Emotional Choices

What story you choose to believe about antidepressants reveals a deeper truth about who you are.

Joli Jensen from the April 2004 issue

(Page 3 of 4)

We also succumb to emotive words ("depression is a disease...") and false analogies ("...to be treated like diabetes"). And we tend to over-rely on authorities ("neuro-scientists believe..."). We like to split the world in two (well or sick, normal or abnormal, functional or dysfunctional). We eagerly deploy circular reasoning ("I feel better now that I'm taking this medicine, which I'm told is treating a chemical imbalance; therefore my brain is imbalanced and I must need the medication"). Why do we fall for hokum? Shermer believes we are vulnerable to false beliefs because we want certainty, especially in an increasingly complex society.

But sorting out what is best to believe requires some heavy intellectual lifting. It requires discursive analysis, empirical analysis, and ideological evaluation. Armed with these, I can get to what counts most: the consequences of belief.

Having concluded that there are three competing discourses at issue (addiction, neuroscience, mental health), I researched the history of mental illness, drugs and drug use, and addiction treatment and recovery, as well as accounts of how wrong and dangerous the dominant perspective in each of these areas has been. The more I read, the more confusing and contradictory things became.

Were evil drug companies profiting from our need to be efficient emotional machines, brainwashing us into thinking we were mentally ill? Was the mental health industry an elaborate, expensive, debilitating sham? Was the pharmaceutical industry creating a nation of addicts for its own profit? Was the medical establishment just trying to keep patients drugged and tractable?

Or did the dramatic rise in mood medication mean that people have been, or are now, suffering depression in epidemic proportions? If so, are they fortunate to have these ways to avoid succumbing to this devastating scourge? According to this story, these medications are a boon, not a conspiracy. They empower people to recover from debilitating conditions that until now have ruined lives.

The "cosmetic psychopharmacology" perspective goes even further. It suggests that we now have the technology and techniques to match our mood to our circumstances, to become the people we need and want to be. This isn't drug addiction, or treating a debility, but a free choice to use whatever means we have at our disposal to make our lives ever better. Just as we would choose to use antibiotics, vaccines, liposuction, orthodontia, or eyeglasses, we could use mood medication to adjust ourselves to -- or triumph over -- the demands of today. As Carl Elliott compellingly explains in the recent Better Than Well: American Medicine Meets the American Dream, there are multiple "enhancement technologies" people use for self-improvement. These medications are modern means to long-sought ends; why not make the most of them?

Between these two claims -- conspiracy and boon -- is the seemingly scientific middle ground, offered by newsmagazines, pharmaceutical P.R., and the mental health community, among others. It goes like this: Americans are experiencing an epidemic of depression, now fortunately treatable by a new class of drugs that restores brain chemical balance. The Zoloft ads, with their childish bubbles of serotonin, are the best example of this version of how and why the latest form of mood medication works. According to this story, these drugs aren't perfect (better, more promising ones are on the way), but they are effective and fairly safe. We are not becoming addicts, and we are not using medicine to feel better than normal; we are simply taking medicine to rectify a brain chemical imbalance. As the pamphlets on depression remind us, it's just like taking insulin if you are a diabetic.

Each of these ways of thinking about mood medication draws in various ways on the three deeper discourses. The neuroscientific perspective focuses on how brain chemicals affect mood; the addiction perspective focuses on how drugs are used to cope with life; and the mental health perspective focuses on what are normal or abnormal feelings. So the next step is to sort out the empirical evidence for each of these stories: What do we really know about brain chemicals, addiction, and mental health?

If only empirical evidence were so easy to evaluate. Instead, each of these perspectives generates its own plausible antithesis; this is the dialectic of discourses. Not everyone believes the serotonin story: There are many reputable neuroscientists, such as Elliott Valenstein, author of the 1998 book Blaming the Brain, who reject the simple model of chemical deficit that the drug companies use to market their products. Nonetheless, the ads and their critics are both using the discourse of neuroscience: They use the same evidence to support or refute the role of serotonin in mood.

Likewise, the dominant 12-step perspective on addiction and recovery has both proponents and critics. Alcoholics Anonymous and related programs are allied, in complex ways, with a rehabilitation industry that treats alcohol and drug use as a disease that can be put into remission but never cured. Critics point out that these programs rely on techniques of brainwashing and conversion to convince people they are victims of a disease that only the 12-step process can treat. But both proponents and critics of these programs share the discourse of addiction and recovery. They draw on or refute experiential as well as experimental evidence about how to address problematic drug and alcohol use.

Already we are combining discourses: Are antidepressants problematic drugs or deficit-correcting medicines? In order to sort out the addiction discourse, we need to figure out the neuroscience discourse. And that doesn't necessarily help us with the third discourse -- on what constitutes mental health.

Emotional Rescue

What is normal mood, anyway? The antidepressant ads suggest that the products they tout help you "feel like yourself again." But who is this "self," and should he or she be the vibrant, active, zest-filled person the ads depict? What makes us so sure that mental health is about feeling good most of the time? There are those who argue convincingly for the value and worth of the darker emotions, who are highly critical of a modern American propensity to make everything sunny.

There are also social critics who argue that it benefits capitalism to keep workers cheerful and productive, and that it benefits patriarchy to keep women chipper and docile. From their perspectives, taking antidepressants prevents the kind of legitimate anger and motivated action that social inequalities require; it makes us all into Stepford employees and partners. But is this argument disrespectful of the genuine suffering these new medications supposedly alleviate? Sorting out what constitutes reasonable and unreasonable emotionality is a highly charged, and often highly personal, endeavor. Whose experiences and beliefs count here? Should we consult the social critics, mental health professionals, our family and friends, or our own preferences?

Your way through this thicket of contradictory, plausible, and interdependent discourses will no doubt be different from mine. All I want to do here is show how I've made my way, trying to evaluate evidence in ways that help me assess the consequences of believing in some stories instead of others. We can never know for sure if we are making the "right" decision. As Shermer notes, I will probably remember only the evidence and arguments that confirm my choice, and ignore or dismiss the evidence that contradicts it. But at least we each have the opportunity to try to sort things out for ourselves.