I began to think of suicide at sixteen. An anxious and driven child, I entered in my mid-teens a clinical depression that would last for 40 years. I participated in psychotropic drug therapy for almost 30 of those, and now, owing in part, but only in part, to the drug Cymbalta, I have respite from the grievous suffering that is mental illness.
As a health policy scholar, I understand the machinations of the pharmaceutical industry. My students learn about “me-too” drugs, which barely improve on existing medications, and about “pay-for-delay,” whereby pharmaceutical companies cut deals with manufacturers of generic drugs to keep less expensive products off the market. I study policymakers’ widespread use of effectiveness research and their belief that effectiveness will contain costs while improving quality. I appreciate that randomized controlled trials are the gold standard for determining what works. Specifically, I know that antidepressant medication is vigorously promoted, that the diagnostic criteria for depression are muddled and limited, and that recent research attributes medicated patients’ positive outcomes to the placebo effect. In my own research and advocacy work, I take a political, rather than a medical, approach to recovery from mental illness.
Cymbalta in particular epitomizes pharmaceutical imperialism. Approved by the FDA in August 2004 for the treatment of major depressive disorder, it has since gotten the go-ahead for treating generalized anxiety disorder, fibromyalgia, and chronic musculoskeletal pain, including osteoarthritis and lower back pain. It remains under patent to Eli Lilly.
I would not have been surprised if Cymbalta had not worked for me or had not bested the myriad drugs and drug combinations that came before. My path through clinical depression is strewn with discarded remedies. “Who are these people?” I wondered about patients who were said to achieve happiness with the first pill and therefore to violate societal notions of identity and independence. I was just trying to get out of bed, and although my first antidepressant, at age 26, had a strong positive result, it also had incommodious side effects, and relief was tentative and partial. Decades of new and evolving treatment regimens followed. I have been treated with every class of antidepressant medication, often in combination with other psychotropic drugs. Some drugs worked better than others, some did not work at all, and some had unendurable side effects. But Cymbalta did not disappoint, and now I have become a teller of two tales, one about health policy, the other about health.
Like many depressed people, I resisted the idea of psychotropic medication. I was deeply hurt when my psychotherapist suggested I see a psychiatrist about antidepressant drugs. How could she think I was that crazy or that weak? But she said she was concerned for my survival, and I eventually did as she asked. I became an outpatient at a venerable psychiatric hospital, where I found a kind stranger who knew my deepest secrets and wanted to end my suffering. He wrote a prescription, and thus began my 30-year trek.
Depression is sometimes confused with sadness. Many depressed people are very sad, as I was, but the essence of my depression was feeling dead among the living. Everything was just so hard. William Styron describes depression as “a storm of murk.” Andrew Solomon’s atlas of depression is titled Noonday Demon. I too found depression to be fierce, wrapping me in a heavy woolen blanket and mocking my attempts to cast it off. The self-loathing was palpable; it felt like I was chewing glass. I sensed that other people were seeing things I did not, and apparently they were, because when I began my first course of antidepressants, it was as if someone had turned on the lights. It did not make me happy or even content. The world simply looked different—brighter, deeper—and I was a part of it. I saw something other than the impassable flatness and enervating dullness, and I was amazed.
My progress came at a cost. In the late 1970s, before Prozac, antidepressant medication was seldom spoken of. The people I told about my treatment echoed my first reaction and sang throaty choruses of why-don’t-you-just-cheer-up and won’t-this-make-you-a-drug-addict. I was also drowsy after I ate, my mouth was always dry, and when a second medication was added, I began to lose control of my limbs and fall down. I insisted to my psychiatrist that it was the second drug that was causing me to fall. A champion of that one, he instructed me to discontinue the first. I responded in the way only privileged patients can: I went around him, using personal connections to wrest an informal second opinion from a resident in the lab run by my psychiatrist’s mentor. My doctor was convinced, and a little embarrassed, and we both learned something about therapeutic alliances. (...)
In the years that followed, we just kept trying. I would remain on a regimen until my psychiatrist proposed another, and, looking back, I was remarkably game. I was treated with monoamine oxidase inhibitors, which can be fatal in combination with some foods, and a famous psychiatrist in Manhattan prescribed a drug sold only in Canada. When a medication produced double vision, my psychiatrist suggested I drive with one eye closed. Drug cocktails deteriorated into over-medication. I tried to enroll in a clinical trial that would implant electrodes in my brain, but it was already full. There was only one remedy I rejected outright: electroconvulsive therapy. I was told by other patients about their memory loss, and I needed a good memory to do my job. (...)
Medications that affect the mind seem to discomfit us deeply, culturally, viscerally. And so do the people who need them: psychiatric patients have gone, in this discourse, from covetous of an unfair advantage to oblivious to a colossal con. I am not sure which characterization I prefer, but I know my heart will break when a friend in the grip of depression forgoes medication—not because it is not right for her, but because it is only for cheaters or fools.
Most parties to the debate agree that antidepressants can be effective for severely depressed patients such as me, but selfishly I fear the rhetoric of antidepressant uselessness will influence the pharmacy policies of my health plan. At present I am charged an inflated copayment for Cymbalta because my health plan claims it is no more effective than generic antidepressants. I am not privy to the basis for this determination; I do not know if it is based on average treatment effects, the preferences of plan professionals, or an overriding concern for cost. I do know that it does not include my experience, and when I queried the plan about an appeal, I was told I could appeal but should not bother: there are no successful appeals. The plan representative was unmoved by my savings on psychiatry, rheumatology, and hospitalization. She intimated that it is just too hard to satisfy individuals and that the plan has enough to do managing costs.
by Sandra J. Tanenbaum, Boston Review | Read more:
Photo: Jordan Olels
