There are two main methods of treating depression: conversational therapy, which operates with words, and physical intervention, including both drug treatment and electroshock therapy (ECT). Combining psychosocial and psychopharmacological approaches to depression is difficult, but necessary. The fact that many people see the situation in the light of “either-or” is extremely dangerous. Medical and psychotherapeutic methods of treatment should not compete in winning over representatives of a limited population of people prone to depression; they should be mutually complementary methods of treatment that can be used together or separately, depending on the patient’s condition. The biopsychosocial model of therapy, which includes different methods, is still not given to us. The consequences of this can hardly be overestimated. It is fashionable among psychiatrists to first tell you the cause of depression (low serotonin levels and early mental trauma are among the most popular), and then, as if there was a logical connection, the remedies for it; but these are all empty words. “I don’t believe that if the causes of your problems are psychosocial, then psychosocial treatment will be required, and if the causes are biological, then the treatment should be biological,” says Ellen Frank from the University of Pittsburgh. It is characteristic that patients who come out of depression thanks to psychotherapy show the same changes — for example, on an electroencephalogram (EEG) during sleep — as those who took medications.
While psychiatrists of the traditional school consider depression as an integral property of the patient suffering from it, and try to achieve changes in the structure of a person’s character, psychopharmacology considers the disease as an externally caused imbalance that can be corrected without taking into account other components of the personality. Anthropologist T. M. Luhrmann recently wrote about the dangers of this split in modern psychiatry: “Psychiatrists should perceive these approaches as different tools from the same set. And they are taught that these are different tools based on different models and used for different purposes.” “Psychiatry,” says William Normand, a psychoanalyst who uses drugs when he feels that they will help — “was brainless, but has become soulless”: practitioners who previously ignored the physiology of the brain in favor of emotional disorders, now neglect the emotional side of the human psyche in favor of brain chemistry. The conflict between psychodynamic therapy and drug therapy is ultimately a conflict of moral assessments: we tend to categorically proceed from the fact that if a problem lends itself to a psychotherapeutic dialogue, then it should be handled with effort, and if it reacts only to chemical intervention, then it is not your fault and no effort is required from you. There is a well-known truth that there is a patient’s fault in depression, and that almost any depression can be relieved by making an effort. Antidepressants help those who help themselves. If you force yourself too much, you will only make it worse, but if you really want to get out, you should make an effort. Medications and psychotherapy are tools that should be used as needed. Don’t blame yourself, but don’t make excuses either. Melvin McGuinness, a psychiatrist at the Johns Hopkins Clinic, speaks of “will, emotions and cognition” as elements of interconnected cycles, almost like biorhythms. Your emotions affect your will and cognitive functions, but they do not destroy them.
Conversational psychotherapy comes from psychoanalysis, which, in turn, originates from the ritual identification of dangerous thoughts, first formalized in the church confession. Psychoanalysis is a form of treatment in which special methods are used to identify mental injuries of an early age that led to neurosis. It usually takes a lot of time (four to five hours a week is the standard norm) and focuses on bringing to light the content of the subconscious. It has become fashionable to scold Freud and psychodynamic theories, but in fact the Freudian model, although not without defects, is an excellent model. According to Luhrmann, it contains “a sense of the depth and complexity of a person, an urgent demand to fight with their own psychological costs and respect for the dignity of human life.” While people argue with each other about the details of Freud’s concept and accuse him of the prejudices of his time, they do not notice the fundamental truth of his legacy, an example of his great humility: we often do not know our own motives in life and are prisoners of what we cannot understand. We can recognize only a small part of our own and an even smaller part of others ‘ life impulses. Even if we take only this from Freud — we can call this force even “unconscious”, even “misalignment of certain brain processes” – then we will already have some basis for studying mental illness.
Psychoanalysis explains well, but does not provide effective methods for changing the state. The energy of the psychoanalytic process will be wasted if the patient’s goal is an immediate change in the general mood. When I hear about psychoanalysis as a means of combating depression, I imagine a man standing on a sandbank and firing a machine gun at the incoming tide. However, psychodynamic methods, which grew out of psychoanalysis, have their own vital role. An unexplored life can rarely be brought back to normal without careful consideration, and the lesson of psychoanalysis is that such consideration is almost always informative. Nowadays, the most popular are those schools of psychotherapy where the client tells the doctor about his feelings and experiences at the present time. Talking about depression — for many years it was considered the best way to deal with it. This is still one of the most effective means. “Take notes,” Virginia Woolf wrote in The Years, — and the pain will pass.” This process is the basis of most methods of psychotherapy. The role of the doctor is to listen carefully as the client comes into contact with his true motives in order to understand why he does what he does. Most of the psychodynamic methods are based on the principle that naming something is a means to master it, and knowing the source of the problem is useful for solving it. However, such schools do not stop at knowledge — they teach ways to harness knowledge for therapeutic purposes. The doctor may make some statements of a non-evaluative nature that will give the client sufficient understanding to change his behavior and improve his life. Isolation often causes depression. A good psychotherapist can help a depressed person to get in touch with the people around him and build support structures that will moderate the strength of depression.
There are, however, such orthodox people for whom such emotional revelations are meaningless. “Who cares about motives and sources? Donald Kline, a leading psychopharmacologist at Columbia University, asks. No one has yet overthrown Freud, because no one has a theory that is even slightly better than the theory of internalized conflict. The main thing is that now we know how to treat it; and philosophizing on the topic of where everything comes from has not yet brought the slightest therapeutic benefit.”
It is true that medicines give freedom, but we should also care about the sources of the disease. Stephen Hyman, director of NIMH, says :” For cardiovascular diseases, we do not just write a prescription for medicines. We also advise people to lower their cholesterol levels, give them a set of exercises, offer a diet and, say, stress control. The combined process is not unique in the treatment of mental illness. The dispute about the methods of drug treatment or psychotherapeutic treatment is ridiculous. Both of these questions are empirical. My personal philosophical prejudice is that they should work together, because drugs will make people more accessible to psychotherapy, help start a spiral upward movement.” Ellen Frank has conducted a number of studies that have shown that psychotherapy is far from being as effective as medications to bring people out of depression, but it has a protective effect against relapses. Although it is difficult to interpret the data in this area, in general, they lead us to believe that the combination of drugs and psychotherapy works better than each of these methods separately. “It’s a treatment strategy to prevent the next bout of depression,” she says. — It is not clear to me what place in the future healthcare will be given to integrated approaches to treatment, and this is frightening.” Martin Keller, an employee of the Faculty of Psychology at Brown University, who works as part of an interuniversity research group, in a recent survey of depressed patients found that less than half of them experienced significant improvements only due to medications, less than half received significant improvement due to cognitive behavioral psychotherapy, more than 80% experienced significant improvement as a result of using both methods. The arguments in favor of combination therapy are almost impossible to challenge.
Robert Klitzman, a fellow at Columbia University, exclaims in despair: “Prozac should not eliminate insights; it should make them possible.” And Luhrmann writes: “Doctors have been taught to see and understand the bizarre form of suffering, and all they are allowed to do is slip his captives a biomedical lollipop and then turn their backs on them.”
If your descent into depression was triggered by some real life experience, you, as a person, want to understand it, even if you are no longer experiencing it; removing or limiting the experience achieved with the help of chemical drugs is not equivalent to healing. Both the problem itself and your attitude to it require urgent attention. Probably, in our pro-drug era, more people will be cured than before, the overall level of health in society will increase. But it is dangerous to postpone psychotherapy for a long time. It is it that allows a person to understand the meaning of the new Self that he has gained by taking medications, and to accept the loss of the Self that was lost during the illness. After a severe attack, it is necessary to be reborn and learn behavioral methods that will protect against relapse. You will have to build your life differently than before, before the attack. “Under any circumstances, it is difficult to regulate your life, sleep, nutrition, physical activity,” says Norman Rosenthal of NIMH. – Imagine how hard it is when you are depressed! You need a therapist who, as a coach, will keep you in shape. Depression is a disease, not a life choice, and to get through it, you need help.” “Medications treat depression —” my therapist said — ” and I treat depressed people.” What calms you down? What increases the symptoms? From the point of view of chemistry, there is no difference between depression caused by the death of a family member and depression caused by the collapse of a two-week love scam. And even if the reaction, which is aggravated to the extreme, looks more rationally explicable in the first case, the clinical sensations are almost identical. As Sylvia Simpson, a clinician at Johns Hopkins, says, ” if it looks like depression, treat it like depression.”
When I had a second attack of depression, I stopped psychoanalysis and was left without a therapist. Everyone kept telling me that I needed to find a new one. Even when you are in good shape and can communicate normally, finding a new psychotherapist is a very difficult task, and when you are in the grip of severe depression, it is completely beyond the limit. Finding a good specialist is a very important and difficult task: I visited eleven in six weeks. I gave each of them a mournful list of my sorrows; at the end it sounded like a monologue from someone’s play. Some of the potential candidates looked wise, others-eccentric. One woman covered all the furniture in the office with plastic wrap to protect her dogs, who were also constantly barking; she kept offering me pieces of unappetizing-looking stuffed fish, which she herself ate from a plastic jar. I left when the dog wet my shoes. One man gave me the wrong address of his office (“Oh, that’s where my office was before”), another said that I don’t have any real problems, but I just need to cheer up a little. Among them was a woman who told me that she did not believe in emotions, and a man who did not believe in anything else. Among them there was one cognitive therapist, one Freudian who chewed his nails throughout the meeting, one Jungian and one self-taught. One of them kept interrupting me to tell me that it was the same with him. A few of them just couldn’t understand anything when I tried to explain who I was. I used to believe that my socially advanced friends should have good psychotherapists. It turned out, however, that many people who have normal relationships with their wives and husbands build crazy relationships with extremely strange doctors in the name of, presumably, balance. “We are trying to explore the comparative advantages of drugs and psychotherapy,” says Steven Hyman. — Has anyone compared talented psychotherapists with incompetent ones? In this area, we are all completely Columbians.”
As a result, I made my choice and am still very happy with it: I found a person in whom I caught a quick mind and the light of true humanity. I chose him because he looked smart and reliable. Having a sad experience of working with a psychoanalyst who constantly interrupted our classes and did not allow me to take medications when I desperately needed them, I was initially wary, and it took me three or four years to learn to fully trust him. He stood firm during all periods of my confusion and crises. In the good times, it was interesting with him; I really appreciate the sense of humor in a person with whom I spend so much time. He worked well with my psychopharmacotherapist. In the end, he convinced me that he knows his business and wants to help me — it’s worth trying ten other options first. Do not go to a therapist who does not like you. Unsympathetic people, no matter how qualified they are, will not be able to help you. If you think that you are smarter than your doctor, you may be right: a degree in psychiatry or psychology does not guarantee genius. Choose a psychotherapist with the utmost care. You can go crazy when you think how people who are ready to drive an extra twenty minutes to use this dry cleaner, and make a scandal to the supermarket manager for not having this brand of canned tomatoes, choose a psychotherapist, as if it were some nameless service staff. Remember — you at least give your mind into the hands of this person. Remember also that you must tell the therapist about what you can’t show him. “It is very difficult,” Laura Anderson wrote to me, ” to trust someone if the problem is so vague that it is impossible to see if he understands; and in this case it is also more difficult for him to trust you.” I am incredibly easily controlled by a psychotherapist, even when I feel midnight melancholy. I sit up straight and don’t cry. I am ironic to myself and use gallows humor in peculiar attempts to make a pleasant impression on the people treating me — people who do not need this pleasant impression. Sometimes I wonder if psychiatrists believe me when I describe my feelings, because I hear a note of detachment in my own voice. I imagine how they must hate this thick social skin, through which so few of my true feelings break through. I often want to give full rein to my emotions in the psychiatrist’s office. I never manage to define for myself the place where psychotherapy takes place, as my private space. The way I talk to my brother, for example, escapes me in conversations with a psychotherapist. It must be a feeling of great risk. And only sometimes, in precious moments, a glimpse of my inner reality breaks through, and then not in my description, but from the essence of the matter.
One of the ways to make a judgment about a psychiatrist is to observe how well he judges you. The art of initial selection is the art of asking the right questions. I have not attended confidential psychiatric interviews face-to-face, but I have often observed the admission of people to the hospital, and I am always struck by the variety of approaches to depressive patients. Most of the good psychiatrists I’ve seen start by letting the patient speak out, and then immediately move on to a clearly structured conversation in search of specific information. The ability to conduct such an interview well is one of the most important professional qualities of a clinician. Sylvia Simpson, a clinician from Johns Hopkins, established in the first ten minutes of the interview that the new patient, just after a suicide attempt, suffers from bipolar disorder. And her psychiatrist, who used her for five years, did not establish this basic fact and prescribed antidepressants without mood stabilizers — a treatment regimen that has long been known for its unsuitability for bipolar patients, because it often causes them a mixed-excited state. When I asked Simpson about this later, she said, ” It took me years of hard work to learn how to ask such questions in interviews.”
Then I was present at interviews with homeless people conducted by Henry Mckertiss, the chief psychiatrist of the Harlem Hospital. He spent at least ten minutes of every twenty-minute interview on incredibly meticulous clarification of the history of when and where each of the patients lived. When I finally asked him why he was so tirelessly investigating this issue, he replied: “Those who have lived in one place for a long time become homeless due to circumstances, but are able to live a normal, orderly life; they need first of all social intervention. If a person constantly moves from place to place, or becomes homeless again and again, or does not remember where he lived, then here we are most likely dealing with a serious illness, and such cases require first of all psychiatric intervention.”
I feel good — my insurance covers weekly visits to a psychiatrist and monthly visits to a psychopharmacotherapist. Most healthcare organizations are happy to provide medicines, which, relatively speaking, are cheap. They do not really welcome psychotherapy and hospitalization. Two types of psychotherapy have shown themselves best in the treatment of depression — cognitive-behavioral therapy (CBT) and personality-oriented psychotherapy (interpersonal therapy, IPT). CBT is a form of psychodynamic therapy based on emotional and mental reactions to external events from the present and from childhood, focused on goals. The system was developed by Aaron Beck from the University of Pennsylvania and is now used everywhere in the United States and most of Western Europe. Beck argues that a person’s thoughts about himself are often destructive, and by forcing the mind to think in a certain way, you can actually change reality; this is a program that one of its developers called “learned optimism”. He believes that depression is the result of false logic, and therefore, by correcting negative thinking, you can improve mental health. SVT teaches objectivity.
The therapist begins by helping the patient to make a list of “data from the history of life”, a sequence of difficulties that led to the current state. Then he systematizes the reaction to these difficulties and tries to identify the characteristic patterns of inadequate response. The patient learns why he considers certain events depressing and leading to depression and tries to get rid of such reactions. This macroscopic part of the SVT is followed by a microscopic one, when the patient learns to neutralize his “automatic thoughts”. Feelings are not direct reactions to the outside world: what happens in the world affects the cognitive (cognitive) abilities, and those, in turn, affect the feelings. If the patient is able to change the features of perception, he will be able to change the accompanying state of mind. The patient may, for example, learn to consider her husband’s excessive employment as his justified reaction to work requirements, and not as inattention to it. Then she may be able to see how her own automatic thoughts (for example, that she is an unloveable nonentity) turn into negative emotions (self-flagellation), and determine how these negative emotions lead to depression. As soon as this circle breaks through, the patient can begin to achieve some self-control. She learns to distinguish what is happening in reality from her own ideas about what is happening.
SVT works according to specific rules. The therapist asks the patient a lot of homework: it is necessary to make lists of positive and negative experiences, sometimes they are summarized in tables. The therapist sets the agenda for each session, conducts the session in a structured manner and ends with summing up, formulating the results of today’s conversation. Circumstances and advice are deliberately withdrawn from the psychotherapist’s conversations. The moments of today that have brought pleasure to the patient are particularly highlighted, and he is instructed in the art of bringing emotional pleasure into his life. The patient should keep a sharp eye on his perception process in order to stop in time when he begins to turn towards negative images, and switch it to a less dangerous system of images. All this activity is combined into a system of exercises. SVT teaches self-awareness.
I did not study SVT, but I learned some of its lessons. If you feel that laughter attacks you in a conversation, you can refrain from it by directing your mind to some sad subject. If you find yourself in a situation where you are expected to have sexual feelings that you don’t really have, you can direct your mind to a fantasy world that is very far from the reality you are experiencing, and then your actions and the actions of your body can take place in some artificial reality, and not in your current one. This is the strategy underlying cognitive therapy. Catching yourself thinking that no one will ever love you or that your life is meaningless, you should reorient your mind and evoke memories, even the most fleeting, of better times. It is difficult to fight with one’s own consciousness: in this struggle there is no other tool than consciousness itself. Just call up sweet thoughts, sweet, pleasant thoughts, and they will smooth out your pain. Think about what you don’t want to think about. Let it be a scam and self-deception, but it works. Banish from your memory the people who are associated with your loss — close their access to your consciousness. A mother who leaves you, a rude lover, a hated boss, an unfaithful friend-lock them away. It helps. I know what thoughts and worries can kill me, and I am very careful with them. For example, I think about those I once loved, and I painfully feel their physical absence; I know that I must get away from these thoughts and worries, and I try not to evoke too many memories of the happiness that once was with us, and now has long passed. I’d rather take a sleeping pill than let my thoughts wander freely around painful topics while I’m lying in bed and trying to sleep. Like a schizophrenic who is told not to listen to voices, I drive away these images.
I once met a woman who survived the Holocaust; she spent more than a year in Dachau, and her entire family died in the camp before her eyes. I asked her how she coped, and she said that from the very beginning she realized that if she allowed herself to think about what was happening there, she would go crazy and die. “I decided —” she told me — ” that I would think only about my hair, and all the time that I spent in this place, I thought only about it. I thought that someday I would be able to wash them. I thought I should try combing them with my fingers. I was thinking about how to behave with the guards so that they wouldn’t shave my head. I spent hours fighting with lice infested everywhere. It gave my mind a point of concentration over which I could have at least some control, and it filled my thoughts, so that I could isolate myself from the reality of what was happening to me, and so I went through everything.” This is how the principle of SVT can be taken to the extreme in extreme circumstances. If you can direct your thoughts to certain images, it can save you.
When I first met Janet Benshoof, she inspired me with a sense of awe. A brilliant lawyer, she was a leading figure in the fight for the right to abortion. This is a very impressive person by any measure: well-read, with a beautiful speech, attractive in appearance, witty, without pretensions. She asks questions with the air of a person who knows how to accurately determine the truth. Extremely restrained, she talked about the depression that had plunged her into the dust. “My achievements are like a whalebone in a corset that allows me to stand straight, without them I would be lying in a heap on the floor,” she says. “Sometimes I do not know who or what exactly they support, but I am sure that this is my only defense.” She underwent a large course of behavioral therapy with a specialist who dealt with her phobias. “Well, let’s say, the fear of flying is one of the strongest,” she explains. – Imagine, this psychotherapist flew with me on planes and watched. I was sure that I would run into someone I hadn’t seen since school; next to him is a fat man whose shirt is falling apart at the seams, and I would have to say: “This is my therapist, we are training to fly on airplanes.” But I have to admit, it worked. We went through everything I was thinking about, minute by minute, and everything changed. Now I no longer have panic attacks on the plane.”
Cognitive behavioral therapy is widely used today and seems to show significant results in depression. Personality-oriented psychotherapy, a treatment regimen developed by Gerald Klerman from Cornell University and his wife Mirna Weissman from Columbia University, also looks extremely effective. IPT focuses on the immediate reality of everyday life. Instead of developing an all-encompassing scheme that explains the entire personal history, it makes an ongoing “repair”. It is not about transforming the patient into a deeper personality, but about teaching him to extract the best from what he has. This is a short-term treatment with clearly defined limits and restrictions. It proceeds from the fact that many depressed people have stress factors in their lives that are either a trigger or a consequence of depression, and they can be “cleaned up” with the help of well-thought-out communication with others. The treatment takes place in two stages. At the first stage, the patient is taught to understand his depression as an externally caused ailment and is informed about the degree of the disorder. All its symptoms are analyzed and called. The patient assumes the role of the patient and determines what the improvement process means for him. He makes a list of all his connections and acquaintances, and then, together with the therapist, determines what each of them gives him and what he wants from them. The therapist works with the patient, working out the best ways to get what he needs in life. The problems are divided into four categories: what causes suffering; mismatch of roles in relationships with family and close friends (for example, between what you give and what you get in return); stressful changes in personal or professional life (for example, divorce or job loss); isolation. Then the therapist and the patient set several real goals and decide how much time they will work to achieve them. IPT lays out your life in front of you in honest, clear terms.
In depression, it is important not to completely suppress your feelings. It is equally important to avoid heated arguments and expressions of indignation. You should stay away from negative emotional behavior. People, of course, forgive, but it is better not to bring things to a state where forgiveness is required. In depression, a person needs the love of others, however, depression contributes to actions that kill this love. Depressed people often stick pins in their own lifebuoys. Man is not helpless: he has consciousness. Quite soon after coming out of the third depression, I was having dinner with my father, and he said something that upset me; suddenly I heard how shrill my voice was becoming and how harsh my words were, and I was terribly alarmed. I noticed a shadow of disgust on my father’s face. Then I took a deep breath and after a tense pause said:
- I’m sorry. I promised that I would not shout at you and speculate on my fortunes — and I could not restrain myself. Sorry.
It sounds sentimental, but the ability to turn on consciousness really changes everything. A witty friend told me, ” For two hundred dollars an hour, I would expect my psychiatrist to change my family and leave me alone.” Unfortunately, this does not happen.
Although both SVT and IPT have many specific advantages, any treatment is good only to the extent that the doctor is good. Your therapist means more than the therapeutic system you have chosen. A person with whom you are deeply connected can probably help seriously just by chatting with you in an informal setting; a person with whom you are not connected in any way will not help, no matter how sophisticated his methods are and no matter how numerous his diplomas are. The most important thing here is intelligence and insight; the form in which he communicates his deep vision, and the way in which he obtains it, are secondary. In a 1979 study, it was shown that any form of therapy that meets certain criteria can be effective: if the psychotherapist works in good faith; if the client believes that the psychotherapist understands the treatment method; if the client sympathizes with the psychotherapist and respects him; if the psychotherapist is able to build mutual understanding relationships. The experimenters chose professors of English who have these qualities and this level of understanding of people, and found out that they were able to help patients no worse than professional psychotherapists.
“The mind cannot exist without the brain, but the mind can influence the brain. This is both a practical and metaphysical problem, the biology of which we do not understand,” says Elliot Valenstein, professor emeritus of psychology and neurology at the University of Michigan. Empirical can be used to influence the physical. As James Ballenger of the Medical University of South Carolina says, “psychiatry changes biology. Behavioral psychotherapy changes the biology of the brain — maybe in the same way as drugs.” Some cognitive therapy methods that are effective in anxiety conditions reduce the level of metabolism in the brain, and also — in a mirror image — pharmaceutical treatment methods reduce the level of anxiety. This is the principle of action of antidepressants: by changing the content of certain substances in the brain, they change the patient’s well-being and behavior.
Most of what happens in the brain during a depressive episode is still not subject to manipulation from the outside. Research on the drug treatment of depression focuses on one thing — the effect on neurotransmitters, mainly because we know how to influence them. Since scientists know that lowering the level of known neurotransmitters can cause depression, they work on the assumption that increasing the level of these same neurotransmitters can relieve depression — and indeed, chemicals that increase the content of neurotransmitters often serve as effective antidepressants. It would be comforting to think that we know the relationship between neurotransmitters and the state of mind, but we do not know them. It seems that the mechanism here is indirect. People with a lot of neurotransmitters “scurrying” in their heads are no happier than people with fewer neurotransmitters. Depressive people, as a rule, do not have a reduced level of neurotransmitters at all. Adding serotonin to the brain does not bring immediate benefits; if you force people to consume more tryptophan (an amino acid found in a number of foods, including turkey, bananas and dates), which increases the content of serotonin, it also does not immediately help, although there is evidence that reducing the intake of tryptophan with food can worsen depression. The current popular focus on serotonin is naive at best. As Stephen Hyman, director of the National Institute of Mental Health, says — rather dryly — “There is too little modern neurology in this serotonin “porridge”. We have decided not to hold a Serotonin Recognition Day yet.” Under normal conditions, neurons produce serotonin, and then they are absorbed again to produce it again. Selective serotonin reuptake inhibitors (SSRIs) block the absorption process, thereby increasing the content of free serotonin in the brain. Serotonin is a widely distributed substance in nature: it is found in plants, in lower animals and in humans. Its functions are represented as diverse, changing from type to type. In humans, this mechanism is one of the controlling constriction and expansion of blood vessels. It is involved in the process of blood clotting. It is involved in inflammatory reactions. It affects the digestion. He is directly involved in the regulation of sleep, depression, aggression and suicidal tendencies.
Antidepressants take a long time to cause tangible changes. Until a depressed patient experiences the real result of changes in the level of neurotransmitters, it takes from two to six weeks. This indicates that the improvement is associated with those parts of the brain that respond to changes in the level of neurotransmitters. There are many theories in use today, and none of them is exhaustive. The most fashionable until recently was the theory of receptors. There are a number of receptors in the brain for each neurotransmitter. When the level of this neurotransmitter increases, the brain needs fewer receptors, because the neurotransmitter is more than enough for all existing receptors. When the level of this neurotransmitter decreases, the brain needs more receptors to absorb every drop of the available neurotransmitter. So, an increase in the level of neurotransmitters will lead to a decrease in the number of receptors and allow cells that acted as such to retrain to perform other functions. However, recent studies have revealed that the retraining of receptors does not take much time, in reality they can change within half an hour after changing the level of neurotransmitters. Thus, the receptor theory does not explain the time delays in the action of antidepressants. Nevertheless, many researchers are of the opinion that gradual changes in the structure of the brain are responsible for the delayed reaction to antidepressants. Apparently, the effect produced by drugs is indirect. The human brain is amazingly plastic. Cells can retrain and change after an injury, they can “learn” completely new functions. When the level of serotonin rises, the number of serotonin receptors decreases, other events occur in other parts of the brain, and what is happening downstream must be correcting the imbalance that initially caused you to feel bad. These mechanisms, however, are decidedly unknown to anyone. “There is a direct effect of the drug, leading to a kind of black box, about which we know nothing,” says Allan Fraser, dean of the Department of Psychopharmacology at the University of Texas at San Antonio. – The same results are obtained from an increase in the content of both serotonin and norepinephrine. Do they lead to two different functional black boxes? Or in the same black box? Or does the first lead to the black box, and the second leads to another place?”
“It’s like putting a grain of sand in an oyster so that it turns into a pearl,” says Stephen Hyman about medication antidepressants. “Adaptation to the altered mediators comes slowly, giving a therapeutic result over the course of weeks.” Elliot Valenstein adds: “Antidepressants are specific in a pharmacological sense, but not in a behavioral one. The chemistry of any drugs is extremely specific, but God knows what is going on in the brain.” William Potter, who headed the psychopharmacological department of NIMH in the 70s and 80s, and now has left for the pharmaceutical company Eli Lilly to work on the creation of new drugs, explains this as follows: “There are several mechanisms that produce an antidepressant effect; drugs with sharply different spectra of biochemical activity actually give very similar results. They agree on something that you don’t expect at all. Very similar antidepressant effects can be obtained through the serotonin and norepinephrine systems, and in some patients through dopamine. It’s like the weather. Somewhere there is some event that causes the wind speed or humidity to change, and the weather becomes completely different, but even the best meteorologists cannot say with certainty what change affects what exactly.” Is it significant that most antidepressants suppress the sleep stage with rapid eye movement, or is this a side effect that is irrelevant? Is it important that antidepressants usually lower the brain temperature, which in depression tends to rise at night? It is only clear that all neurotransmitters interact and each affects the others.
The results of experiments on animals are imperfect, but their study can give a lot of useful information. Monkeys separated from their mothers in infancy grow up psychotic: their brain becomes physiologically different, it produces much less serotonin than in monkeys who grew up with their mothers. Repeated periods of separation from mothers cause an increase in the level of hydrocortisone in a number of animals. Prozac reverses these processes. If you put a dominant male from one marsupial colony into another group where he does not dominate, he will react with weight loss, reduced sexual activity, sleep disorders and all other symptoms of severe depression. If you increase his serotonin level, he may well have a remission of these symptoms. Animals with low levels of serotonin are prone to bully other animals, they expose themselves to unnecessary and inexplicable risks, show gratuitous hostility. Examples of the effects exerted on animals by external factors and serotonin levels are highly informative. A male monkey who rises in the hierarchical structure of his group shows an increase in serotonin levels as the rank increases, and a high level of serotonin is associated with reduced aggressiveness and suicidality. If such a male is isolated, deprived of his status in the group, his serotonin will decrease even by 50 %. Taking selective serotonin reuptake inhibitors (SSRIs), he will become less aggressive and less prone to self-destructive actions.
Currently, there are four classes of antidepressants. The most popular SSRIs are those that increase the content of serotonin in the brain. Prozac, Luvox ,Paxil, Zoloft and Celexa are all SSRIs. There are two older types of antidepressants. Tricyclic antidepressants (or simply tricyclics), so named for their chemical structure, affect serotonin and dopamine. These include elavil( Elavil), anafranil( Anafranil), norpramin (Norpramin), tofranil (Tofranil) and pamelor (Pamelor). Monoamine oxidase inhibitors (MAOI) inhibit the breakdown of serotonin, dopamine and norepinephrine. These include Nardil (Nardil) and parnate (Parnate). The fourth category, atypical antidepressants, includes drugs that work in several neurotransmitter systems simultaneously: asendin, wellbutrin, Serzone and effexor.
The choice of specific medications is usually based, at least initially, on side effects. There is hope that one day we will find a way to test patients ‘ reactions to certain drugs, but so far we do not know how to do this. “With rare exceptions, the scientific basis for choosing a specific antidepressant for a particular patient is not rich,” says Richard A. Friedman of the Payne-Whitney Clinic at Cornell University. — The past reaction to this medicine predicts well the future reaction to the same medicine. And if you have a special subtype of depression — atypical depression, in which you eat or sleep too much-MAOI will help you more than tricyclics, although most clinicians still use more modern drugs in this case. That’s all the possibilities — choose a drug with the smallest set of side effects. Sometimes you decide to give an activating drug like wellbutrin to a person who is too self-contained, or a sedative to someone who is very excited, but that’s all, and then-a trial and error method for each patient. The annotations will tell you that one drug is more likely to give some side effects than another, but my clinical practice shows that within each class, the overall level of side effects from one drug to another varies little. But the difference in the reaction of individual people can be very pronounced.” The current huge popularity of SSRI-class drugs — the “prozac revolution” – is explained not by their higher efficacy, but by a smaller set of side effects and safety. Taking them, it is almost impossible to commit suicide, and this is an important consideration in the treatment of depressive patients, who may be inclined to self-destruction during recovery. “Prozac is a very gentle medicine,” says one scientist from Eli Lilly. Limited side effects mean not only greater willingness of people to take medications, but also more accurate adherence to the regime. The principle is the same as for toothpaste: if it tastes good, maybe you will brush your teeth longer.
Some people taking SSRI have upset stomachs, there are separate reports of headache, feeling intoxicated, insomnia and drowsiness. Their main side effect is the suppression of sexuality. “When I was taking prozac,” my depressed friend Brian D’Amato told me — ” Jennifer Lopez herself could have appeared at my bedside in a sarong, and I would have asked her to help me sort papers.” Tricyclics and MAOI also have negative side effects in the sexual sphere. Since these drugs, which dominated the market until the end of the 80s, are more often used for severe depression, against the background of which side sexual effects look like a minor inconvenience, their suppression of erotic sensations did not cause such an intense and wide discussion as in the case of SSRI. Studies conducted at the time of the introduction of prozac revealed a limited number of patients who reported negative sexual effects. In subsequent studies, when patients were specifically asked about sexual problems, the vast majority confirmed them. Anita Clayton from the University of Virginia divides a sexual event into four stages: desire, arousal, orgasm and relaxation. Antidepressants affect all four. Desire is weakened by a reduced libido. Arousal suffers due to reduced sexual desire, blunted genital sensations, impotence or lack of vaginal lubrication. The orgasm is delayed; some people completely lose the ability to do it. The picture is confused by the fact that these effects are irregular: today everything goes fine, and tomorrow you are impotent, and it is impossible to predict what will happen tomorrow until you act. If there is no desire, no excitement, no orgasm, the relaxation phase, of course, loses its meaning.
Sexual side effects on the background of severe depression are often dismissed as insignificant, and by these standards they are really insignificant. Nevertheless, they are unacceptable. One patient I interviewed told me that he could not achieve orgasm during sexual intercourse, and described the difficult process of refusing medications for a long enough period to make his wife pregnant. “If I hadn’t known about the terrible consequences of refusing medications,” he said, ” I wouldn’t have used them at all. Where are you, my sexy Self — how good it is to get it back for a few days! I wonder if I will ever be able to have an orgasm with my wife again?”
When you start to get out of depression, your head is occupied with too many ideas, and sexual inferiority does not particularly care, but later… overcoming unbearable pain at the cost of giving up erotic pleasure? No, this is a lousy deal for me. In addition, this is also an excuse not to follow the regime, which is perhaps the biggest problem in the treatment of depression. Less than 25 % of those taking antidepressants survive for six months, and many quit them because of the side effects associated with sex and sleep.
As soon as sexual side effects occur, anxiety about sexuality begins, and then erotic contacts can become moments of failure, exacerbating the problem; under this pressure, people can develop a psychological aversion to sexual contact, which makes the symptoms worse. Most men with potency problems suffer from depression; eliminating impotence may be enough to reverse depression. To isolate sexual problems characteristic of deep psychology, which could lead a person to depression, is important and at the same time difficult, as Clayton notes; sexual problems as a result of depression (99% of people with severe depression in an acute form report sexual dysfunction) and sexual problems as a result of treatment with antidepressants. Clayton insists on the need for tactful, but rigorous examination of patients for sexual problems.
It is believed that many substances resist the side effects of sexual antidepressants: there are serotonin neutralizers, for example, ciproheptadine and granisetron (cyproheptadine and granisetron); alpha-2 neutralizers of the yohimbine and trazodone type (yohimbine and trazodone); cholinergic neutralizers, for example, bethanechol; dopamine enhancers, such as bupropion, amantadine and bromocriptine (bupropion, amantadine and bromocriptine); autoreceptor neutralizers — buspirone and pindolol (buspirone and pindolol); stimulant drugs-amphetamine, methylphenidate and ephedrine( amphetamine, methylphenidate and ephedrine); herbal drugs — Chinese ginkgo and L-arginine (ginkgo biloba and L-arginine). A short break in taking medications — usually for three days-sometimes gives positive results. Sometimes a change of medications helps to increase libido. None of these drugs have shown much effectiveness, but they give something, depending on the patient. One woman, whose story is given in this book, something monstrous happened when she was prescribed a whole “constellation” of such drugs, including dexedrine: she had such a sharp surge of libido that it became physically difficult for her to sit out daily meetings at work. It got to the point that she began, completely contrary to her usual behavior, to have sex with strangers in the elevator. “I could come three times between the eighth and fourteenth floors,” she said. — I stopped wearing underwear because it took too long to take it off. The guys thought that they were doing something unthinkable — it’s embarrassing for me, but I think I raised many of them self-esteem. But it couldn’t go on like this. I am essentially a reserved person, as befits a white Anglo-Saxon Protestant. I’m not that young. I wasn’t ready for all this.” Small adjustments reduced her sexual arousal to a manageable level. Unfortunately, the same drugs did not help my other friend at all: “I wouldn’t have had an orgasm if I’d been stuck in an elevator with a young Montgomery Clift for four hours,” she told me sadly.
Injections of testosterone (male sex hormone) in order to increase its amount in free form in the body may have some effect, but they are difficult to control, and their effect is not fully understood. The brightest ray of hope is Viagra. Due to its psychological and physical effects, it seems to have an effect on three of the four Clayton stages; the only thing that it does not cope with is the stimulation of libido. As a secondary effect, it can help a person restore confidence in their sexual abilities, and this helps to relax, which, in turn, is useful for libido. It is hoped that the dopamine activators currently being developed will take care of this side of the matter, since dopamine seems to be strongly involved in the libido mechanism. With regular use, viagra also restores a nocturnal erection in men, which antidepressants often suppress. This also has a positive effect on libido. Some people suggest that men who live on antidepressants take viagra every night as a therapeutic tool, even if they do not have sex every time after taking it. In fact, it can serve as a fast-acting and effective antidepressant: a high level of sexual function, like almost nothing else, improves the state of mind. Research conducted by Andrew Nirenberg from Harvard and Julia Warnock from the University of Oklahoma shows that viagra, although not officially approved for women, has a positive effect on their sexuality and can promote orgasm. This is partly due to the fact that, thanks to the influx of blood, it increases the clitoris. Hormone therapy is also good for women with sexual dysfunctions. An increase in the level of estrogen helps to improve mood, and a sudden drop in its level can be disastrous. A drop in the level of estrogen by 80 %, which occurs in women during menopause, has a pronounced effect on the state of mind. Women with low estrogen levels develop a variety of ailments, and Warnock emphasizes that before Viagra can have a beneficial effect, it is necessary to normalize the level of estrogen. The level of testosterone in women should not be raised too much, so as not to cause excessive hair loss and aggressiveness, but this hormone is necessary for female libido, and it also needs to be maintained at the proper level.
Tricyclic antidepressants are included in the work of several neurotransmitter systems, including acetylcholine, serotonin, norepinephrine and dopamine. Tricyclics are especially useful for severe depression, in particular, with hallucinations. The suppression of acetylcholine has a number of unpleasant side effects, such as dry mouth and eyes, constipation. Tricyclics can also have a slight sedative effect. The use of tricyclics by patients with bipolar disorder can plunge them into a manic state, so they should be prescribed with extreme caution. SSRI and bupropion can also turn on mania, but with less probability.
MAOI are especially indicated when depression is accompanied by acute physical symptoms — pain, energy decline, sleep disturbance. These drugs block the enzyme that breaks down adrenaline and serotonin, thereby increasing the level of these substances in the body. MAOI are excellent drugs, but they have many side effects. Patients taking them should avoid a number of foods that cause harmful reactions. They can also affect some functions of the body. One patient who gave me an interview received a complete urinary retention as a result of using MAOI: “To urinate, I almost had to run to the hospital every time, and this is not very convenient.”
Atypical antidepressants are exactly like this: they are atypical. Everyone has their own incomprehensible mechanism of action. The effector affects both serotonin and norepinephrine. Wellbutrin affects dopamine and norepinephrine. Asendin and serzon work in all these systems. Now it is fashionable to try so-called “pure” drugs — those that have a narrowly focused effect. “Clean “drugs are not necessarily more effective than “dirty” ones, their specificity may to some extent be related to the control of side effects; in general, the impression is that the more you study the brain, the higher the probability of effective treatment of depression. “Pure” drugs are developed by pharmaceutical companies that extol sophisticated chemical delights, but in the therapeutic sense, such drugs are not distinguished by anything outstanding.
The results of using antidepressants are unpredictable, and they can not always be preserved. Nevertheless, Richard Friedman says: “I do not believe that complete failure happens as often as it is reported. As a rule, I think it is necessary to adjust the dosage or “dilute” the drug. Psychopharmacology is a complex art. And many of those who do have a complete failure simply lose the placebo effect, which is usually short-lived.” Well, many patients really experience only temporary relief from medications. Sarah Gold, who has suffered from depression all her adult life, experienced a complete remission from wellbutrin — but only for a year. Then an effector brought a similar effect, but it also disappeared in about eighteen months. “People began to notice this. I rented a house on shares with other people, and one woman told me that I have a black aura and that she can’t be in the house at the same time as me, even when I’m in my room behind a closed door.” Gold started taking a mixture of lithium, zoloft and ativan; now she is on anafranil, celex, Risperidal (Risperdal) and ativan; she is ” less energetic, does not feel completely safe, but is able to cope.” Maybe none of the currently available medications will be able to give her a stable remission, as they are given to some, and a person who is forced to constantly be on medication, such rushing from one solution to another is very demoralizing.
A number of drugs, such as buspar, which acts on certain nerve structures that are sensitive to serotonin, are used for long-term control of anxiety. There are also fast-acting drugs, benzodiazepines — the category of which includes klonopin, ativan, seduxen and xanax. Halcion and Restoril, prescribed for insomnia — are also benzodiazepines. These medications are taken as needed to immediately relieve anxiety. However, the fear of addiction has led to a serious restriction in the use of benzodiazepines. These are miraculous medicines for short-term use, during periods of acute anxiety, they can make life bearable. I have met people torn apart by mental torments that could be eliminated if their doctors were more tolerant of benzodiazepines, and I remember how my first psychopharmacotherapist told me: “If you get used to it, we will be able to wean you off. In the meantime, let’s ease your suffering.” Most people who take benzodiazepines develop a habit and become addicted: this means that they will not be able to stop abruptly and immediately, but they will not have to increase the dose to maintain the therapeutic effect. “With these drugs,” says Friedman, ” drug addiction is a problem mainly for those who already have a history of abuse. The risk of addiction to benzodiazepines is greatly exaggerated.”
In my case, xanax made my horror disappear like a hare magician. While the antidepressants I was taking worked slowly, like the dawn coming, shedding light on my personality and allowing it to step out into a familiar and orderly world step by step, xanax gave a huge and instant relief from anxiety — “a finger in the dam at a critical moment,” as James Ballenger, an expert on anxiety states, says. For people who are not prone to abuse, benzodiazepines often save lives. “What is known to the general public,” says Ballenger, ” is largely incorrect. The sedative effect is side — effect, and the use of these drugs as a sleeping pill is abuse, they should be used only against anxiety. Stopping taking it causes some symptoms, but this happens with so many drugs.” Benzodiazepines, although they help with anxiety, do not relieve depression by themselves. They can have a negative effect on short-term memory. Over time, they can show properties that lead to depression, and therefore they can be taken for a long time only under the careful supervision of a doctor.
Since my first visit to a psychopharmacotherapist, I have been continuing to “play” with medications for seven years. For the sake of my mental health, I lived, in different combinations and different dosages, on such drugs as zoloft, paxil, navan, effexor, wellbutrin, serzon, buspar, ziprexa, dexedrine, xanax, ambien and viagra. I was lucky: I was well affected by drugs of the same class with which I started. Nevertheless, I can personally testify to the hell of experiments. Trying different medications, you feel like a target for a game of darts. “Depression is curable these days,” they tell me. “You take an antidepressant, like you take aspirin for a headache.” This is not true. Depression can be treated these days; rather, you take an antidepressant, like radiation for cancer. Sometimes they work wonders, but it’s never easy, and the results are unstable.
I haven’t been through a full-fledged hospitalization yet, but I know that someday I may need it. Usually in the hospital you are offered medications and / or electric shock. However, one of the components of treatment is the hospitalization itself, the vigilant attention of the staff, structures designed to protect you from destructive or suicidal impulses. Hospitalization should not be a last resort to save a desperate person. It should be one of the means, along with others, and it should be considered as an option as necessary, if only your insurance allows it.
Now researchers are working in four directions in search of new treatment methods. The first is to shift the focus to prevention as much as possible: the sooner you identify a mental illness of any kind, the better for you. The second direction is to increase the specificity of drugs. There are at least fifteen different serotonin receptors in the human brain. There is evidence that the effect of antidepressants depends on only a small number of them, and many of the bad side effects of SSRI are probably related to others. The third direction is to fast-acting drugs. The fourth is the movement towards greater specificity in relation to symptoms, and not to a specific biological state, in order to abolish experimentation in the choice of drugs. If we discover, for example, some labels that allow us to identify genetic subtypes of depression,it will become possible to find specific means for these subtypes. “Existing drugs,” says William Potter, a former NIMH employee, ” work too indirectly for us to manage them well.” Apparently, this kind of specificity will continue to elude us. Disorders of the mental state are accompanied not by a single signal from a single gene, but by many genes, and each brings its own small element of risk, and each is activated by external circumstances, creating a total vulnerability.
The most successful physical method of treating depression is the least pure and specific of all. Antidepressants are effective in about 50 % of cases, maybe a little more, electric shock has a significant effect in 75-90 % of cases. Half of those whose condition has improved from electric shock still feel well after a year, but the other half requires repeated courses or regular maintenance sessions. ECT works fast. Many patients begin to feel better after just a few days of using electric shock — a boon, especially valuable in comparison with the long, slow process of drug treatment. ECT is especially suitable for suicidal patients who often cause themselves bodily injuries, whose situation is therefore urgent: it is precisely because of the speed of exposure and the high therapeutic susceptibility of patients that it is used for pregnant women, physically ill and elderly people. ECT, unlike most drugs, does not have systematic side effects and problems of interaction with other drugs.
After the usual blood tests, cardiograms, fluorography and checks related to anesthesia, patients who are recognized as suitable for ECT sign a form giving their consent to the procedures; the form is also presented to their families. On the evening before the session, the patient does not eat anything; he is connected to a dropper. In the morning, he is escorted to the ECT office. After connecting the patient to the monitors, the medical staff lubricates his temples with gel and connects the electrodes: for unilateral ECT to the non — dominant hemisphere, usually the right one — this is the preferred method to start with-or, for bilateral, to both. Unilateral ECT has fewer side effects, and recent studies show that it is just as effective as two-hemisphere ECT. The doctor conducting the therapy also makes a choice between a sinusoidal wave form (alternating current), which gives a more stable stimulation, and a rectangular (direct current), that is, short pulses that give convulsive paraxisms with fewer side effects. Through an intravenous infusion, the patient is put into a state of short — term general anesthesia, which completely turns him off for ten minutes, and also gives a drug for muscle relaxation to prevent physical cramps (the only movement during the session is a slight wiggling of the toes, unlike the ECT of the 50s, when patients rushed and inflicted injuries on themselves). The patient is connected to electroencephalographic and electrocardiographic devices to constantly scan the heart and brain. Then a second shock causes temporal and occipital paraxism, lasting about thirty seconds-enough to change the chemistry of the brain, but not enough to fry the gray matter. The shock energy is usually about two hundred joules, which is equivalent to a hundred-watt light bulb; most of it is absorbed by the soft tissue and the skull, and only a tiny fraction reaches the brain. After ten or fifteen minutes, the patient wakes up in the postoperative ward. In most cases, the course consists of ten to twelve sessions in six weeks. Increasingly, ECT is performed on an outpatient basis.
The writer Martha Menning described her depression and the course of ECT in a charming and surprisingly funny book “Undercurrents” (Undercurrents). Now her condition is stable — she takes wellbutrin, a small dose of lithium, depakot, klonopin and zoloft. “To look at them is like holding a rainbow in your hands,” she jokes. “I am like an indefinite practical task in chemistry.” She dealt closely and for a long time with ECT during the most difficult moments of her depression. She signed up for therapy the day she found the address of the nearest firearms store, intending to shoot herself. “I wanted to die not because I hate myself, but because I love myself so much that I want to stop this suffering. Every day I leaned against the door of my daughter’s bathroom and listened to her sing — she was eleven years old, and she always sang in the shower — and this was an incentive not to try another day. I didn’t care about anything, but suddenly I realized that if I took out and used a gun, I would stop this child’s song. I’ll make her mute. That day, I signed up for ECT, as if saying “I give up” to the opponent who put me on the shoulder blades. The treatment lasted for weeks: after each session, you wake up with a hangover, ask for a diet Coke and feel that it will be a day on tylenol.”
ECT really disrupts short-term memory and can affect long-term memory. These disorders are usually temporary, but some patients have a permanent memory defect. I met a woman who was a practicing lawyer, and after the ECT course she remained without the slightest trace of the law school in her memory. She could not remember what she had studied, where she had studied, or with whom she had studied. This is an extreme and rare case,but it also happens. ECT is also associated with a fatal outcome — according to one study, in about one case out of ten thousand, usually due to cardiac problems after procedures. Whether these deaths are a coincidence or a consequence of ECT is not entirely clear. Blood pressure during ECT really increases significantly. ECT does not seem to cause physiological damage; indeed, Richard Abrams, the author of a fundamental work on ECT, describes a patient who underwent 1,250 ECT sessions, whose brain, when she died at the age of 89, turned out to be in perfect condition. “There is no evidence — and almost no probability — that ECT, as it is used now, is capable of causing brain damage,” he writes. Many of the short-term side effects — including unsteadiness in the legs and nausea-are caused not by the ECT itself, but by the anesthesia used for it.
ECT still bears the stigma. “You really feel like a Frankenstein on this table,” says Manning — ” and people don’t want to hear about it, no one will bring you food bowls when you pass the ECT. It’s very isolating from the family.” On a speculative level, this can also be traumatic for the patient. “I know that it works,” says an employee of the healthcare system. — I’ve seen how it works. But when I think about losing this dear memory of my children, of my family — I, you know, have neither parents nor a husband. Who will find this memory for you? Who will tell you about the past? Who will remember the special recipe for a pie that we baked fifteen years ago? Not being able to dream will only play into the hands of my depression. It is the memories, thoughts of past love that help me to live the day.”
On the other hand, ECT can be miraculous. “Before, every sip of water was like backbreaking work for me,” says Menning — ” And after the ECT, I thought: do normal people feel like this all the time? It’s as if you haven’t understood the humor in a brilliant joke all your life.” At the same time, the results usually come quickly. “The vegetative symptoms went away, then my body became lighter, then I really wanted a big mac, “says Manning.” I felt like I was hit by a truck some time ago, but it was, comparatively speaking, not so bad.” Manning is atypical. Many people undergoing electroshock therapy resist the idea that it is useful, especially if they were struck by temporary memory loss or if their life was restored gradually. Two of my friends took ECT at the beginning of 2000. Both reached the limits-unable to get out of bed and get dressed, always exhausted, ominously negative in the perception of life, without interest in food, unable to work, with a suicidal mood. Both of them were electroshocked, first the first, and a few months later — the second. The first experienced a serious and obvious memory loss — he was an engineer and now did not remember how the electrical circuit works. The second one came out in the same gloomy state in which she came, because she was still besieged by real life problems. The engineer’s memory began to return after three months, and by the end of the year he was able to get up and go out, returned to work and functioned normally. He said it was ” probably a coincidence.” The second repeated the course, despite the conviction that the first one did not help her. After the second series of sessions, her personality began to return, and by the fall she already had not only a new job, but also a new apartment and a new man. She continued to claim that ECT was doing more harm than good, until I finally suggested to her that the memory that ECT had erased from her was the memory of what she used to be. When Menning’s book was published, pickets of protesters against “electronic brain management” lined up at her presentation readings. In many US states, ECT is prohibited by law; the treatment methodology is subject to speculation; this therapy is not for everyone, it can not be used en masse or without the full consent of the patient, but it can be miraculous.
Why does ECT work? We don’t know. It seems that it strongly activates dopamine and affects other neurotransmitters as well. Maybe it affects the metabolism in the frontal cortex. High-frequency currents seem to increase this exchange, low-frequency ones-lower it. Of course, we do not know whether depression is one of the symptoms of hypometabolism (low metabolism), and agitated depression is a symptom of hypermetabolism (increased metabolism), or both depression, and both of these metabolic disorders are derivatives of some other change in the brain. ECT temporarily lowers the blood-brain barrier  . The effect of ECT is not limited to the frontal cortex; the electric charge temporarily affects even the functions of the brain stem.
I decided not to give up medicine. I am not sure that I have a drug addiction, but I definitely have a certain addiction: without them, I am at risk of developing symptoms of the disease. The line here is thin. I gained an obscenely large weight. I have strange urticaria for no apparent reason. I’m sweating more. My memory, and always not very strong, is somewhat damaged; I often forget what I’m saying, right in the middle of a sentence. I often have a headache. Sometimes it cramps the muscles. Sexual urges come and go, sexual function is unstable; orgasm is now an event for me. It’s not perfect, but it looks like a wall has been erected between me and depression. The last two years were undoubtedly the best in a decade, now everything is gradually getting better for me. Two of my friends had recently died, both in stupid disasters; I was terribly sad, but I did not feel my Self slipping out of my hands: to feel just grief was a kind of (I know it sounds terrible, but in some selfish sense it is true) almost satisfaction.
The question of what functions depression performs in this world inhabited by us is not exactly the same as the question of what function antidepressants are preparing to perform. James Ballenger, an expert on anxiety states, says: “We are twenty centimeters taller than we were before the Second World War, and much healthier, and we live longer. No one complains about these changes. When you eliminate one cause of unhappiness, people go out into life and find something new, both good and bad.” And this, I think, is the real answer to the question that everyone has asked me, to whom I have just mentioned this book: “Aren’t medications emptying your life?” No. On the contrary, they allow me to suffer for really significant reasons and reasons.
“We have twelve billion nerve cells,” says Robert Post, head of the department of biological psychiatry at the National Institute of Mental Health. — And each of them has from a thousand to ten thousand chromosome conjugations, and all of them change at a significant rate. We are still very, very far from getting them to work properly, so that all people constantly feel completely happy.” James Ballenger says: “I don’t feel that the level of suffering in the universe has decreased significantly with all our improvements, and I don’t think that we will reach a tolerable level in the foreseeable future. Full control of the brain should not occupy our thoughts at the moment.”
“Normal” is the word that haunts the depressed. Is depression normal? I have read in studies about “normal” and “depressive” groups; about medications that can “normalize” depression; about “normal” and “atypical” sets of symptoms. One person I met while conducting this study said: “At first, when these symptoms appeared, I thought I was going crazy. It was a great relief to find out that it was just clinical depression, and in general I am normal.” Indeed, it was a completely normal way to go crazy: depression is a mental illness, and when you are in its grip, you are stupid as a stump, you are crazy, you are not all at home, there are not enough balloons, the roof is going…
At a cocktail party in London, I met a friend and mentioned that I was writing this book.
“I was terribly depressed,” she said. I asked her what she had done for the occasion. “I didn’t like the idea of taking medication,” she replied. — I realized that my problem is related to stress. And I decided to remove everything that causes stress from my life—” — I quit my job. I broke up with my boyfriend and didn’t really look for anyone else. I moved away from a friend and now I live alone. I stopped going to parties if they last late. I rented a smaller apartment. I left most of my friends. I gave up, by and large, cosmetics and good clothes. I looked at her in horror. — It doesn’t sound very attractive, but I’m actually much happier and less afraid than before. She was obviously proud of herself. — And without any medications.
Someone standing next to her grabbed her arm:
— This is pure madness! This is the craziest thing I’ve ever heard of! Are you crazy to do this to your life!
Is it crazy to avoid behaviors that make you crazy? Or is it madness to take medication in order to be able to maintain a life that makes you insane? I could put my life in a lower category — doing less, traveling less, knowing fewer people, not writing books about depression — and maybe if I changed all this, I wouldn’t need medication. I could lead a life within the framework in which I can withstand it. This is not what I have chosen for myself, but it is undoubtedly one of the reasonable choices. Living with depression is like trying to maintain balance while dancing with a goat — it would be extremely reasonable to prefer a partner with a better sense of balance. And yet the life I lead, complex and full of adventures, brings such great satisfaction that I hate the very idea of giving it up. I hate her more than anything else. I would rather triple the number of pills I take than halve my circle of friends. Unabomber , whose methods of presenting his Luddist sentiments were disastrous, but his insights into the dangers of technological civilization are quite solid, wrote in his manifesto: “Imagine a society that puts people in such conditions that they are deeply unhappy, and then gives them drugs to eliminate their unhappiness. Science fiction? This is already happening…By their action, antidepressants are a means of changing the internal state of an individual in such a way as to make him able to tolerate social conditions that he would otherwise consider unbearable.”
When I first observed clinical depression, I did not recognize it; in fact, I did not even notice it. In the summer after the first year of college, my friends and I spent time at my parents ‘ country house. With us was my good friend Maggie Robbins, the charming Maggie, always sparkling with energy. In the spring, she had a manic breakdown, and she was in the hospital for two weeks. Now she seems to have recovered. She no longer uttered crazy words about finding secret information in the basement of the library or about having to go to Ottawa on the train like a hare, so we all thought Maggie was mentally healthy; her long periods of silence that summer were meaningful and deep, as if she had learned to weigh her words. It was strange that the girl did not bring a swimsuit with her — and only years later she told me that without clothes she felt naked, vulnerable, unprotected and was afraid of this feeling. We all, as sophomores should, had fun and frivolously splashed in the pool. Maggie, on the other hand, was sitting on the diving platform in a calico dress with long sleeves and, with her knees pulled up to her chin, watched our fun. There were seven of us; the sun was hot, and only my mother said (to me alone) that Maggie looked extremely reserved. I had no idea how hard Maggie tried not to give the slightest hint of what she was overcoming in herself. I didn’t notice the dark circles that were under her eyes-I learned to look for them later. I remember, however, how we all teased her that she didn’t swim and missed all the fun, until finally she stood at the end of the springboard and dived headfirst down as she was, in a dress. I remember how her heavy clothes stuck to her body when she swam to the end of the pool and then walked, all wet, to the house, and the water dripped from her on the grass. It was a few hours before I found her in the house — she was asleep. She didn’t eat much at dinner, and I decided that either she didn’t like the steak, or she was saving her figure. It is curious that I remember this weekend as a happy time, and I was shocked when Maggie described her experiences at that time as an illness.
Fifteen years later, Maggie suffered the worst depression I have ever met. Her doctor, showing amazing incompetence, had said shortly before that after fifteen quite prosperous years, she could try to stop taking lithium, as if there had been a cure and her severe bipolar disorder had evaporated. Maggie gradually lowered the dosage. She felt great: she lost weight, her hands finally stopped shaking, some of the old energy that filled her when she first told me that her life’s goal was to become the most famous actress in the world returned. Then she began to feel quite inexpressibly beautiful. We all asked if she was afraid that she was becoming a little manic, but she assured us that she hadn’t felt so good in years. That should have said it all: feeling so good is not good at all. Rather, everything was very bad. Less than three months later, Maggie decided that God was guiding her, and her mission was to save the world. One of the friends took matters into his own hands and, unable to get through to her psychiatrist, found another, and Maggie was put back on medication. In the months that followed, she collapsed into depression. The following fall, she entered graduate school. “Graduate school gave me a lot; to begin with, it gave me time, a place and a loan for two more depressive breakdowns,” she joked. In the second semester, she had a mild hypomanic episode, then a mild depressive one; at the end of the fourth, she soared to complete mania, and then collapsed into a depression so deep that it seemed bottomless. I remember her curled up in a tight ball on the sofa in our friend’s apartment, shuddering as if bamboo chips were being driven under her nails. We didn’t know what to do. It was as if she was speechless; when we finally squeezed a few words out of her, they were barely audible. Fortunately, her parents had thoroughly studied bipolar disorder over the years, and that evening we helped her move in with them. That was the last thing we were going to hear from her for two months: she lay in a corner, not moving for several days in a row. I already knew depression myself and wanted to help her, but she did not pick up the phone and did not receive visitors, and her parents were knowledgeable enough to give her free rein in her silence. With the dead, and then I had a closer communication. “I will never allow this to happen again,” she has told me since then — I absolutely refuse to tolerate it.”
Maggie is fine now – on depakot, lithium and wellbutrin, and although she keeps xanax ready, she hasn’t needed it for a long time. She no longer takes klonopin and paxil, as at first. But he will take medications constantly. “I had to cultivate humility in myself to say:” Well, well, probably many people who decided to take medications are the same people as me, who never intended to depend on medications for anything, under any circumstances. And then they agreed, and it helped them.” She writes and draws, and during the day she works as an editor in some magazine. She doesn’t want a more responsible job. From work, she needs some kind of confidence in the future, some kind of medical insurance and a place where she does not have to constantly shine. When she is sad — or angry — she writes poems about a certain alter-ego that she invented for herself and named Susie. She has poems about manic state and about depressive:
Someone is standing in the bathroom, staring into Susie’s eyes.
Someone whose appearance and voice Susie doesn’t recognize.
Someone who lives in the mirror.
Someone with a round face that cries and cries.
Susie’s skull is stuffed tight, something is pounding there.
Susie’s teeth are wobbly.
Susie’s hands are shaking and barely moving, covering the glass with soap foam.
In the summer, Susie studied knots. Susie doesn’t know how to tie a noose.
Susie feels the veil being lifted.
Susie hears the veil being torn.
And then the truth lies before her, pinned, naked and tossing, awakened, battered.
The pangs of hunger — that’s all we know for sure.
Everything that is given to us at birth.
“When I was eight years old,” she says, ” I decided that I was Maggie. I remember standing in the school hallway and saying, ” You know, I’m Maggie, and I’m going to be Maggie forever. Here I am, the one I will always be. I’ve been different because I can’t remember some moments of my life, but from now on I’m Maggie.” And so it turned out. It was a sense of self-determination. Now I am the same person. I can look back and say: “My God, why did I do this stupid thing at my seventeen years old?” But it was me. My Yane is continuous.”
To always maintain a sense of Self in the storms of manic-depressive psychosis is evidence of great strength. Maggie had periods when she wanted to free herself from this consistent Self. In this terrifying, stupefying depression, she says, ” I was lying in bed, endlessly singing “Where are all the flowers, where are all the flowers” to occupy my thoughts with something. Now I realize that I could have taken other medications or asked someone to come and spend the night in my room, but I was too sick to think about it. I didn’t know what I was so afraid of, but I was ready to explode with anxiety. I sank lower, and lower, and lower. We changed medications, and I kept diving. I believed the doctors; I always accepted as a fact that I would someday get back to normal. But I couldn’t wait, I couldn’t even live through the next minute. I kept singing to drown out what my mind was telling me, and that’s what it was: “Do you know who you are? You don’t even deserve the right to live. You’re worthless. You will never become anyone. You are nobody.” That’s when I really started thinking about suicide. I had thought about it before, but now I started planning. I was imagining my own funeral almost all the time. While I was living with my parents, I had a detailed picture of myself climbing out on the roof in my nightgown and falling down. There was an alarm on the door leading to the roof, I turned it off, but it didn’t matter; I would have jumped off before anyone could have reached it anyway. It was impossible to take risks, it was necessary to act for sure. I even chose a nightgown in which it is more convenient to do all this. But then some fossil remnant of self-respect would wake up and remind me how many people would be sad if I did this. It was impossible to take responsibility for so many man-hours of sadness, and I had to admit suicide as aggression against others.
I think that I suppressed a considerable part of the memories of this. I can’t remember everything; and I don’t need to, because it’s pointless. I remember some rooms in the house, and how bad it was for me there. I also remember the next phase, when I was constantly thinking about money. I start to fall asleep and suddenly wake up in alarm — I couldn’t drive it away in any way. There was no reasonable explanation for this: at that time I was not in any financial trouble. And I thought: what if in ten years I won’t have enough money? And this state of anxiety had nothing to do with the fear and anxiety that I experience in normal life. They were different not only quantitatively, but also qualitatively. All in all, it was a terrible time. Finally, I was smart enough to change doctors, and I was prescribed xanax. I took half a milligram or so and felt a giant hand on my hips, a palm squeezing my sides, holding my fingers on my shoulders. Then this hand pushes me into the bed about five centimeters. Then I finally fell asleep. I was scared to death to get used to it, but the doctor assured me that I would not get used to it — my dose was far from sufficient for this — and even if I did, he would wean me when I could cope with life better. Well, all right, I decided, I won’t think about it, I’ll accept it, and that’s it.
When you are depressed, you don’t think that you have been put on a gray veil and you look at the world through a veil of heavy mood. You think that the veil has been removed from you — the veil of happiness — and now you see everything in its true light. You try to grasp the truth and deal with it, and you think that the truth is something fixed, and it is alive and moving. It is possible to cast out demons from schizophrenics who feel something alien inside themselves. But it is much more difficult with the depressed: we believe that we are seeing the truth. But the truth lies. I look at myself and think: “I’m divorced,” and it seems terrible. Whereas I could think: “I’m divorced” – and rejoice in my freedom. During all this time, only one remark helped me. My friend said: “It won’t always be like this. Try to remember this. This is only now the case, but it will pass someday.” And she also said: “It says depression. Depression speaks to you.”
The most affordable remedies for depression are psychotherapy and medications, but faith has helped many people cope with the disease. Human consciousness can be considered as enclosed between the sides of a triangle: theological, psychological and biological. It is infinitely difficult to write about faith, because it operates with the invisible and indescribable. In addition, in the modern world, faith tends to be highly personal. Nevertheless, religion is one of the main ways to get along with depression. Religion provides answers to questions that have no answers. As a rule, it cannot bring a person out of depression; moreover, even deeply religious people find that when they are in the depths of depression, their faith becomes thinner and disappears. However, it can hold the defense against the disease, and this helps to survive in bouts of depression. This gives an excuse for life. There is much in religion that allows us to see suffering as something praiseworthy. In our helplessness, it gives us dignity and purposefulness. Many of the tasks of cognitive and psychoanalytic therapy are solved by the systems of views underlying the main world religions — refocusing energy on something outside of oneself, awareness of the need to take care of oneself, patience, and breadth of understanding. Faith is a great gift. It provides a person with many advantages of close relationships without depending on the whims of another, although, of course, God is also famous for his quirks. The deity completes our intentions, even if contrary to our plans. Hope is a powerful prevention, and it is faith that gives hope.
In depression, you survive by believing in life, which is as abstract as any system of religious beliefs. Depression is the most cynical thing in the world, but it also gives something like faith. To stand up and remain yourself means to make sure that what you did not have the courage to hope for may turn out to be true. Faith, like romantic love, has a certain drawback: it is fraught with disappointments. For many people, depression is an experience of rejection by God, a feeling of abandonment by Him, and many who have experienced depression say that they cannot believe in any God who treats his children so callously. For the majority of believers, such resentment against God passes along with depression. If faith is your norm, you return to it, as you return to any norm. The systems of organized religion lie outside the sphere of my upbringing and experience, but it is difficult for me to dismiss the feeling of some kind of interference that characterizes our ups and downs. All these are too deep states to occur without the participation of God.
Science resists a close study of the relationship between religion and mental health, mostly for methodological reasons. “When it comes to such things as meditation or prayer, where can I find a suitable standard for the “double-blind” method  ? Stephen Hyman, director of the National Institute of Mental Health, asks. — Is he praying to the wrong God?” This is the fundamental problem of testing the therapeutic value of prayer.” A priest, among other things, is also a more accessible option for a psychotherapist. The priest Tristan Rhodes told me how for several years he was busy with a woman suffering from depressive psychosis, who refused psychotherapy, but confessed every week. She told him her stories; then he shared essential information with a psychiatrist friend; then he told her what the psychiatrist had told him. In the most literal sense of the word, she received psychiatric help in a religious environment.
For Maggie Robbins, faith and illness coincided in time. She became a very pious parishioner of the High Episcopal Church  . She regularly goes to church: for vespers on weekdays, for the liturgy on Sundays, and sometimes for two services (one to receive communion, the other just to listen), a Bible circle on Mondays and a full variety of parish activities the rest of the time. She is on the editorial board of the parish magazine, teaches at the Sunday school, paints the backdrops for the Christmas performance. She says: “You know, Fenelon  wrote: “Suppress me or exalt me — I worship all Your thoughts.” Quietism may be heresy, but it is the central tenet of my faith. You don’t have to understand what’s going on. I used to think that we should do something with life, even if it is meaningless. It is not meaningless. Depression makes you believe that you are worthless and should die. How can I answer this, except by another faith?” Nevertheless, when Maggie Robbins was in the worst phases of depression, religion did not help her much. “When I was getting better, I remembered:” Oh, yes, religion, why didn’t I call it to help?” But it wouldn’t have helped at the bottom of the well.” Nothing would have helped. Evening prayer calms her down and helps to keep the chaos of depression in check. “It’s such a powerful help —” she says. — You get up and say the same prayers every night. Someone has decided that you will tell God, and others also say it with you. The divine service, the biblical texts and especially the Psalter are like the wooden frame of a box where my experiences, my inner experience are stored. Going to church is a set of exercises for training attention, promoting you spiritually.” This sounds pragmatic: apparently, we are not talking about faith, but about structuring time, and this can be achieved with the same success with the help of aerobics classes. Maggie admits that this is partly true, but denies the gap between the spiritual and the utilitarian. “I have no doubt that it is possible to reach the same depths in another religion, and completely outside of religion. Christianity is just one of the models. When I discuss my religious experience with a psychotherapist and my experience of psychotherapy with my confessor, both models show great similarities. My confessor recently said that the Holy Spirit is constantly using my subconscious! With the help of psychotherapy, I learn to build up the boundaries of my ego; in the church, I learn to drop them and become one with the whole universe, or at least a member of the Body of Christ. I will learn to build boundaries and discard them until I can do it with the same ease, ” and she snaps her fingers.
“According to Christian teaching, you are not allowed to commit suicide, because your life does not belong to you. You are the guardian of your life and your body, but they are not given to you for destruction. You don’t have to fight inside yourself; you think that you are fighting shoulder to shoulder with other actors, with Jesus Christ, and God the Father, and the Holy Spirit. The church is an external skeleton for those whose inner skeleton has been corroded by mental illness. You build yourself into this skeleton, adapt to its shape, and already inside it you build up your spine. Individualism, separation from the rest of the world, distorts modern life. The Church teaches that we must act first as members of our community, then as members of the Body of Christ, and finally as members of humanity. Of course, this is not quite in the American spirit of the XXI century, but it is important to me. I agree with Einstein: humanity lives in an “optical illusion”, believing that everyone is isolated from others, from the rest of the material world, from the entire universe, while we are all inseparable parts of it. Christianity for me is an experience of what real love consists of, useful love, and an understanding of real attention and care. People think that Christianity is the enemy of pleasure, and this is sometimes true; but it is a great supporter of joy. You are striving for a joy that will never go away, no matter how much you suffer. But, of course, you still experience suffering. I asked the priest when I wanted to commit suicide: “What is the purpose of this suffering?” and he replied: “I hate phrases that contain the words suffering and purpose at the same time. Suffering is only suffering. But I really believe that God is with you, although I doubt that you can feel it in any way.” I asked him how it could be put into the hands of God, and he said, ” What does it mean to betray, Maggie? It is already in His hands.”
Another friend of mine, the poet Betsy de Lotbinier, also had difficulties with faith during the depression, and for her faith was the main path to recovery. Being in a deep depression, she says: “I naturally hate my mistakes, but when I lose tolerance, I lose generosity and hate the world and the mistakes of others; as a result, I want to scream, because there are spilled coffee, and stains on the carpet, and dry leaves, and parking tickets, and people who are late and do not answer the phone. There is nothing good in this. Soon the children will start crying, and if I ignore this, they will calm down and become very obedient, which is even worse, because the tears will now be inside. They have fear in their eyes, they are very quiet. I stop hearing about their secret grievances, which are so easy to smooth out when everything goes well. I hate this kind of myself. Depression is sinking me lower and lower.”
She grew up in a Catholic family and married a deeply religious Catholic. Although Betsy does not go to church as regularly as he does, she turned to God and to prayer when she felt that reality was slipping away from her, and saw how despondency was destroying the joy of communicating with children in her, and the joy of life in them. But she did not adhere to Catholicism alone — she tried 12-step programs, Buddhist meditation, walking on coals, visiting Hindu temples, studying Kabbalah — everything that looked like spiritual. “Praying in a moment of anxiety or an inadequate reaction is like pulling a ring and opening a parachute that will not allow you to crash into a brick wall with all your strength; it is a fast and terrible fall in which your entire emotional body will collapse —” she wrote to me when I myself had a difficult time. – Prayer can become a brake for you. Or, if your faith is strong enough, prayer can become your accelerator, your sound signal, sending information to the universe about which direction you want to move in. This idea-to stop and look inside yourself-exists in one form or another in most religions, hence the kneeling, the lotus position, and prostration. They also have movements designed to push aside everyday life and reconnect with the great ideas of Being — hence the music and rituals. To get out of depression, you need both. People with at least some faith, while they have not yet reached the devastating darkness of primordial Chaos, have a way back. The main thing here is to find a balance in the darkness, and this is where religions can help. Religious teachers have a rich experience in bringing people to spiritual stability along well-trodden paths leading out of darkness. If you are able to build a balance with external support, then maybe you will be able to achieve balance within yourself. And then you are free again.”
Most people can’t get out of a really serious depression by fighting alone; serious depression needs to be treated, or it can go away on its own. But while you are being treated or waiting for it to pass, it is necessary to fight. To take medicines as part of the strategy of this battle is to fight fiercely, and to refuse them is as ridiculous and self — destructive as entering a modern war on horseback. Taking medication is not a weakness and does not mean that you cannot cope with your personal life; it is a manifestation of courage. It is not a weakness to seek help from a knowledgeable psychotherapist. Faith in God and any form of self-belief is beautiful. You must involve all methods of treatment in the fight. You can’t wait to be cured. “Work should be healing, not empathy. Work is the only radical cure for ingrained sorrows, ” wrote Charlotte Bronte. Work is not all that is needed for healing, but only it brings healing. Happiness itself can be a great work.
Nevertheless, we all know that work as such cannot bring joy. The same Charlotte Bronte writes in “Villette”: “No nonsense in this world is so empty for me as the one when they tell me to cultivate a state of happiness. What does this instruction mean? Happiness is not a potato to plant in the ground and fertilize with manure. Happiness is the Glory that shines on us from the heavenly heights. It is the Divine dew, and the soul, in some of its summer morning moments, feels how this dew descends on it from the amaranth flowers and the golden fruits of Paradise. “Cultivate a state of happiness —” I immediately replied to the doctor. — Do you cultivate? And how do you manage it?” Luck plays a significant role, it accidentally sprinkles us with this dew of happiness. Some people respond well to one treatment, others to another. Someone goes into remission spontaneously after a brief struggle. Someone does not tolerate drugs and can achieve a lot in conversations with a psychotherapist, and someone, having spent thousands of hours on psychoanalysis, gets relief from the first pill. Someone pulls himself out of an attack with the help of one means, only to immediately fall into the next breakdown, which requires a completely different one. Someone has a persistent depression that does not let go, no matter what they do. Someone has frightening side effects from any treatment, and someone does not experience the slightest inconvenience from the most frightening therapy. Maybe the time will come when we will learn to analyze the brain and all its functions and will be able to explain not only the origin of depression, but also the reasons for all these differences. I wouldn’t wait for this with bated breath. While the court is on the case, we must accept as a fact that fate has given us a great vulnerability to depression, and that among those who suffer from such vulnerability, there are people whose brain responds to treatment, and those whose brain resists it. Those of us who are getting much better in any sense, no matter how terrible our breakdowns are, should count ourselves among the lucky ones. Moreover, we must treat those for whom there is no recovery with patience. Resistance to external influences is a common, but not a universal gift, and no secret, even from this book, or from anywhere else, will help the most unsuccessful of all.