Bipolar Expeditions (30 page)

Although the contemporary chart seems to offer more hope of improvement through medication than does Kraepelin's, one effect of the detailed moment-by-moment scrutiny is to emphasize the abnormal. People could mark their moods and other states right along the middle axis of the chart, along “normal,” but, in fact, they seldom do. What counts as “normal” can occupy as little as one point on the chart, as on the Harvard Bipolar Research Program home page—and this point can be easy to miss. Also, as one charting regular asked me, “Who wants to be a zero?” While for some the zero of normality is tinged negatively, for others the whole chart is negative territory. At a lecture I gave at the University of Texas, Austin, I showed several slides of Kraepelin's mood charts, coded, as I already described, in shades of red for mania, shades of blue for depression, and white for lucid intervals. A woman in the audience, identifying herself as a person from the Austin community diagnosed with bipolar disorder, commented, “Thank you for giving me the white spaces. I am going to go home and just be in a white space.” This woman evidently felt relief at being able to visualize “the white spaces”—places where her moods were not disordered and she did not have to monitor them constantly.

In support groups, I observed directly how difficult it is to occupy the zero point as long as one has the diagnosis of a mood disorder. Groups often followed the practice of beginning each meeting by going around the room for brief introductions. Each person would state his or her first name and then, using a kind of oral mood chart, give a number on a scale from -5 to +5, indicating a range of moods from very depressed to very manic. “I'm Jan and I'm +3,” “I'm Dave and I'm -2,” and so on. Only people with a diagnosis of manic depression attended most meetings, and I never heard anyone choose zero. But one time a woman who attended regularly brought along her husband, who does not have the diagnosis of manic depression. He listened as each person gave his or her name and score. When it was his turn he said uncertainly, “I'm Brad and I guess I must be zero.” In sum, everyone can see himself somewhere on the chart and (unless he is a zero) he can see how his emotional states could be moderated by psychotropic medications. Being zero, being normal, placed Brad orthogonal to the chart and out of reach of its demand for self-surveillance.

Mood Hygiene

In a popular book about manic depression, keeping a mood chartis said to be part of “mood hygiene.” Francis Mondimore includes a picture of Hygeia, the Greek goddess of health, who, in this context, stands for “Practices and habits that promote good control of mood symptoms in persons with bipolar disorder.” In the context of the image of Hygeia, Mondimore points out that research shows “just how important preventive measures can be for improving symptom control in bipolar disorder.”
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This is a powerful image because it is well known (and Mondimore emphatically reminds us) how efficacious hygienic practices (cleaning water, sweeping houses, and washing bodies) were in the reduction of mortality and morbidity that took place in the early twentieth century. But this is also an odd image. Hygiene reduces physical disease by eliminating
pathogens.
What is the hygiene of moods meant to reduce or eliminate? Are the surges and dips above and below the line of “normal” meantto be reduced? If this were to happen, would emotions, feelings, and sentiments in general be reduced? Would it be more “hygienic” if they were reduced to almost nothing? In Mondimore's book, these questions are left unanswered.

To push these questions further, I turn back to a book from 1978:
Mood Disorders: The World's Major Public Health Problem.
Why might “mood disorders” have been considered a public health problem in 1978? The main reason this book cites is that “[d]epression is a public health problem because it is frequent, causes distress and suffering for many patients and their families, and results in severe socioeconomic losses.”
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The link between mood and productivity in the workplace was well entrenched in North America by the end of World War II. An early 1950s public health education film made clear the link between depression and decreased ability to work. Called
Feelings of Depression,
the film tells the story of John, a depressed young man who believes he is failing at his job, and more seriously, believes his company itself is on the brink of failure.
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The notion that mood disorders were a public health problem was doubtless fueled by the development of a new form of antidepression medication. Frank Ayd, coeditor of the 1978 book, ran Merck's clinical trials for their antidepressant Elavil. Merck bought 50,000 copies of another book Ayd wrote,
Recognizing the Depressed Patient,
and distributed them worldwide. This played a significant role in Elavil's success: “Merck not only sold amitriptyline, it sold an idea. Amitriptyline became the first of the antidepressants to sell in substantial amounts.”
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More recent items in the media continue to associate “moods,” especially depression, with lack of productivity or inability to work. A public health poster from 1991 captioned “Not everyone who is depressed is this visible” depicts a scene of a contemporary open office space in which several (presumably depressed) workers are shown as immobile white plaster statues. In 2001, the business news reported that Bank One, concerned about productivity losses because of depression among its employees, instituted programs to encourage education, screening, and treatment. But the outcome for the bank was that the number of employees taking disability leaves for depression skyrocketed.
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In 2003, a widely reported study, “Cost of Lost Productive Work Time among U.S. Workers with Depression” (funded by Eli Lilly, manufacturer of the antidepressant Prozac), found that depression costs employers $31 billion per year in lost productive time.
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Since this study also discovered that use of antidepressants among depressed workers was low, it made the dotted lines between taking antidepressants and increasing productivity easy to connect. Similar lines were connected in the spate of articles in print media, the Web, and on television looking at links between moods like depression and the inability to leave the welfare rolls by means of finding a job.
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In a
60 Minutes
story on welfare and depression, Lesley Stahl begins,

One reason there are still five million people on welfare is that “a huge number of them are depressed, not just suffering from a case of the blues, but seriously medically depressed. It's an epidemic of depression among America's poor.”

Dr. Kessler of Harvard's School of Public Health estimates between a third and a half of people still on welfare are clinically depressed.

Dr. Carl Bell
(of a mental clinic in Chicago): The state of Illinois, bless their heart, finally figured out that maybe the people who were going to be left on welfare were people with psychiatric disorders, and so maybe somebody ought to be here screening for that and referring people for treatment.

Lesley Stahl:
So people come in for welfare, for their checks, to make their applications, and if somebody is there that perhaps spots these symptoms …

Dr. Bell:
You can screen them out—everybody can get a very simple screening form—find out who's got what, and then treat them.
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It goes without saying that welfare recipients should be able to reap the same benefits of the latest medication and therapies for depression as economically better-off citizens. But how do we separate those who would be depressed whether rich or poor and those who are depressed
because
they are poor? Screening alone will not do the job.

In the
60 Minutes
scenario, the participants imagine that it would be best for depression to simply disappear. Of course, no one would wish to perpetuate the suffering caused by the despair and paralysis of depression. Least of all would pharmaceutical advertisements, which frequently imply that depression can be eradicated, and that its eradication would be a good thing.
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On behalf of Prozac and Serafem, Lilly urges you to “Get your life back” (from the depression that has taken it away) and after treatment to remove the depression, declares, “Welcome back!” On behalf of Zoloft, Pfizer exhorts, “When you know more about what is wrong, you can help make it right.” Taking Zoloft will correct the “chemical imbalance of serotonin in the brain,” which, it is suggested, is the physical signature of depression. In
Against Depression,
Peter Kramer warns us not to romanticize depression as a form of “heroic melancholy,” but instead treat it as a disease we can cure. Although I would agree that the suffering caused by depression should not be endowed with virtue, I want to call attention to the socially based reasons why we want to eliminate some moods but keep others. Kramer exempts mania and hypomania from elimination because “they may drive productivity in many fields.”
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Once again, mania is valuable because of its association with motivation and productivity.

Practices of screening populations to detect undesirable mental states have now gone far beyond welfare offices. Heralded through the Bush administration's New Freedom Commission on Mental Health and given a test run as the Texas Medical Algorithm Project (TMAP), systematic screening has already been instituted as official policy in more than ten states. The program is slated for national use. Pennsylvania has run into trouble because Allen Jones, a self-identified whistle blower, publicized the connections between the pharmaceutical industry, the specific, brand-name drugs Pennsylvania placed on its formulary (the list of drugs physicians must choose from), and the financial interests of numerous state and federal officials. My point is not that we should deny the best mental health care—including drugs—for everyone, but that cultural values in favor of productive moods can be tied in a troubling way to economic interests.
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With depression eliminated, the way would be open to cultivate a kind of manic energy stripped of its moodiness. Indeed, self-help experts have marketed explicit programs to help achieve this end. Through many best-selling books and television programs, Barbara Sher advocates a program of self-improvement in which moods are considered a distraction. Moods are important to identify so they do not get in the way of the real goal: building motivation. She writes, “You can't ignore your emotions. They're strong and primitive and must be dealt with.”
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But moods and emotions are to be identified and swept away (as if by Hygeia's broom) so that your “hidden motivators” and “untapped energy sources” can be unleashed, even when, as her Web site states, “you are in a lousy mood.”
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Although mood charts are mostly for people who are afflicted by their moods and need to know them in order to control them by practicing mood hygiene, the word “hygiene” should be a tip-off to us that
selections
are being made among mood states. Just as at the turn of the twentieth century when “unhygienic” behavior was discouraged and “hygienic” behavior was encouraged, the notion is that as depression withers away altogether, the wild, raw mania of the manic depressive can be tamed or optimized, the better to enable individuals to succeed and economies to grow. Key agents in this picture are the growing numbers of psychopharmaceutical drugs. They are what allow contemporary doctors to give a patient a diagnosis of mood disorder and treat it, rather than (as in earlier historical periods) lay the patient's problems at the feet of her temperament or character.
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This transformation has certain benefits, not least that drugs can be effective and patients can feel less personally responsible for their condition. A newspaper article by a doctor praises the transformation because it unmasks “cheerful character” as “hypomania” (a mild form of mania) and “gloomy temperament” as “hypomania's dark twin ‘dysthymia' [a mild form of depression].”
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In the unmasking, these conditions are rendered treatable. But they are also rendered as conditions that are greatly more susceptible to whatever cultural ideals are in play. It becomes thinkable to manage and adjust moods and motivations in directions that are apparently necessary for survival in the fierce economy of the present. We will see in
chapters 8
and
9
how mania (with its intense motivation) gathers attention from the workplace and the “marketplace”: I will argue that mania's connection with strong motivation is part of what lies behind our current sense that it is something that can be harnessed as an asset in the workplace.

Concern for the control of mood disorders has even spread beyond the national borders of the United States. In 2001, the World Health Organization (WHO) declared mental illness the main global health crisis of the year. Chief among WHO's concerns were two: the loss of productivity to the world's economies because of depressed mood; and making effective pharmacological treatments more widely available. For their part, the pharmaceutical industry, by the 1990s in possession of a greater range of drug treatments, clearly envisioned the market for these drugs on a global scale, and began to speak of the “global Central Nervous System therapeutics market” estimated at approximately $44 billion.
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A number of factors are coming together here: dissemination of mood charts for individuals to track their moods on a daily or hourly basis; a strong link between mood and productivity; and interest in increasing the recognition and treatment of mood disorders across the globe. The modest technology of mood charting has had an important role to play in the claim, first made in 1978 and reiterated often since, that mood disorders are a threat to the health of populations—mood disorders are a public health crisis. For people who feel compromised by their moods, this attention is welcome because it acknowledges the extent of the problem and legitimates its significant impact on life. My argument is that in the process of coming into being, the public health crisis in moods has changed the way people experience their moods. Increasingly, there seems to be one universal set of mood categories that everyone experiences. Through the simple act of recording their moods in terms of these categories, people form the habit of thinking in terms of a standardized taxonomy of mood.
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As they become more and more aware of their moods at a detailed level, they are likely to feel greater personal responsibility for practicing good mood hygiene. Thus, subjectivity changes. These changes have contradictory aspects. On the one hand, moods gain more and more concreteness as real things in nature, with a biochemical basis. On the other hand, people come to feel more and more responsible for manipulating their environments (lifestyles) and their affective constitutions, through biochemical means if necessary. Affective “nature” is not a given any longer; it is raw material needing management.
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Nothing less is involved in personal, national, and global success and failure. New habits of recording moods in turn enable governments, public health agencies, and pharmaceutical corporations to compile national and global statistics. These statistics then play their part in convincing organizations like the WHO or state and federal agencies in the United States to target the link between depression and productivity, as we saw in
chapter 1
. Something very small in scale (keeping a daily record of one's moods) becomes something very big in scale (global statistics that link mood and productivity), which can then loop back and change subjectivity yet again.
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