In Japan just a few decades ago, the concept of "depression" was just as foreign as the drugs now commonly used to treat it. It was up to pharmaceutical giant GlaxoSmithKline to change all that, says Ethan Watters in his book Crazy Like Us: The Globalization of the American Psyche. The book is a searing investigation into how Americans export, not just our drugs, but our whole way of looking at mental illnesses.
"The idea that states of melancholy can be almost transcendent states of being" needed to be changed in Japan in order for mental health professionals to prescribe American drugs, Watters told NPR's Marketplace program recently. So GlaxoSmithKline (GSK) hired cross-cultural psychologists, who translated the Nipponese concept of mystical, significant sadness "into this idea that states of melancholy were mental illness, and bam! -- they had a tremendous market for the drug, and they're now selling a billion dollars worth of Paxil a year."
I am looking at my family's prescription benefit statement and it reads like a bill of lading. Of the five of us, two are on antidepressants and two are still too young to be considered candidates. What makes it even more (dare I use the word) crazy: I've done everything I can to get the rest of the synthetic chemicals out of my family's life. We don't even use shampoo, what with the phthalates and the parabens and God knows what else in it that can interfere with hormonal levels in people, and in fish. I bake bread using sourdough ("Yeast I caught myself!" I say proudly) and locally-grown flour and oats to avoid preservatives. I save wine bottles to fill with olive oil, vinegar and maple syrup, to avoid the BPAs in plastic. And yet, at the breakfast table, next to the glass of raw milk from grass-fed cows, I slide my oldest son two white pills chock-full of the American pharmaceutical industry's finest chemicals.
When Depression Is a Solution, Not a Problem
If I've been thinking, lately, that our medication levels are a bit high, I'm obviously not the only one. Watters' argument that we're exporting our own cultural approach to mental illness -- squash it with pills, then talk about it as often as possible -- to the rest of the world echoes many of the themes of an extremely provocative essay in this week's The New York Times Magazine.
Jonah Lehrer writes about a theory explored by psychiatrist Andy Thomson and evolutionary psychologist Paul Andrews: that depression serves a biological purpose, allowing us to focus our mental energies on a problem. In the best case scenario, the improved "capacity for intense focus" brought on by depression would help us to "ruminate" and solve the "complex life problem that triggered the depression" and relieve the sadness.
Thomson and Andrews don't go so far as to say all depression is good, or suggest we should halt all American-style sadness-squashing treatments altogether. Instead, their research suggests that clinicians should be giving it more thought before administering drugs. In Lehrer's essay, Thomson, who has treated patients for decades in Charlottesville, Va., relates the story of a patient who came in asking him to reduce her dosage. "I asked her if the antidepressants were working, and she said something I'll never forget. 'Yes, they're working great,' she told me. 'I feel so much better. But I'm still married to the same alcoholic son of a bitch. It's just now he's tolerable.'"
"Wisdom Isn't Cheap, and We Pay for It With Pain."
The concept that our problems -- our alcoholic spouses or bad career choices or crippling parental pressure -- need to be solved, not simply made tolerable, is sensible, and it has as many fervent opponents as any logical conclusion. Just because an answer is logical does not necessarily mean it is correct, of course, but in this case, it's a logic that I love. (For the record, opponents point to suicide as one reason this theory is ineffective; and one critic says that depression and sadness are distinctly different -- depressed people don't have problems to solve, except, of course, the depression.)
Perhaps my husband's and oldest son's recurring states of sadness are really melancholy, a tool of the problem-solver's soul, and by picking up their prescriptions each month, I am depriving them of a mental state they need. These men in my life are fixer-uppers, or as Lehrer writes more poetically, "wisdom isn't cheap, and we pay for it with pain."
I have also been reading about the new draft of the Diagnostic and Statistical Manual of Mental Disorders, DSM-V, and what I've read has been devastating my spirit. It was released by the American Psychiatric Association in February, and the revision nearly a decade in the making could impact the diagnosis of more than a million troubled children by the time it's published in 2013. The changes it makes from the previous edition are numerous, and they will affect (among other things) which drugs insurance companies will reimburse for, which families are eligible for social services, and how the needs of children are addressed by their public schools.
The change which most concerns me is the addition of a condition known as "temper dysregulation disorder," a diagnosis which would apply to children of elementary-school age. In many cases, this new diagnosis would be applied to children who once would have been classified as having pediatric bipolar disorder.
Twenty years ago, the creation of this "new" descriptive wouldn't have felt important. In fact, it is only in the last 15 or so years that children have been diagnosed with pediatric bipolar disorder. But during that period, it has gone from "somewhere between 'never' and 'vanishingly rare'" to a condition diagnosed in 1 million American children. Diagnosed and treated, most often with antipsychotic medications.
The Difference Between 'Medicate for Life' and 'Medicate for Awhile'
If this new diagnosis survives to become part of the final DSM-V, I believe it has the potential to have a profound effect on the prescribing behavior of mental health professionals.
It's unclear how many kids would fit the temper dysregulation criteria, instead of the bipolar criteria; it's unclear whether prescribers would turn to the antipsychotics (many of which have not been clinically tested on children) to treat them, after all. What proponents of the new diagnosis say is that it will emphasize this key point: Many of these children should not be expected to suffer from the symptoms of explosive temper for their entire lives; at some point, for children diagnosed with temper dysregulation, the medications can and should stop.
What is clear to me is that my son's symptoms, which his doctors say don't fit the criteria for pediatric bipolar disorder, do fit the description of temper dysregulation disorder to a T.
It is my belief that the American Psychiatric Association, with this proposed change to the DSM, hopes to reduce the frequency at which children are prescribed medication, and the duration those kids stay on it -- a belief nourished by reading many psychiatrists' takes on the DSM-V draft. In books and scholarly articles, I see lines being drawn in the sand by those who recognize our society's growing discomfort with the vast number of psychiatric medications we've been ingesting.
Perhaps the drugs themselves are dulling our ability to focus in on the problem. Are we helping ourselves by making the pain less painful? Or are we creating as many issues as we're fixing by manufacturing and selling and creating markets for ever more billions of dollars worth of brain-numbing drugs? Shouldn't we be focusing on the causes instead of refining the palliatives?
I'm looking for hammers and nails, not decoupage, but I'm not sure yet what's structural and what's baby fat. I'm already looking at this whole issue through new lenses, and the many books, articles and studies on the subject are evidence that our national diagnosticians are headed for eye exams, too. We could be in for the downward-sloping segment of the pharmaceutical market's growth curve; I, for one, am hoping for a nice swift ride with my feet off the pedals.
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