years, 50 percent of people hospitalized for depression had no recurrence of their illness. Only a small minority of those with unipolar depression—one in ten—became chronically ill, Guze and Robins concluded.
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That was the scientific evidence that led NIMH officials during the 1960s and 1970s to speak optimistically about the long-term course of the illness. “Depression is, on the whole, one of the psychiatric conditions with the best prognosis for eventual recovery with or without treatment. Most depressions are self-limited,”
Jonathan Cole wrote in 1964.
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“In the treatment of depression,” explained Nathan Kline that same year, “one always has as an ally the fact that most depressions terminate in spontaneous remissions. This means that in many cases regardless of what one does the patient eventually will begin to get better.”
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George Winokur, a psychiatrist at Washington University, advised the public in 1969 that “assurance can be given to a patient and to his family that subsequent episodes of illness after a first mania or even a first depression will not tend toward a more chronic course.”
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Indeed, as Dean Schuyler, head of the depression section at the NIMH explained in a 1974 book, spontaneous recovery rates were so high, exceeding 50 percent within a few months, that it was difficult to “judge the efficacy of a drug, a treatment [electroshock] or psychotherapy in depressed patients.” Perhaps a drug or electro-shock could shorten the time to recovery, as spontaneous remission often took many months to happen, but it would be difficult for any treatment to improve on the natural long-term course of depression. Most depressive episodes, Schuyler explained, “will run their course and terminate with virtually complete recovery without specific intervention.”
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The history of trials on the short-term efficacy of antidepressants is a fascinating one, for it reveals much about the capacity of a society and a medical profession to cling to a belief in the magical merits of a pill, even though clinical trials produce, for the most part, dispiriting results. The two antidepressants developed in the 1950s, iproniazid and imipramine, gave birth to two broad types of drugs for depression, known as monamine oxidase inhibitors (MAOIs) and tricyclics, and studies in the late 1950s and early 1960s found both kinds to be wonderfully effective. However, the studies were of dubious quality, and in 1965, the British Medical Council put both types through a more rigorous test. While the tricyclic (imipramine) was modestly superior to placebo, the MAOI (phenelzine) was not. Treatment with this drug was “singularly unsuccessful.”
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