Shopping cart

Show cart
   

QUARTERLY ESSAY 18 The Worried Well

 

Correspondence

Guy Rundle

In a world where kids are routinely dosed with amphetamine variants to change their behaviour, and thousands upon thousands of people are persuaded that their misery is a “disease” unrelated to their lives or the society they live in, Gail Bell’s essay is a fantastic demolition job – and all the more powerful for the manner in which it combines front-line experience with reflection and scholarship. 

As I read it, Bell’s argument is that the key causes of the whirlwind of antidepressant prescription are to be found in a range of commercial and ideological practices. Bell describes how Merck fashioned the idea of undetected depression around its first antidepressant drug in the 1950s, to create an illness (and has continued doing so ever since). The tricylics became staples of GP-prescribing in the ’60s and ’70s at the same time as a culture of individualism and personal fulfilment developed – thus the second major cause became the widespread belief that one had a “right to be happy”. As neurology developed and SSRIs entered the market, the markers and understanding of self as depressed (rather than “miserable” or “blue”) became widespread, and people began presenting to GPs with implicit and explicit demands for drugs. GPs, by now overwhelmed with such patients and with limited capacity to offer counselling or referral, became increasingly likely to resort to prescribing such drugs – even when they knew that the cause of such moods was probably transient emotional exhaustion. Eventually they too, and pharmacists like Bell herself, found their thinking colonised by the physicalist model implied by the drug companies – depression was overwhelmingly a product of a neurochemical imbalance. 

Bell is not an anti-psychiatrist in the manner of Szasz, nor is she a stiff upper lip depression-denialist. But my impression is that that she believes that the modern condition of depression is overwhelmingly a constructed one – made by corporations and then patients out of a mix of the raw materials of eternal conditions such as melancholia. Antidepressants have a place, because we would not want to deny people the free choice to use whatever works, but it would be better if people could pursue the cures offered by someone such as Burton in the Anatomy of Melancholy – living well, taking care of ourselves with food, wine, sleep, friends. 

In arguing that a lot of what is self-labelled depression can be treated by living better, slowing down and other non-prescription pursuits, Bell has my complete agreement. Nevertheless, in diagnosing the causes of the antidepressant phenomenon I think Bell has missed a whole level of social life and social process, and that the absence of such an account makes it impossible for her to formulate a decisive answer to the question posed by “Angie”, the troubled, Zoloft-taking, Foucault-reading 22-year-old whose encounter with Bell at a party provides the kick-off point for the essay. At the conclusion, Bell can only say in response to Angie’s existential concerns about taking such drugs, that sometimes we need to do so – a non-conclusion that indicates that the essay has not got at the key questions about depression and drugs. 

Let me suggest an alternative interpretation of the current spread of the depression diagnosis. Much of what is currently called “depression” is a new and real social-psychological disorder, produced by widespread transformations of Western societies in the past three decades. In response to these transformations – in shorthand, the media revolution, and the changes to work and home life, and social space and culture – many of us have become more vulnerable to the onset of feelings that selfhood, existence and connection to others have been pulverised, and that meaning and contentment are not only absent, but impossible. Depression and melancholia have existed throughout modernity and before, but a widespread low-grade depression has now become an existential common cold. Yet it is not simply an ennui – it is a more deeply rooted state that differs from a condition such as “the blues”. In some cases (but only some) it produces a real neurochemical change in the subject. In many others it simply produces a view of self as hopelessly miserable – but many such people often latch onto a neurochemical explanation because it offers a simple, quick and physicalised explanation for what would otherwise be interpreted as social failure. 

Depression, as an experience and as a social object, is separated from misery by its categorical nature. The depressive cannot remember the feeling of being cheerful or purposeful, cannot imagine the circumstances by which one would become so, or by which one would feel connected to another human being, and so on. Everything has slipped through the floorboards – the world (in the sense of a meaningful place, a field of purpose), the self (in the form of a loss of desire) and others (the internalised presence of loved ones). This is more or less a cultural universal – almost every culture has a term for “sadness without object or without end”. 

Yet such experiences are much rarer in traditional cultures, and even in more closely knit and stable modern cultures, than in our own. Why would this be? My suggestion is that in many lives, we see a comparative absence of the structures that shape a stable, meaningful existence. Even a few decades ago, most people lived within much closer networks of kin and neighbourhood. Obviously this was often constricting and frustrating, but it was also the guarantor of a certain sense of real identity, grouped around extended family, clan, neighbourhood, congregation, union, association, whatever. The identity of being X’s son, daughter, wife, husband, a fitter and turner, a Methodist of St Mark’s parish, etc., was, in other words, both internal and external. Not only was one connected to others, one was recognised and known by them – and they by you. A certain minimum, rock-solid selfhood was guaranteed by these relationships, as was a world of relatively stable meaning, mediated by symbols and ceremonies, ethnic, religious, national or otherwise. 

Of course such a world was often prejudiced and stifling, a point to which I’ll return. But a solid and meaningful existence was, in effect, a firebreak on sadness. Because one’s worth and self were not dependent on a self-made trajectory of success, career, power and the like, there was less capacity for bad events and disappointments to become all-consuming annihilations, negations of self. 

In the past few decades we have swept those social networks away as comprehensively as we have many of the physical neighbourhoods they dwelt in. Much of this has had a positive dimension – people get an education, mobility, travel, befriend and marry outside their ethnicity and so on. But such a world places an extraordinary burden on the individual, since they must increasingly make their own networks and worlds of meaning. Recognition – the sense that we are known and of worth to others – must be earned, and that raises the possibility that we will fail to earn it, and that that failure will be unmitigated. At the same time as this is going on, economic changes – the demolition of the manufacturing base in particular – have reduced the number of places where people can find permanent work and stable workplaces. As the mediating institutions fall away, the individual finds that there is nothing between them and the entire world – now coming in their headset/console as a plethora of images of, increasingly, power, wealth and celebrity. Such images increasingly become the “others” that people – especially adolescents – internalise. By definition they cannot provide a stable world of meaning, nor can they offer reciprocal recognition.

The result is a society whose principal purpose, it can seem, is to make as many people as possible feel like shit as often as possible. All the time. When people have felt like shit for long enough, they go to their GP. By this time they have felt like shit for so long that the psychological factors may – in some cases – have caused physiological changes. When the prescribed antidepressants kick in – in the second to third week of regular use (serotonin levels are elevated immediately by SSRIs, but it takes weeks for knock-on processes, such as re-regulation of cortisol levels, to occur) – the depressed person feels a basic sense of life they had forgotten was possible – the sensuous particularity of the world, and desire within it. Others benefit from the social effect of being medicated: the pill gives hope, evidence of care by another, absolution from failure and the renewed sense of specialness (“I’m a depressive!”) necessary to a functioning ego. 

The question is this: have we created a society in which large numbers of people – even when they are in society – do not really feel of it? In the midst of cities, jobs, study, they are more exposed to bad times that can readily tumble into a permanent sense of malaise and reduced energy. We have assumed that human nature, being transformable, is infinitely so – that there is no social-psychological cost to living in a hi-tech, high-mobility world. If antidepressants have any effect above that of a placebo (and we may eventually find that they don’t), it is because we are “hard-wired” for a form of social life which involves reciprocity and mutual recognition, and the prolonged absence of that will have a neurochemical effect. 

If that is the case, then antidepressant medication is not properly understood as a treatment for a disease. Rather it is a crude chemical biotechnology designed to re-engineer humans in line with the needs of a global market society. This may explain the paradoxical side effects of “happy pills” – the creation of anxiety and suicidality. Since the physical is only one level of the psychological make-up of a human being, the energy inserted at the physical level can come into conflict with an untransformed unhappiness felt at the level of self. The antidepressants may give people either the energy to feel shriekingly, energetically alarmed about their distress (anxiety) or the strength to do something once and for all about the fact that they still feel worthless, futile and alone. 

If that is the case – and such an argument builds on the insights of a whole tradition of social commentary by writers such as Riesman, Sennett, Fromm and writers from the Arena group – then Bell, with the best of motives, has misread the social process that is occurring, and placed too much emphasis on the surface ideological effects of the Prozac revolution – the profit-driven nature of Big Pharma, the mechanistic understanding of the human being advanced by many GPs and psychiatrists. Hence she is at an impasse when confronted with someone who both feels better because of the drugs, but guilty or worried at the undermining of authenticity created by them. The cultural problem is not that SSRIs don’t work, but that they do.

For many GPs and health professionals, however, there is no problem. They have identified an effective remedy for contemporary problems – certainly one that is more effective than either the “stiff upper lip” school, various forms of psychotherapy, or the idea of living well. 

However, the problem is that the widespread use of such medicines undermines the cultural framework – the network of social meaning – that it seeks to reintroduce its users to. Like it or not, SSRIs transform the emotional meaning of life events. They’re not tranquilisers – they don’t even things out to blandness – but they do provide a certain level of chemically supplied enthusiasm which would not otherwise be there. If one person within a group is thus reconstituted, it is of no great import. But what if two are? What is the status of a conversation between two chemically altered subjects? Or a whole group of people? And what happens if successive generations of these drugs become more effective at s(t)imulating certain types of emotional response? 

It should be clear that at some point in that scenario the meaning of social life drains away. If I can never know whether the laugh or the smile of the other is because of their relationship to me and the meaning of what I have said to them, or whether it is because molecule BX11185G is playing on receptor site DC9122Z, and if they cannot know the same about me, then what is the meaning of our exchange, or our relationship? Once the chemical transformation of emotional life crosses a certain threshold, then that question becomes a central one. The result eventually is a collapse of trust, connection and meaning. Eventually the chemical stimulation of emotion would cease to work, because the emotional webs it sought to counterfeit were no longer there. 

Take, by way of example, the figure of Angie, whom Bell introduced. She is not-untypical – humanities-educated, ambitious to take a place in the cosmopolitan global world, eager for an experience of depth (else why would she study philosophers and theorists), yet seemingly crushed by both some violence in her past and a sense of the world’s indifference (“I’m not going to commit suicide. I haven’t made my mark on the world”). Zoloft enables her – or she believes it does – to acquire some of the personality traits necessary to making her mark – a degree of energy and confidence which will get her to New York, where she “falls in love with a skyline”. When she gets there, like as not, she’ll meet people very much like her – on or off various combinations and versions of antidepressants and anti-anxiolitics. What is going on when a bunch of people from around the world are having a conversation, and they’re all on an antidepressant? Is anything happening at all? Or, in the pursuit of difference has she simply encountered a mass-produced sameness? In looking for an experience of depth has she come into a more superficial experience? The journey to New York was – as all such journeys are – not just about what one sees, but about what one becomes, about individuation. Yet if the prerequisite for “becoming” is to use a chemical to bypass some of one’s fears and anxieties, what has one become? And once again, if that can be got away with on an individual basis, what happens to the meaning of experience when a significant number of people are doing it?

Such concerns are usually labelled as science-fictive by the enthusiasts for chemical alteration. Taken in isolation, they are. A range of new miracle pills are, of themselves, not going to turn us into autonomous emotional zombies. However, there are two key qualifications to make about that. The first is that, in areas of social life where antidepressant use has become so widespread as to be dominant, it has, I believe, contributed to a cultural change – in particular, to a higher degree of atomisation and emotional solipsism. There are other factors in this, but mood control pills contribute to a wilful dissociation from social life – from seeing what one is as connected to what one does, or is a part of. The second caveat is that the current generation of pills are so crude in effect that they do not, of themselves, have the capacity to more exactly reprogram the brain. But with the rise of genetic medicine (as Bell notes) future generations of drugs may allow for a much greater hi-tech manipulation of one’s emotional states. Whether or not that sounds like something from a Philip K. Dick novel, it is worth starting to think about what sort of effect it would have on a culture. 

What many people want to avoid by using antidepressants is the process of reflection and rethinking by which one’s fears and dark areas are reclaimed, and by which authentic relations with others are built. And who can blame them? Our culture – especially in the last five to ten years – has become one in which strength, aggressiveness, selfishness and hardness have become the cardinal virtues. The hard-bodied ethos of the gym, the competitive nature of contractual and outsourced work, the visibility of enormous wealth, the surgically enhanced standards of beauty, and the theme of social-life-as-competition (à la Big Brother) have become central motifs. Even in areas of public emotional life – pop music, TV shows like Oprah – the “touchy-feely” content is frequently subsumed under the idea of shaping oneself for maximum success. Part of this is an inheritance of the individualistic strands of the ’60s and ’70s (the “me” decade), but these ideas have been substantially transformed – the introspective and pastoral dimension of the “me” decade has been discarded (thus Angie rejects psychotherapy by describing it as “live your dream”-style blather) and the individual self-shaping has been fused with the cultural and economic imperatives of neo-liberalism. This is one step on from “greed is good” – it is not money per se, but power, recognition and the capacity to “make a mark” that one shapes oneself towards. What could be more self-defeating than to detour via the introspection and self-disassembling of therapy? What could be worse than to admit that something is wrong? 

So where does that leave us? On the basis that the indefinitely expanding use of mood-modifying drugs is culturally contradictory, we can suggest an ethos for chemical therapies that gives one something more to say than Bell’s comment that a younger generation finds the contradictions easier to live with. We could say, for example, that in most (but not all) cases one should try to avoid chemical antidepressants until one has thoroughly explored the reasons for the feeling – with or without some form of guided psychotherapy. There is something inherently pointless about making such pills one’s first (or second) resort if one’s aim is to explore the deep experiences of life that might be offered by the writings of Foucault or a city such as New York. 

At the same time we can say that there is a chemical dimension to our emotional lives, and that chemical solutions are much better as a later, or last, resort than as an earlier one. An extreme humanist response – never use antidepressants – is silly and futile, given what we know about the relationship between self and brain. And there are cases – people with a family history of bipolar disorder (manic depression), for example – where it is reasonable to try chemical solutions much earlier, because the condition itself can be reasonably supposed to be genetic in origin, and part of a relatively autonomous neurological process. It is also possible (though more hypothetical) that victims of sustained violent child sexual abuse have been “neurologically scarred” by traumatic events that occurred at a time when the brain was still in development and that some – but not all – such people may require some mood stabilisation prior to trying to work through problems and issues at the psychological level. The point is that all such suggestions – tentative and exploratory as they must be – are a product of our developing understanding of the self–brain relationship. Rather than throwing up our hands and treating these as insoluble contradictions, or thinking wishfully about a pre-scientific world of “melancholia”, we have to take the opportunity science offers to come to a fuller understanding of what it is to be human, and build a relatively complex ethos of psychiatry on its foundations. 

Of course this will often fall on deaf ears. You only live once, and many people feel an urgent existential demand to “get a life”. Who wants to be told that they should try to work and think through their problems? Even the argument for psychotherapy is of limited use since some forms of it – psychoanalysis, for example – take people further in the direction of individualising a cultural problem, rather than out towards the world. Psychotherapy – and more general sources of social understanding, such as high-school level social studies – should incorporate a more critical social dimension which helps people to understand the rapid manner in which everyday life is being transformed, and the degree to which issues of power, media and community have a role in forming selfhood. The current depression “epidemic” is a social symptom of a wider cultural problem, rather than a particular effect of more superficial commercial practices and ideologies. 

 

Guy Rundle is an executive producer of ABC Arts. For many years he was the co-editor of Arena magazine. He is also the writer of political satires performed by Max Gillies and of Quarterly Essay 3, The Opportunist: John Howard and the Triumph of Reaction, published in 2001.

CONTINUE READING

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.


ALSO FROM QUARTERLY ESSAY

Peter Hartcher
Waking Up to China’s Challenge
Annabel Crabb
Australia’s Parenthood Trap
Erik Jensen
How Scott Morrison won and Bill Shorten lost
Rebecca Huntley
Listening to the Nation
Sebastian Smee
The Inner Life in the Digital Age
Laura Tingle
Democracy and the Rise of the Strongman