Antidepressants and Strength of Character

You're not a bad person if you take any of these roads. I promise.

Spoiler alert: They have nothing whatsoever to do with each other.

There are different levels of stigma surrounding mental illness. There’s the stigma of having a disorder in itself, the stigma of being in treatment for a disorder, and, perhaps most of all, the stigma of that treatment being pharmacological.

People love to hate psychopharmacology, especially antidepressants, the efficacy of which is constantly being questioned (often for good reason). However, I’ve noticed that drugs like antidepressants receive a special type of scorn, one that cannot be based solely on the efficacy mystery.

I’ve found that where mental treatment is concerned, therapy holds some sort of moral superiority over drugs in many people’s eyes. I think many people still feel that mental disorders are spiritual illnesses, not medical ones, and that treating them with a pill is some sort of cop-out. (Imagine the public furor if researchers came up with a pill to, say, erase the feeling of guilt.)

This would explain why, though therapy is still stigmatized–after all, the Ideal Person works out these issues on his or her own–it is considerably less looked down upon than psychotropic medication. Our culture values struggle and hard work so much that even recovering from an illness should be mentally effortful.

What people don’t realize is that there are plenty of perfectly legitimate reasons why someone might choose medication over therapy, at least in the short term. Consider, for instance, the situation I found myself in a month before I began my sophomore year of college. Having spent my entire freshman year growing progressively more depressed, I’d thought that coming home for the summer would magically fix everything. It didn’t. With a month to go, I realized that I felt like I’d rather die than go back to school.

That was when I was first diagnosed with depression, and I think my psychiatrist realized, as did I, that I just didn’t have time to muck around with my feelings–I had to get better quickly, or else going back to school would be more upsetting and stressful than I could handle. So I started taking antidepressants and quickly improved enough to feel like I could deal with being in school. The mucking around with my feelings came later.

Aside from that, I can think of many other reasons medication can at times make more sense than therapy. For example:

  • Financial concerns. Antidepressants cost me $30 a month, while therapy costs $80 for four weekly sessions. That’s a pretty big difference for many people.
  • Time. Some people are at a point in their lives where they literally can’t spare an hour or more a week for therapy. That might sound ludicrous to you, but if you’re a college student, a new parent, or a low-income worker, it probably doesn’t.
  • Availability. Unfortunately, not everyone lives in an area where good therapists are available and accessible (and bad therapists will do more harm than good). This is especially true for members of marginalized communities, who may have a hard time finding therapists who are sensitive to their issues. Not all therapists are as open and accepting as they should be.
  • Insurance. I’m lucky to have a fantastic insurance policy that covers basically everything I’ve ever needed. However, many policies are very picky with regards to therapy (as opposed to medication, which does require a prescription from a person with an MD). For instance, some policies refuse to cover therapy unless there’s an official diagnosis, and you don’t necessarily need to have a diagnosable mental disorder in order to need help. Besides, you can’t be diagnosed without going to a specialist to begin with.
  • Nature of the disorder. Although most mental illnesses obviously involve a psychological component, some do not. For example, many people in temperate climates get Seasonal Affective Disorder (SAD) during the winter months, which is characterized by a low-grade depression as well as various physical symptoms. It’s usually treated with antidepressants or light therapy, which actually has people sit in front of full-spectrum light.
  • Language. Therapy requires people to talk pretty extensively about themselves and their lives, something that would be very difficult for, say, a new immigrant who’s just learning English. Unless such people are able to find a therapist who speaks their native language, it would be pretty hard for them to get anything out of therapy.
  • Comfort. As a future therapist, I obviously wish that everyone were comfortable with the idea of therapy. But not everyone is. That could be because of cultural factors, family attitudes, personality, or negative experiences with therapy in the past. I think that using medication to improve your quality of life while working up the courage to see a therapist is perfectly okay.

I hope that this list shows that making decisions about mental health isn’t that different from making decisions about physical health–it has more to do with personal preferences and practical concerns than with the strength (or lack thereof) of one’s character.

Of course, I do believe that therapy is really important and generally awesome, which is why one of my upcoming posts will be about why I think that everyone (or almost everyone) should see a therapist. Stay tuned.

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Sleep: Forgotten Martyr of College Life

See? It's even on a shirt.

Academicssocial life, and sleeppick two.” -popular advice given to college freshmen

I’m sure you’ve heard that one before. Most college students, it seems, pick the first two.

What surprises me isn’t so much the fact that they do, but the fact that sleep deprivation is considered such a routine part of college life. Nobody seems to see anything wrong with this idea that getting through college necessitates depriving oneself of sleep.

I have a different way of looking at things because I have a different body. More specifically, living with depression means that sleep takes on a central significance in my daily life. Get too little, even by an hour, and I’m facing the sort of fatigue most people experience only after an all-nighter. Get too little too often, and I’m significantly increasing my chances of relapsing.

Most people don’t have depression (though many do, especially in college), but everyone knows, in the backs of their minds, that sleep is really, really important. Lack of sleep is implicated in all sorts of health problems, from susceptibility to stuff like colds and flu, to obesity, diabetes, attention and memory problems, and, of course, depression. Fatigue also makes the other two items on that list, academics and social life, nearly impossible to handle.

What’s strange is that sleep is probably unique in its complete invisibility as a college health issue. Dining halls increasingly provide healthy options, including full salad bars at each of Northwestern’s. Campus medical centers provide free condoms and cheap STI testing. Campus gyms are open from 6 AM to 11 PM each day and provide plenty of free (or cheap) classes, intramural sports teams, and what have you. Counseling centers provide free counseling and stress management workshops (though of course there’s much to be desired in that department). Anti-binge drinking initiatives abound.

But sleep is that subject that nobody ever seems to touch. After all, exercise makes you look good and can be fun, grabbing a free condom is easy, and getting a salad instead of a pizza is no big deal. Getting enough sleep, meanwhile, requires actual lifestyle changes–and, sometimes, actual sacrifices.

Ultimately, though, I think that the whole “pick two” joke is a false dichotomy (trichotomy??). I know that having all three is possible, because I have all three. I have great grades, I have great friends, and I sleep a solid 8-9 hours a night.

(A few weeks ago, frustrated by the fact that I’m usually exhausted by the time I come home from classes at 6 or 7 PM, I called my mom to complain. She said, “Of course you’re tired. It’s normal to be tired after a long day of classes.” Until she told me this, I’d never realized that. Because the campus culture I’m steeped in tells me that I should come home in the evening, go to meetings and do homework until midnight, and then engage in a social life until 2 or 3 or later–or, if I’ve been procrastinating with my homework, I should just stay up all night.)

What worries me most is that people wear their sleepless nights like badges of pride. You never hear anyone say, “Dude, I’ve legit been eating three slices of pizza EVERY DAY this week,” or “Man, guess how long I’ve managed to go without working out!” or “Guess what, guess what? I totally didn’t use a condom last night!”

But they make those comments about their lack of sleep. The only comparison is the way people talk about binge drinking.

Why is sleep deprivation cool? Probably for similar reasons as binge drinking is. It’s a mark of physical endurance, in a way, and it’s a way of displaying that you have the “right” priorities–socializing, usually–and not the “lame” ones.

Yet colleges actively try to combat the culture of binge drinking, but they ignore the problem of sleep deprivation. Why?

Fatism and Going to Extremes

Discrimination against fat people is a problem. People who are overweight are often judged to be less competent, less intelligent, and more lazy–not to mention less attractive–than people who are of a “normal” weight. They face discrimination in the workplace, and there are some jobs for which they are unlikely to ever be hired at all.

It’s only natural, then, that a movement has sprung up to combat “fatism”–and that’s awesome. What bothers me, however, is the tendency of anti-fatism activists to deny the fact that being severely overweight has negative effects on one’s health. I hear a lot of “weight has nothing to do with health” arguments these days, and this sort of denialism is simply dangerous. Obesity is a problem in America, and it does put you at increased risk for a lot of health problems, such as:

  • high blood pressure
  • heart disease
  • stroke
  • type 2 diabetes
  • sleep apnea
  • breast and colon cancer
  • osteoarthritis
Given that heart disease is the leading cause of death in the United States, I feel like its prevention is something that should be taken seriously.

Regardless, denying these health problems does not help anyone, and admitting that being obese is unhealthy is not tantamount to justifying discrimination against obese individuals. After all, one’s health is one’s own business, and not taking care of your body shouldn’t result in being discriminated against.

It worries me when social movements respond to a problem in society (such as fatism) by taking the extreme opposite view. This happens a lot with progressives. For instance, noticing that our society has pervasive and restrictive gender roles, some claim that gender is entirely socially constructed and has no basis in biology whatsoever. (Apparently these people never noticed that men and women do actually have at least one very noticeable biological difference.) Some note that homophobia is rampant in society, so they insist that heterosexuality is actually constructed and unnatural, and that same-sex relations are the only “genuine” ones. Similarly, some people think that because discrimination against fat people exists and discrimination is wrong, therefore, there is nothing whatsoever bad or unhealthy or in any way undesirable about being overweight.

But being fat isn’t the same as being part of other marginalized groups, such as being a woman, being gay, being transgender, or being Black. No reputable scientific study has ever found that being gay or transgender is in any way unhealthy or abnormal (except, of course, in the statistical sense). No reputable scientific study has ever found that women or African Americans are inferior in any way to men or Caucasians. But our entire body of medical evidence shows that being severely overweight comes with significant hazards to your health. This is something that is simply true. Regardless of whether you think BMI is a good measure of obesity, and regardless of how easy or difficult it is for you to lose weight, being obese is unhealthy. Does this mean that discrimination against fat people is okay? Hell no. But it does mean that obesity is something that should be discouraged.

Incidentally, some of the things that anti-fatism activists consider discrimination simply aren’t. For instance, when airlines ask obese people to buy two seats, guess what–it’s not because they just don’t like obese people. It’s because if your body requires more than one seat, then you should have more than one seat–in which case, it follows that you should pay for more than one seat, because it wouldn’t be fair to give some people a second seat for free. Furthermore, it would be unfair for a person who paid for a seat to effectively receive only half a seat because the person sitting next to them clearly requires part of theirs. Does it suck to have to pay more to fly if you’re fat? Yes. But in that case, lobby for airlines to make seats bigger, not to give you permission to use half of another customer’s seat.

Also, companies that provide incentives for their employees to exercise/get down to a healthy weight/whatever are not being fatist. They’re doing two things: 1) encouraging their employees to be healthier, and 2) saving themselves money by reducing lost productivity due to medical problems and by reducing the amount they have to pay as insurance. Fact: being healthier and not obese reduces medical expenditures. Similarly, doctors who recommend that their obese patients lose weight are not being fatist. They are being doctors. I am terrified of the day when doctors are prevented from dispensing sound, evidence-based medical advice for fear of offending someone.

Regardless, it is, in fact, quite possible to discourage obesity without promoting eating disorders, obsessive dieting and exercising, and holding oneself to an impossible standard of beauty, as the mass media does. Conflating  efforts to discourage obesity with efforts to promote unhealthy behaviors or stigmatize fat people is intellectually lazy. There is, for every issue, a solution that is healthy, reasonable, and benefits the greatest possible number of people. Just because that solution is extremely hard to find doesn’t mean it doesn’t exist. It’s there, and I can guarantee that it is almost never at one extreme or the other. It’s usually somewhere in the middle.

Kids These Days

I am going to do something I rarely do–label something with an “ism.”

A post on CNN’s health blog, The Chart, points out that oral sex can increase cancer risk–valuable information, to be sure. But for some unknown reason, the blog frames the information like this:

Here’s a crucial message for teens: Oral sex carries many of the same risks as vaginal sex, including human papilloma virus, or HPV. And HPV may now be overtaking tobacco as the leading cause of oral cancers in America in people under age 50.

“Adolescents don’t think oral sex is something to worry about,” said Bonnie Halpern-Felsher professor of pediatrics at the University of California, San Francisco. “They view it as a way to have intimacy without having ‘sex.'”

Actually, the author of this blog and the professor quoted in it might be surprised to know that adults also occasionally engage in oral sex, so this might be a “crucial message” for them as well as for teens. In fact, sometimes these adults even view it as a way to have intimacy without having ‘sex’!

But of course, there’s no need to miss another valuable opportunity to insert a “kids these days” reference into a completely unrelated topic. Which is, yes, ageism.

On another note, since when does a random doctor or professor get to unilaterally define “sex”? Just because oral sex undoubtedly carries risks doesn’t make it equivalent to, say, vaginal or anal sex. Different people ascribe different significance (or lack thereof) to different sexual behaviors. To many people, oral sex is not as “serious” or meaningful as penetrative sex. This doesn’t mean they shouldn’t be aware of its risks, but it does mean that no higher authority can or should try to define “sex” for everybody.

Preventing Depression

I love it when people who actually know what they’re talking about confirm something I’ve believed for ages.

In this case, a study at the Feinberg School of Medicine (that’s Northwestern’s med school) showed that one out of every four or five college students who come to their school’s health center may be suffering from depression. The study also recommended that colleges should start screening students for depression. This way, they might even be able to pinpoint students with minor depression and help them get treatment before their depression worsens.

Ever since I’ve started seriously reading about psychology and depression, I’ve felt that we should start taking a preventative approach to it–not just in colleges, but everywhere. Depression tends to worsen with time, and even when it does remit on its own, it usually comes back later, with more intensity. Furthermore, distorted thinking patterns seem to precede the development of a full-blown depressive episode, so why not address those earlier rather than later?

For instance, parents take their kids to the doctor to make sure that they’re growing at a normal rate and developing the cognitive abilities they’re supposed to develop–why not also check to make sure that kids aren’t developing negative and maladaptive thinking patterns that could increase their risk for becoming depressed later?

You might think that kids are too young to show definitive patterns, but I think that’s false. My own little brother, who’s eight years old, constantly complains that he’s fat and needs to exercise, despite being underweight for his age. He also says that everyone at school hates him (they don’t) and that his school is awful and should be burned to the ground (and various other sentiments that have gotten him sent to the principal’s office before). Perhaps most importantly, he also has a pervasive family history of depression.

The unfortunate truth is that society views mental illnesses as fundamentally different from physical illnesses. One is a straightforward matter–you go to a doctor for checkups, and if something is wrong, you receive treatment. The other is for some reason shrouded in mystery, and people generally don’t go seek help for it until they’re already barely functioning.

As recent scientific developments are beginning to show, however, it may be that all mental illnesses actually have a physical basis. More and more psychologists and psychiatrists (notably, Peter D. Kramer of Listening to Prozac fame) are starting to take this view. If they’re right, it follows that we should try to take a preventative approach in treating mental illness, not a palliative one.

However, many people still have negative attitudes about the idea of psychological screening. One of the students quoted in the article linked to above said that these screenings are a bad idea because someone could just “be having a bad day” and–oh, the horrors–get recommended for counseling. First of all, however, counseling isn’t exactly the same as taking antibiotics or getting a spinal tab. Second, that just means that we need to develop better depression screening tools, not that we shouldn’t screen for it at all.

In college especially, conditions like depression can take a turn for the worse rather quickly, as evidenced by the several suicides we’ve had on campus while I’ve been a student here. Every time a tragedy like that occurs, friends and family are often quoted as saying that they “never saw it coming.” Maybe a professional psychologist would’ve.