Living Crazy

Gary Greenberg, a clinician and freelance journalist, recently published an article in Harper’s (May 2007) on his participation in a clinical trial for depression. The article is full of wonderful insights:

• The disconcerting way in which to be found eligible for a clinical trial, you must submit your life experiences to scoring on one or another symptom list. The interviews leave no room for discussion of what the words describing one’s symptoms mean.
  
  Papakostas, the psychiatrist doing the intake interview, asks Greenberg, "Are you content with the amount of happiness that you get doing things that you like or being with people that you like?"
  Greenberg responds:

"I’m not big on contentment," I said. Is anyone? I wondered. Is anyone ever convinced that his or her pursuit of happiness has reached its goal? And what would happen to the consumer economy if we began to believe that any amount of happiness is enough? "I’m sorry to seem dense," I explained, "but it’s not how I usually think about things."
Papakostas was reassuring. "You know, this question condenses a lot of areas of life into just a number. It doesn’t work well," he said. "Some questions we just don’t like."
Well, if these are dumb questions, I wanted to shout, then why are you asking them? Why are we pretending that these answers mean anything? Indeed, if I’m just the middleman here, the guy you’ve got to go through to get to the molecular essence of my troubles, then why ask me any questions at all?

• Greenberg then makes the crucial point that there is no other criterion for depression except the person’s own self-description. There is no blood test, genetic test, or brain scan to detect the state of depression. Greenberg again:
  Later, when he asked how many days there were in the last week that I had napped for more than thirty minutes, and I told him four, he said, "See, some of the questions are really nice in terms of being objective," before putting me down for two points on that item.
  "I suppose it would be easier if there were biochemical markers," I offered. "Otherwise, you’re just stuck with language.""Hey, we’re psychiatrists," Papakostas said. "Language is good."
  Now I was really confused. Hadn’t we just spent the last half hour circumventing language’s approximations? If language is good, then why wasn’t he taping this visit, taking down my words instead of translating them into the tests’ pale simulacrum of language? For the same reason, I suppose, that he doesn’t seem to think that consciousness itself, in all its insuperable indeterminacy, matters very much . . .
• Consciousness, the only route to a diagnosis of depression, is treated as a kind of foggy patch that will resolve into clarity when it comes into contact with diagnostic categories. But isn’t that a weird sort of disconnect? Wouldn’t you think the categories ought to be exquisitely sensitive to the meanings of words in everyday language?

• Next Greenberg takes on drugs that have efficacy (it would seem) but that are not in clinical trials at all because they offend Americans’ sensibilities about consciousness-transforming drugs and do not have a great potential for making profits.

I ask Papakostas about a promising new experimental treatment for depression, one that uses an anesthetic drug called ketamine. A government psychiatrist was trying to bring ketamine in from the cold, from the psychiatric underground where LSD and psilocybin are used for transformative purposes (9) and where ketamine has a reputation for delivering a powerful and salutary (if terrifying) experience of being disembodied and dislocated—not unlike a near-death encounter. To Papakostas—who is not familiar with this unofficial research, discredited since the excesses of the sixties grew like an adipose layer over the therapeutic promise of psychedelic drugs—I’m explaining the idea that a single whack upside the head, one glimpse into the cosmos and all its glory and indifference, can set you straight for a long time. I am getting to the part about how inconvenient the economics of a one-time-only drug are for an industry addicted to One-A-Days, when he interrupts me.
"Sort of like ECT," he says, using the new and improved name for electroshock therapy. "The way it’s supposed to reset your neurotransmitters. But we know that theory doesn’t work, because ECT patients relapse."
"But isn’t there a difference between ECT and ketamine?"
"Well, of course ketamine works mostly on glutamate pathways …"
"No. I mean that you’re conscious when you take ketamine and unconscious when you get ECT."
The distinction seems lost on Papakostas, or maybe he just doesn’t have time for a discussion on the nature of consciousness. Either way, you cannot help but admire the purity of his devotion to the material, the way he has pared down psychic life to its bare bones. His is a spare and unrelenting pursuit, and his single-mindedness right now seems nearly ascetic.
Papakostas may be circumscribing my subjectivity in order to make it work for the drugs, but he’s also renouncing his own subjectivity, putting aside whatever curiosity he might have about the shape of the self, the objects of consciousness, the raw nature of our encounter, in order to make good his claim to possess the instruments of science. Armed with them, he can take my emotional measure and report my depression with the dispassion and confidence of an astronomer reporting the distance to a star. The truth thus derived, decontaminated of aspiration and expectation, is better, truer somehow, than the one we know through our credulous senses and fickle sensibilities. Maybe that’s why I don’t argue with him when he adds up my numbers and tells me that in the world behind the world, the one in which I am officially depressed, the survey says I’m getting better.