There are few conditions at once as undertreated and as overtreated as depression. People who become totally dysfunctional are ultimately hospitalized and are likely to receive treatment, though sometimes their depression is confused with the physical ailments through which it is experienced. A world of people, however, are just barely holding on and continue, despite the great revolutions in psychiatric and psychopharmaceutical treatments, to suffer abject misery. More than half of those who do seek help -- another 25 percent of the depressed population -- receive no treatment. About half of those who do receive treatment -- 13 percent or so of the depressed population -- receive unsuitable treatment, often tranquilizers or immaterial psychotherapies. Of those who are left, half -- some 6 percent of the depressed population -- receive inadequate dosage for an inadequate length of time. So that leaves about 6 percent of the total depressed population who are getting adequate treatment. But many of these ultimately go off their medications, usually because of side effects. "It's between 1 and 2 percent who get really optimal treatment," says John Greden, director of the Mental Health Research Institute at the University of Michigan, "for an illness that can usually be well-controlled with relatively inexpensive medications that have few serious side effects." Meanwhile, at the other end of the spectrum, people who suppose that bliss is their birthright pop cavalcades of pills in a futile bid to alleviate those mild discomforts that texture every life.
It has been fairly well established that the advent of the supermodel has damaged women's images of themselves by setting unrealistic expectations. The psychological supermodel of the twenty-first century is even more dangerous than the physical one. People are constantly examining their own minds and rejecting their own moods. "It's the Lourdes phenomenon," says William Potter, who ran the psychopharmacological division of the National Institute of Mental Health (NIMH) through the seventies and eighties, when the new drugs were being developed. "When you expose very large numbers of people to what they perceive and have reason to believe is positive, you get reports of miracles -- and also, of course, of tragedy." Prozac is so easily tolerated that almost anyone can take it, and almost anyone does. It's been used on people with slight complaints who would not have been game for the discomforts of the older antidepressants, the monoamine oxidase inhibitors (MAOIs) or tricyclics. Even if you're not depressed, it might push back the edges of your sadness, and wouldn't that be nicer than living with pain?
We pathologize the curable, and what can easily be modified comes to be treated as illness, even if it was previously treated as personality or mood. As soon as we have a drug for violence, violence will be an illness. There are many grey states between full-blown depression and a mild ache unaccompanied by changes of sleep, appetite, energy, or interest; we have begun to class more and more of these as illness because we have found more and more ways to ameliorate them. But the cutoff point remains arbitrary. We have decided that an IQ of 69 constitutes retardation, but someone with an IQ of 72 is not in great shape, and someone with an IQ of 65 can still kind of manage; we have said that cholesterol should be kept under 220, but if your cholesterol is 221, you probably won't die from it, and if it's 219, you need to be careful: 69 and 220 are arbitrary numbers, and what we call illness is also really quite arbitrary; in the case of depression, it is also in perpetual flux.
Depressives use the phrase "over the edge" all the time to delineate the passage from pain to madness. This very physical description frequently entails falling "into the abyss." It's odd that so many people have such a consistent vocabulary, because the edge is really quite an abstracted metaphor. Few of us have ever fallen off the edge of anything, and certainly not into an abyss. The Grand Canyon? A Norwegian fjord? A South African diamond mine? It's difficult even to find an abyss to fall into. When asked, people describe the abyss pretty consistently. In the first place, it's dark. You are falling away from the sunlight toward a place where the shadows are black. Inside it, you cannot see, and the dangers are everywhere (it's neither soft-bottomed nor soft-sided, the abyss). While you are falling, you don't know how deep you can go, or whether you can in any way stop yourself. You hit invisible things over and over again until you are shredded, and yet your environment is too unstable for you to catch onto anything.
Copyright © 2001 by Andrew Solomon
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