Ordinarily Well: The Case for Antidepressants




IF KUHN’S STORY plays an important role in my imagination, it is because all psychiatrists of my generation were discoverers. Each of us came upon antidepressants for the first time—the first in our own careers, anyway.

I saw imipramine in action in my freshman year of medical school, at Harvard. When I arrived, in 1972, the medical school was a Brigadoon, caught in the psychiatry of fifteen or even fifty years earlier. Other programs had moved on. Harvard remained a bastion of Freudianism.

I liked the outdated orthodoxy. After college, while studying literature and philosophy in London, I had undergone psychoanalysis and decided to become a psychiatrist. I entered medical school not knowing the location of the liver or the cause of measles. To maintain my sanity in the early going, I signed on to spend spare hours interviewing psychiatric patients at Boston’s Beth Israel Hospital, steps from the academic campus.

The clinic was my haven from anatomy and biochemistry. One chief resident, a tall woman, called me the departmental mascot, although perhaps that was because I ventured upward glances at her with puppy-dog eyes. At twenty-three, I could scarcely have been greener. Still, by the second semester I had achieved the privilege of conducting psychotherapy.

One of my first patients was a twenty-six-year-old elementary-school teacher, Adele. Since her teens, Adele had suffered intervals of moodiness in which she had functioned poorly. In the months before her visit to the clinic, a down period had deepened. She was distraught. She considered suicide.

Adele had her reasons. A two-year romantic relationship had ended. When her fiancé moved on, Adele had returned home to a disorganized mother. Adele’s younger sister was involved with an abusive older man, and Adele had attempted a futile rescue effort. Meanwhile, she was under pressure from a rigid school principal who seemed jealous of Adele’s youth and idealism.

I gave what I had from my time on the couch. I listened. I inquired. Suicide?

Adele was half-Irish, half-Italian, a Boston type, the sober member of a loud, impulsive family. Her only dramatic act had been cutting herself, in high school. Then, she felt dejection. Now, she was coming out of her skin.

That last remark made me curious. For a first-year adviser, Harvard had assigned me an endocrinologist, another Boston type, the lone professional in a working-class, left-wing family from the North End. Psychiatry was on the list of indulgences she disdained. If I wanted to understand mood disorders, I should learn about glands. I knew that thyroid abnormalities could produce the psychic and bodily discomfort that Adele described.

Because my adviser had half my loyalty (psychotherapy had the rest) and because Adele was convincing when she called her agitation unfamiliar, I tested her thyroid. When initial blood results came back normal, I had vials run for a second form of thyroid hormone, one that had only lately been implicated in disease.

Adele did have an overactive gland. News of my “catch” sped through the psychiatry department. The holdout from the circle of admiration was my supervisor for the prolonged elective, Theodore Nadelson.

A skilled therapist, Ted would become known for work in psychosomatics, the overlap of psychiatry and general medicine. He warned me to keep track of Adele as she moved to the endocrine and later (after a radioactive-iodine swallow failed to destroy the gland) the surgical service. He predicted that Adele would emerge from her thyroid treatment still in need of psychotherapy, as she did. We gave the replacement hormone time to reach the proper level. If anything, Adele’s despondency deepened.

Ted never explained why he considered antidepressants for Adele. In Boston, recourse to psychiatric medication was thought to signal a failure of imagination on the part of the doctor. The therapist’s goal was not to mute symptoms but to understand them and allow them to act as spurs to self-examination. A patient offered antidepressants might sit back and wait for the drugs to take effect. She would get a read on her doctor’s anxiety as he adjusted the dosage. Because the patient was on medication, the real treatment, based on the doctor’s neutral presentation of self and resulting in the patient’s increased tolerance for feelings, would bog down.

Freud had compared the setting for psychoanalysis to the surgeon’s sterile field. In this clean work space, unsullied by the therapist’s intrusions, insights into the patient’s mental makeup might emerge. But for Adele, the treatment relationship was already contaminated. With other doctors, I had held forth a promise of a cure through powerful interventions: radiation and surgery. Now Adele required adjustments of the hormone she took in pill form, so she got repeated indications of her doctors’ assessment of her well-being. How much confusion would an antidepressant add?

Perhaps a bigger factor in Ted’s decision to consider antidepressants was a change in Adele. With the thyroid under control, she appeared more purely despairing. There was so much she could not save: job, romance, sister. By Adele’s new account, she had always seen life as bleak, always wanted death to come to her young.

Doubtless Ted was uncomfortable with the idea of a first-year trainee’s mucking about in the unconscious of a morbid young woman. Ted arranged for the chief resident to assess Adele for treatment with medication. The resident prescribed imipramine. The dose was raised until Adele complained of constipation. She was offered a stool softener and a dose decrease.

I wanted Adele out of pain and danger, but more, I wanted her better, which was a different matter, involving self-understanding.

Imipramine acted in a fashion I later came to call courteous. It afforded modest but invaluable relief. Imipramine quieted ruminations, damped impulsivity, and restored concentration. This quick improvement, however partial, was arresting.

In twice-weekly meetings, Adele had discussed her emotional responses to neglect by her mother, intrusion from her stepfather, and rejections by men. She had gone in circles, turning from blame to self-recrimination. On medication, Adele became reflective, arriving at a stable assessment of her background. Her distress seemed proportionate to her practical frustrations. She found allies at school. If she continued to seek out unreliable lovers, she handled them more prudently.

Antidepressants were short-term treatments. After four months, the resident tapered the drug. Adele and I were at work on our project, confronting masochistic drives, when a job offer drew her to another city and I lost contact.

Later, prescribing antidepressants to other patients, I witnessed dramatic remissions of the sort that had set Kuhn on his way. Adele’s subtler improvement had its own special impact: imipramine had made me a more competent therapist.

Only once have I had a similar experience, and that was on the ski slopes. In 1996, a magazine commissioned me to write a first-person piece about whether expert lessons could lift an unathletic, uncoordinated skier above the intermediate plateau. Midway through the experiment, an instructor put me on the new, shaped—parabolic—skis. The technology trumped the teaching. With no further learning, I had more control and more courage on the steeps.

In the work with Adele, imipramine made my level of skill suffice.

As an acolyte, I retained my teachers’ misgivings about drug treatment. If medication made therapy more productive, still perhaps Adele had skipped some necessary step. What I did not doubt was imipramine’s ability to moderate symptoms in short order.

I gave little thought to placebo effects. If Adele had been a placebo responder, her low mood would have disappeared in the face of radiation or surgery.

Because my teachers at Harvard considered pharmacotherapy only in medically complex cases, I had this sort of experience repeatedly—seeing antidepressants work for patients who had not responded to a host of prior treatments.

Adele was the first in a private series, patients I worked with in psychotherapy and then followed as they began antidepressants. The library of cases is what we have in mind when we speak of experience. We like doctors to have firsthand familiarity with treatments they offer.

But then, experience does not arise in isolation. Ted read the journals. It was because imipramine tested out well in formal studies that I got to see Adele’s new openness to change.

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