Wednesday, October 15, 2003

Depression. People who have never suffered it don't get it. You can be talking along with them, thinking you're talking about the same thing; it's all the same words -- then suddenly you realize they're just talking about being bummed out, a little sad, a little blue. They have no idea of that terrifying weight bearing down on you, of the state of mind in which suicide seems the only rational response to the world. And so when they think about anti-depressants, they imagine taking drugs so that you just don't have to feel bad, ever. A whimpy thing to do.

So: to those of you who haven't suffered depression -- no. That's not it. Oh, I have no doubt that the drug companies would love everyone to be taking anti-depressants to cure the passing griefs and sadnesses of everyday life. But everyone I know who takes anti-depressants does so simply to stay alive.

A person in a severe depression doesn't have bad feelings every once in a while. He doesn't return occasionally to despairing thoughts. He is in constant emotional pain, and every single positive thought, every single impulse to action, is met by a host of despairing thoughts. Every one. I'm not exagerating here. Every single one. The idea of brushing his teeth. The idea of eating breakfast. The idea of getting dressed. The idea of going to work. The idea of lifting the curtain to see what the weather is like. Every one of them is met by a swarm of bitter, ridiculing thoughts.

By the time a depressed person has gotten to work, he's already fought dozens of exhausting battles with his own mind. Won some, lost some. He's looking forward to the same all day.

What do anti-depressants do? Well, they don't stop you from feeling bad or having gloomy thoughts, at least none that I have taken do. What they do is stop the swarming. There's space between the despairing thoughts, there's time to lift your head and think, "maybe there are other ways to be."

There's still all the work to do. You have to undo the cognitive habits of depression. You have to change your life to avoid the things that trigger depressive episodes. You have to meditate, or pray, or whatever it is that your people do to learn to know their psychic world. You have to pay attention. You have to exercise and eat good food. If you don't do the work, anti-depressants won't do it for you. All they do is open the space for that work. You still have to do it.

Okay. Back up a bit. This is what anti-depressants do when they work. When you have the right kind, or mix of kinds, in the right dosages. The way medical care is given in America, at any rate, you will probably also have to do this work all by yourself -- establishing the right kind of drug and the right dosage. People talk about anti-depressants being overprescribed, and maybe they are; I don't know. I do know that they are under-monitored. Anyone who prescribes anti-depressants and then just sends their patient off with them should have their license to practice medicine revoked, but it's a common -- maybe the most common -- scenario. What ought to happen is several months of experimentation and close observation, till the right drugs and the right dosages are established: and unfortunately even when that's been established, it can change, probably will change. Unless you luck out (as I did) you won't get this kind of care. You'll get a randomly selected drug from the current pharmacopia, prescribed at a fairly arbitrarily chosen dosage, and be sent on your way.

So you need to do the research and experimentation. Don't, for God's sake , take unsafe doses -- if the largest usual dose doesn't work, then it's the wrong drug, that's all, or else it needs to be taken in tandem with something else. If possible, verify your results with someone who knows you well. "Have I seemed different in the last two weeks? In what ways?" And remember that many of these drugs have a long ramp-up time: it can be a month or two before they start having significant observable effects.

Last caveat. Read the damn labels and pamphlets, and pay attention to them. It's likely enough that your doctor has never read them, but you need to. If they tell you, for instance, not to suddenly stop taking the drug -- to tail off slowly, if you're going off it -- then don't stop taking it suddenly, and tail off slowly.

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