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QUARTERLY ESSAY 18 The Worried Well

 

Correspondence

Elizabeth A. Wilson

“Worried well” is a term of disdain. It has become a common way of dismissing the distress experienced by a significant sector of the community, and it does little to help us understand what is at stake – politically and psychologically – in the current psychopharmaceutical climate. Much of the rhetorical strength of Gail Bell’s analysis follows from the distinction she makes between the seriously depressed and those “with the sort of normal sadness that afflicts us all, the people with low-level sorrow”. In the first group, Bell asks us to imagine a twenty-something woman who self-harms, or a withdrawn and suicidal teenager who doesn’t leave his bed. These are the people for whom antidepressants were invented, Bell claims; and there is no question in her mind that these disabling conditions warrant pharmaceutical intervention. On the other hand, we have the worried well. These are the people who have fallen victim to less significant worries – falling out of love or becoming stressed at work. A psychiatrist might categorise these kinds of ills as dysthymia (chronic, low-level sadness). Bell is much less convinced that the worried well require the level of pharmaceutical treatment they have been receiving (mainly from GPs) since the introduction of Prozac in the late 1980s. 

While the category of the worried well may be intuitively appealing, it is extraordinarily unhelpful for analysing the nature of depression and for thinking about its treatment. Distinctions between the deserving and undeserving depressed profoundly underestimate the psychological, and indeed physiological, issues at stake. That there are different kinds of depression is not in dispute. Depressions can be major, bipolar, post-natal, dysthymic, acute, seasonal, fatal. They can manifest with or without psychotic features, with or without the co-morbidity of trauma, an eating disorder, indefinite detention or cancer. Bell seems less interested in the heterogeneity of depressive experience than she is in demarcating a particular subgroup of depressives (the worried well), and then withdrawing empathy and the justification for pharmaceutical treatment from them. 

Bell suggests that the phrase “worried well” comes from Freud. It does not. But what she may be thinking of is a widely circulated quote from Freud, in which he advises that the best psychoanalysis can do is to turn acute misery into everyday unhappiness. Let me quote Freud fully – as I think attention to the detail may enable us to find a way past Bell’s rhetorical, political and (worst of all) moral demarcations. In 1895, at the very end of his Studies on Hysteria, Freud writes:

When I have promised my patients help or improvement by means of a cathartic treatment [the precursor to psychoanalysis proper] I have often been faced by this objection: “Why, you tell me yourself that my illness is probably connected with my circumstances and the events of my life. You cannot alter these in any way. How do you propose to help me, then?” And I have been able to make this reply: “No doubt fate would find it easier than I do to relieve you of your illness. But you will be able to convince yourself that much will be gained if we succeed in transforming your hysterical misery into common unhappiness. With a mental life that has been restored to health you will be better armed against that unhappiness.”

In these early years, when Freud was immersed in the treatment of hysteria, he was finely attuned to the needs of his patients. His texts, while fully medicalised, are notable for their empathic engagement with women in particular. He makes no judgment about whether or not a patient ought to be unwell. He treats every patient on her merits, and he asks us to take every affliction seriously, even those that seem petty, disagreeable or self-indulgent. Bell, in repeatedly making a distinction between those who are miserable and those who are merely unhappy, lacks this attentive eye for psychological detail. Where she is concerned that the category of depression has become too large as a result of the big pharma’s marketing and advertising, I am troubled that the category of “common unhappiness” has been expanded so that increasing levels of stress, anger, low mood and self-hatred are seen as a normal part of life. In the end, the politics and rhetoric of those who agitate against the overuse of antidepressants often feel disdainful of certain kinds of emotional distress. Put simply, the category “worried well” tends to obstruct rather than facilitate an understanding of the experience of depression. 

There is now a large body of evidence that suggests not only that drug treatments and psychological treatments of depression work best when combined, but that – more provocatively – psychological treatments have material effects on the nervous system. Freud’s work was prescient in understanding this essential intimacy of neurology and words. The choice between Freud and Prozac (to use Bell’s shorthand) turns out to be less ideologically and medically definitive than we have been led to believe in the post-war, post-Freudian, pro-pharmaceutical years of the twentieth century. Psychoanalysis and psychopharmacology are not competing ideologies of depressive malady – they are different lines of attack into the same bioaffective system. Which line of attack, for how long and at what level of intensity is an issue for each individual in consultation with their mental health practitioner and in accordance with that patient’s circumstances, anxieties and emotional preferences. It is not an issue of principle or politics that can be adjudicated in advance (and for this reason it is exceedingly difficult for those not working at the psychological coalface to know whether or not antidepressants are being over-used). The pro-Freud/anti-Freud, pro-drug/anti-drug debates that have occupied the political field since the anti-psychiatry movement of the 1960s are becoming less potent as we see growing sophistication (and increasing collaboration) in psychodynamic and psychopharmaceutical research. In the years to come, the difference between treating a depression biochemically and treating it psychologically may be less fraught than we currently suppose. With this future in mind, Bell’s call for a greater variety of resources for treating mild to moderate depression need not also be a battle cry against psychopharmaceuticals.

Perhaps most importantly of all, what Freud is advocating in his treatment of hysteria is not an acceptance of common unhappiness, but the building up of psychic robustness so that life’s misfortunes and heartbreaks can be understood and worked through. This kind of robustness is precisely what depressives (major and minor) lack. Without this psychic strength, every blow – even the smallest – is amplified in force. The damage from being battered by the quotidian events of life ought not to be underestimated. For many, many patients, antidepressants have proven themselves to be an effective bulwark against such everyday battles. Freud himself struggled for the last decades of his life, without the aid of psychopharmaceuticals, to find his emotional equilibrium and buoyancy after the death of his favourite daughter and a grandchild, the exhausting effects of professional battles, the deprivations the Great War had inflicted on those living in Vienna, and then finally the onslaught of cancer. Readers of Bell’s essay who are dissatisfied by her disregard for the harmful effects of mild depression may want to look at Peter Kramer’s new book Against Depression. Kramer (the author of the 1993 bestseller Listening to Prozac) argues that chronic low-level depression eats away at us not just psychically, but also physiologically. Far from being benign, the dysthymic complaints of the worried well register a serious attrition of psyche and nerves. There are no gains to be made from moderate depression (as Bell contemplates), and no excuses for letting it proliferate among individuals or across the culture under the romantic ideal of artistic genius, comedic spark or existential rumination. 

What we need in the public sphere is a greater empathy for what depression – even when minor – feels like, and a wider awareness of the damage it does to our emotional strength, our relationships, our bodies and our capacity to work and play. One of the things that chronic low-level depression may do is make those so afflicted unlikeable and tedious. Further distaste, elicited under the shaming rubric of the “worried well”, only makes the political and emotional challenges of dealing with depression that much harder.

 

Elizabeth A. Wilson is a psychologist and an ARC Fellow in the Research Institute for Humanities and Social Science at the University of Sydney. She is the author of Psychosomatic: Feminism and the Neurological Body.

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This correspondence discusses Quarterly Essay 18, The Worried Well. To read the full essay, subscribe or buy the book.

This correspondence featured in Quarterly Essay 19, Relaxed & Comfortable.


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