One of the interesting and inescapable features of our knowledge-building efforts is just how hard it can be to nail down objective facts. It is especially challenging to tell an objective story when the object of study is us. It's true that we have privileged information of a particular sort (our own experience of what it is like to be us), but we simultaneously have the impediment of never being able fully to shed that experience. As well, our immediate experience is necessarily particular -- none of us knows what it is like to be human in general, just what is is like to be the particular human each of us happens to be. Indeed, if you take Heraclitus seriously (he of the impossibility of stepping in the same river twice), you might not even know what it is like to be you so much as what it is like to be you so far.
All of this complicates the stories we might try to tell about how our minds are connected to our brains, what it means for those brains to be well, and what it is for us to be ourselves or not-ourselves, especially during stretches in our lives when the task that demands our attention might be figuring out who the hell we are in the first place.
Katherine Sharpe's new book Coming of Age on Zoloft: how antidepressants cheered us up, let us down, and changed who we are, leads us into this territory while avoiding the excesses of either ponderous philosophical treatise or catchy but overly reductive cartoon neuroscience. Rather, Sharpe draws on dozens of interviews with people prescribed selective seratonin reuptake inhibitors (SSRIs) for significant stretches from adolescence through early adulthood, and on her own experiences with antidepressants, to see how depression and antidepressants feature in the stories people tell about themselves. A major thread throughout the book is the question of how our pharmaceutical approach to mental health impacts the lives of diagnosed individuals (for better or worse), but also how it impacts our broader societal attitudes toward depression and toward the project of growing up. Sharpe writes:
When I first began to use Zoloft, my inability to pick apart my "real" thoughts and emotions from those imparted by the drug made me feel bereft. The trouble seemed to have everything to do with being young. I was conscious of needing to figure out my own interests and point myself in a direction in the world, and the fact of being on medication seemed frighteningly to compound the possibilities for error. How could I ever find my way in life if I didn't even know which feelings were mine? (xvii)
Interleaved between personal accounts, Sharpe describes some of the larger forces whose confluence helps explain the growing ubiquity of SSRIs. One of these is the concerted effort during the revisions that updated the DSM-II to the DSM-III to abandon Freud-inflected frameworks for mental disorders which saw the causal origins of depression in relationships and replace them with checklists of symptoms (to be assessed in isolation from additional facts about what might be happening in the patient's life) which might or might not be connected to hunches about causal origins of depression based on what scientists think they know about the actions on various neurotransmitters of drugs that seem to treat the symptoms on the checklist. Suddenly being depressed was an official diagnosis based on having particular symptoms that put you in that category -- and in the bargain it was no longer approached as a possibly appropriate response to external circumstances. Sharpe also discusses the rise of direct-to-consumer advertising for drugs, which told us how to understand our feelings as symptoms and encouraged us to "talk to your doctor" about getting help from them, as well as the influence of managed care -- and of funding priorities within the arena of psychiatric research -- in making treatment with a pill the preferred treatment over time-consuming and "unpatentable talk-treatments." (184)
Sharpe discusses interviewees', and her own, experiences with talk therapy, and their experiences of trying to get off SSRIs (with varying degrees of medical supervision or premeditation) to find out whether one's depression is an unrelenting chronic illness the having of which is a permanent fact about oneself, like having Type I diabetes, or whether it might be a transient state, something with which one needs help for a while before going back to normal. Or, if not normal, at least functional enough.
The exploration in Coming of Age on Zoloft is beautifully attentive to the ways that "functional enough" depends on a person's interaction with environment -- with family and friends, with demands of school or work or unstructured days and weeks stretching before you -- and on a person's internal dialogue with oneself -- about who you are, how you feel, what you feel driven to do, what feels too overwhelming to face. Sharpe offers an especially compelling glimpse at how the forces from the world and the voices from one's head sometimes collide, producing what professionals on college campuses describe as a significant deterioration of the baseline of mental health for their incoming students:
One college president lamented that the "moments of woolgathering, dreaming, improvisation" that were seen as part and parcel of a liberal arts education a generation ago had become a hard sell for today's brand of highly driven students. Experts agreed that undergraduates were in a bigger hurry than ever before, expected by teachers, parents, and themselves to produce more work, of higher quality, in the same finite amount of time. (253)
Such high expectations -- and the broader message that productivity is a duty -- set the bar high enough that failure may become an alarmingly likely outcome. (Indeed, Sharpe quotes a Manhattan psychiatrist who raises the possibility that some college students and recent graduates "are turning to pharmaceuticals to make something possible that's not healthy or normal." (269)) These elevated expectations seem also to be of a piece with the broader societal mindset that makes it easier to get health coverage for a medication-check appointment than for talk-therapy. Just do the cheapest, fastest thing that lets you function well enough to get back to work. Since knowing what you want or who you are is not of primary value, exploring, reflecting, or simply being is a waste of time.
Here, of course, what kind of psychological state is functional or dysfunctional surely has something to do with what our society values, with what it demand of us. To the extent that our society is made up of individual people, those values, those demands, may be inextricably linked with whether people generally have the time, the space, the encouragement, the freedom to find or choose their own values, to be the authors (to at least some degree) of their own lives.
Finding meaning -- creating meaning -- is, at least experientially, connected to so much more than the release or reuptake of chemicals in our brains. Yet, as Sharpe describes, our efforts to create meaning get tangled in questions about the influence of those chemicals, especially when SSRIs are part of the story.
I no longer simply grapple with who I can become and what kind of effort it will require. Now I also grapple with the question of whether I am losing something important -- cheating somehow -- if I use a psychopharmaceutical to reduce the amount of effort required, or to increase my stamina to keep trying ... or to lower my standards enough that being where I am (rather than trying to be better along some dimension or another) is OK with me.
And, getting satisfying answers to these questions, or even strategies for approaching them, is made harder when it seems like our society is not terribly tolerant of the woolgatherers, the grumpy, the introverted, the sad. Our right to pursue happiness (where failure is an option) has been transformed to a duty to be happy. Meanwhile, the stigma of mental illness and of needing medication to treat is dances hand in hand with the stigma attached to not conforming perfectly to societal expectations and definitions of "normal".
In the end, what can it mean to feel "normal" when I can never get first-hand knowledge of how it feels to be anyone else? Is the "normal" I'm reaching for some state from my past, or some future state I haven't yet experienced? Will I know it when I get there? And I can I reliably evaluate my own moods, personality, or plans with the organ whose functioning is in question?
With engaging interviews and sometimes achingly beautiful self-reflection, Coming of Age on Zoloft leads us through the terrain of these questions, illuminates the ways our pharmaceutical approach to depression makes them more fraught, and ultimately suggests the possibility that grappling with them may always have been important for our human flourishing, even without SSRIs in our systems.