Today, Explained - Why we’re all on antidepressants

Episode Date: January 5, 2023

Ray Osheroff was a successful doctor in the DC area until his depression became debilitating. The way he was treated — and not treated — changed psychiatry. Rachel Aviv tells the surprising story of the rise of psychiatric medication. Today’s show was produced by Miles Bryan and edited by Matthew Collette. It was engineered by Paul Robert Mounsey, fact-checked by Laura Bullard, and hosted by Noel King. Transcript at vox.com/todayexplained   Support Today, Explained by making a financial contribution to Vox! bit.ly/givepodcasts Learn more about your ad choices. Visit podcastchoices.com/adchoices

It's Today Explained. I'm Noelle King. Today's show is about diagnosis. You get sick, go to the doctor, the doctor tells you what's wrong. You have been diagnosed, and then you get medicine, and then you get better. Or, a different story. You're sick, you go to the doctor, the doctor tells you what's wrong, and then, without even realizing what you're doing, you adjust your behavior somewhat to fit your diagnosis. So you're diagnosed with anxiety, and now you're an anxious person. Depression, and now you're a depressed person. Rachel Aviv, a writer for The New Yorker, found herself wondering whether a diagnosis of mental illness could lead a person to behave differently.

More in line with the diagnosis, perhaps, than with themselves. If you have ever been diagnosed with anything, you won't want to miss what's coming up. This NFL season, get in on all the hard-hitting action with FanDuel, North America's number one sportsbook. You can bet on anything from money lines to spreads and player props, or combine your bets in a same-game parlay for a shot at an even bigger payout. Plus, with super-simple live betting, lightning-fast bet settlement,

and instant withdrawals, FanDuel makes betting on the NFL easier than ever before. So make the most of this football season and download FanDuel today. 19-plus and physically located in Ontario. Gambling problem? Call 1-866-531-2600 or visit connectsontario.ca. It's Today explained. In her new book, Strangers to Ourselves, Rachel Levive looks deeply into the life of a man who changed the way that we and the field of psychiatry think about mental illness and about how we treat it. Ray was a very successful doctor in the D.C. area in the late 70s.

And he became depressed and sort of stopped in this hole of rumination where he felt like he'd made a series of bad decisions related to his two children. He had sort of left them go to Europe with his ex-wife and related to his business. He had sold a portion of his business and he was like stuck in a thought loop where he kept rehearsing like the horrible decisions he'd made.

I could eat the most elegant food and not enjoy it. I could participate mechanically in sex and not feel a sense of enjoyment or transportment. I was a man alone. I would say to myself, I'm living, but I'm not alive. I'm living, but I'm not alive. I'm living, but I'm not alive. He would pace. It was almost like the physical manifestation of his circular thoughts.

Now, not only could I not stop pacing, but when I'd lie down in bed at night, my feet would move. I would have restless legs. He just couldn't sit still. He couldn't even sit still long enough to eat. He was just sort of going in circles physically and mentally. If somebody said to me, you must keep your feet still, I could keep them still. But their normal position, their baseline position would not be of rest. It would be of continuous motion. He was ultimately told by his wife that he needed to check into a psychiatric hospital. And so he chose this hospital called Chestnut Lodge, which had a reputation for being the most sort of elite psychoanalytic hospital in the world. And it was unusual in the sense that it was this hospital entirely devoted to analysis.

Tell me about what made it elite. What might I have seen or experienced if I were there? It was almost utopian in the belief that no matter how sick you are, if you just sit in the therapist's office four times a week, the therapist will ultimately be able to understand what's going on and that you will ultimately be able to understand what's going on and that you will ultimately be able to gain a sense of insight into what has been causing your distress. And so there was just this incredible belief in the power of one person listening to another person and ultimately

understanding how that person works and thinks and how to sort of help them move forward in life. I remember one psychiatrist who was the former head of the American Psychiatric Association told me it felt like Valhalla. It was just like the place where the best people were going to unravel the mysteries of the mind. How does Ray, himself a doctor, do among these doctors? Well, he has a sense of his own status and he feels that he's being treated as a patient and he quickly really deteriorates. He sort of loses a sense of who he is and what is meaningful to him in his life. He loses 40 pounds and sort of stops eating well, stops caring about any of the things in his life that he'd previously cared about.

When I say I play the trumpet, I practice two hours a night virtually every day religiously, okay? I went for a year at the lodge with maybe picking up the trumpet once. And after six months, when his mother visits him, she's essentially appalled by like what a sort of husk of a man he is. I would ask for my doctor, how do I get out? And the answers that were given to me were, when you stop using your shirt for napkin, when you run out of money, and I can't give you the will. It was a kind of hopelessness.

Does he say to them, guys, this isn't working, I'm going to need something different? He did. He asked for antidepressants, and his mother asked for antidepressants. And the psychiatrist there said, you know, he needs to learn how to stand on solid ground on his own. He needs to learn insight, and antidepressants would be maybe a temporary fix, but we're looking for something that is more, you know, holistic and complete. You never used medication in this case, did you? No, I didn't.

And why not? Because I thought over the long haul that we'd get a better result if we did not use medication. And I thought if he could begin to see that there was the possibility of organizing his life in another way, in a way that was more comprehensible to himself, that he would have a better result. And so they say, no, he cannot have antidepressants. And what does he do? After six or seven months there, his mother removes him against medical advice and transfers him to this other hospital in Connecticut that is more open

to using psychiatric medications. How common were psychiatric medications in the late 70s? They were in use for a few decades, but they were still viewed with suspicion. There was the sense, it sometimes got called pharmaceutical Calvinism, the sense that like, yeah, medications might work, but there was also something morally wrong, or you'd have to pay for what you're doing in the future somehow. It was just this general sense of suspicion, like the real good way to resolve your conflicts is through self-understanding, and medications were still seen as a little cheap.

He gets them. He gets them, though. And how does he respond to medication? He responds really well. He suddenly stops pacing. He previously felt like he could never be a doctor again, and he tries on his suit and suddenly feels like he's fit to return to work, and he's discharged from the new hospital and sent home. I think the first thing I noticed, the first change I noticed in myself

was that there were other emotional things being open to me. And one of them was sadness. And I thought about, my God, I haven't seen my kids in a year. And then I started to weep. Once he recovered so quickly with antidepressants, he was kind of consumed by anger that he'd been made to suffer for so long. And so he decided to sue Chestnut Lodge for malpractice and for essentially causing him to lose his job and to lose contact with his children

and sort of making him absent from life in a way that he didn't have to be. Isn't that what you've alleged in this suit? That had they given you medication, you wouldn't have had any of these problems? Had they given me medication and treated the illness, then I would have been a functional person able to deal in the world. The case then became this kind of cause for others. At that time, there were a lot of psychiatrists who were becoming a lot more interested in a biological approach. And they sort of embraced Ray's case as a way to prove that psychoanalysis was sort of past its day. When psychiatrists testified on Ray's behalf, what was the argument they'd make?

They were arguing that psychoanalysis was a kind of ideology and that biological psychiatry was science and that it was malpractice to sort of persist in this belief that talking would cure someone when there was a medication at hand that could do the job. The lawsuit kind of represented like this ultimate collision between these two different approaches of understanding mental illness and the mind. And Ray won. Essentially, he settled the lawsuit, but that was because this arbitration panel ruled in his favor. And it was seen as his victory. There was a lot of writing about the case at the time among psychiatrists, and it was seen as like, here is the proof that the tide

needs to shift and that psychoanalysis is outdated and that the new way forward, the way we're going to understand the mind is biological psychiatry. Meaning drugs. If we've got drugs at work, we don't need people to sit with a therapist for hours a day or hours a week. We can just give them something. Right. The psychiatrist Peter Kramer described it as Roe v. Wade for psychiatry, just this like sense of, you know, there's no going back, which I guess is a bad analogy at this point, but that like medication sort of renders the project of psychoanalysis futile and kind of silly. That was the idea. Do you think it changed the way the fields of psychiatry thought about understanding one's self? I think it crystallized a change. I think that there were already

changes going on. And part of that was structural. Like there was this move to managed care. And with managed care, you need to sort of quantify someone's improvement. And so you look to symptoms. You don't look at something kind of inexpressible, like a person's insight about who they are and what made them suffer. But that case also made people afraid, made psychiatrists afraid that if they didn't give medications to someone, it was malpractice. So there was, I think, a fear that that lawsuit instilled in psychiatrists. Up next, Ray Oshiroff's case led to a world in which many of us are medicated. But should so many of us be? Support for Today Explained comes from Ramp.

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Ray Oshroff is best known for the lawsuit that he filed against the psychiatric hospital that wouldn't give him antidepressants. But you kept reporting on his life after that. What ended up happening to this man? You know, his story was that he did stay on medications for the rest of his life, but he also really struggled to maintain a connection with his children, to have a job. He essentially got involved in like criminal activity as it related to insurance fraud with his job. And he was constantly trying to figure out like why the life he felt entitled to and the life he felt he was supposed to live just sort of ended like 30 years earlier than it should have. And he was writing this memoir for years and he wrote thousands of pages. more and more closed to other understandings of himself and more and more tied to the sense that, like, Chestnut Lodge was the thing that had derailed his life.

Is Ray's story told still in the field, either in the books that college students have to study or graduate students have to study? It's sort of, like, told in three paragraphs in textbooks as this very important case that signaled a shift in psychiatry. Now, I see my chapter about him as a correction to the history that's been told, but I don't know how much it's changed. At this point, the way that it appears in textbooks is like, this man triumphed thanks to antidepressants.

You follow the story of a young woman who is very much living in Ray's world. She is medicated to the hilt. Tell me about her. Her name is Laura, and she grew up in Greenwich, Connecticut, in this very wealthy family. She was like one of the best squash players in the country. She went to Harvard. Beyond the closed doors of my home, I had no space to release what I was holding within me. So I eventually began to release it all onto my parents through screaming and cursing and physicality. I just didn't know what else to do. Not long after, I'd be sent to my first therapist who would conclude I was too serious of a case for her and refer me instead to Dr. P, a psychiatrist.

After 50 minutes, Dr. P would tell me that my explosive anger was a sign of mania, that I had a lifelong brain disease called bipolar disorder. She would hand me two prescriptions for Depakote and Prozac and tell me to have my mom call her to schedule next week's appointment. But what she really did that day was plant in me the seed of a belief that I was fundamentally broken and would have to spend the rest of my life trying to fit into the human race. I was 14. And then over the course of about 10 years, nothing was quite working. And so her psychiatrist kept prescribing more and more medications. And eventually she realized she'd been on 19 medications and she just wasn't sure

she was feeling any better than she had when she began the process. What ends up happening? I mean, I think she realized like she no longer knew who she was before the medication. She'd lost a sense of what her baseline self was. I no longer believed that I could grow and evolve or that my life had options because I had an incurable, lifelong, serious and persistent mental illness. And so after trying like every solution that psychiatry offered her, she decided to try to see what it was like to go off the medications. There I was, curled in the fetal position on my family's couch, days unshowered, miserable and out of my mind in early withdrawal.

Toxic smells emanated from my skin as my body pushed out lithium. After she finally went off the medication, she felt like she was able to have relationships, like romantic and sexual, in a way that she hadn't previously been able to. She felt like as if there was something synthetic about her interactions with people, and she as if there was something synthetic about her interactions with people. And she wondered if that was because she was on so much medication

that she really wasn't feeling. So for her, going off the medications did feel healing. And I think in part because she also connected to a community of people who were in very similar situation as her where they had been on medications for a long time and they were sort of helping each other get off them in a reasonable way and in a way that made them feel sort of more ownership over their emotions. I felt myself opening up to a glimmer of camaraderie, solidarity, that beautiful sense of being a part of something. And so to go back to your original point, what you have in Laura is a woman realizing she is more than a diagnosis. Yeah. I mean, I think with Laura, she felt as if the diagnosis explained everything about her for a really long time. It was like she was bipolar and that was who she was. And every time she felt sad, it was

because she was bipolar. And after she went off medication, she started rethinking that kind of narrative, the sense that like she was doomed to this life of illness because of this diagnosis. And she was able to like create a new kind of story for what her life could look like. Laura, in some ways, is like the outgrowth of the kind of world that Ray and the psychiatrist who supported him were pushing for. And she should have been the success. Like, look how quickly she got medications. Look how knowledgeable her doctors were in giving her these medications. And I think what felt profound was that that's just not enough. She felt like no one was actually like interrogating why it was that she was in such distress. And instead, she was being given like one after another medication. And there was this belief that like if they just

found the right medication, she would finally be at peace. In the book, you also write about your own experience getting on and then trying to get off of psychiatric medication. Can you tell me your story? Well, I was in my late 20s, and I was having various forms of social anxiety, and my friend recommended the psychiatrist she really liked. And I went there, and in the first appointment, he said that he thought I would benefit from Lexapro, which is an SSRI. And I kind of was willing to try and tried. And it was like this incredible experience where I felt like I was just like liking my brain more.

Like I was sort of feeling more warm and outgoing and all these things. And then after six months, I had the sense that it was a six-month trial. So I decided to go off. It worked well, but like the logical leap was not. And so therefore, I take it for the rest of my life. So I went off. And then it was this very confusing experience of going off and then feeling as if I was experiencing something that was depression in a way that I had never experienced depression. And it was hard to know, is it that I had just gotten used to like a different level of living life and therefore this felt more acute to me? Or was it some kind of experience of withdrawing from the medication

that is not well documented where it just takes far longer to recover from the experience of going off the medications. And so eventually I went back on and I would like experiment with going off and on. And I felt like, you know, I confronted this problem of feeling like the medications had sort of allowed me to operate at a kind of higher level. And then you build a life on that higher level. And then you kind of like feel that higher level. And then you kind of like feel like in order to continue being the person you are, you need to keep taking that

medication. So that was sort of this weird like existential confusion of like, is this medication making me a better person than I'm supposed to be somehow or a better person than like who my essential self is? God, that is such a freaking interesting way of putting it. Are you still taking medication? I am. And, you know, I've sort of tapered down. And then I think at some point, like last year, I was like, what am I doing? Like, what is the point of this?

What am I trying to prove? And I think I thought a lot about like, who am I to my kids? Who do I want my kids to remember me as? And, you know, I could even reflect back on like my parents and sort of how they might have been different with this. But it's something I still feel uneasy about. And I just think that we sort of know the way it works medically, but it just raises a lot of questions about like personality and sort of choices about who we are. Over the past 40 years, the story that we tell ourselves about mental health

and how we get it and mental illness and how we beat it, it keeps changing. But none of the stories are completely adequate for explaining the fullness of human experience. At the end of the day, how do you reckon with all of this without getting very frustrated by the fact that it's been 40 years? Like, we've had chances here. Science has advanced, psychiatry has advanced, and yet we still seem stuck in, like, black or white to some degree. Right. I mean, I guess one thought that comes up when you say that is, you know, Laura is so different from Ray. And so why do we expect, like, the same solution to work for both of them? I think it has been presented as the story of the field

to a large extent is swinging from these different overarching explanatory theories. And I think, you know, one of the most important ideas for me was that it's not usually like one explanatory theory that works for someone. Sometimes someone can believe that they're having a mystical experience, but also that they need medication and that both of those sort of ways of explaining their experience can be necessary for them to start to get better. There has been this like either-or dynamic in psychiatry where we're looking for like one sweeping theory. And there have been, you know, for 40 years, scientists have been looking for some sort of like genetic marker that will correspond with the diagnosis.

And that really hasn't led to any discrete successes in that regard. So why wouldn't we start to think about all the facets of suffering that are kind of not captured by the theories that are sort of supposed to explain why someone is mentally ill. We sort of localize people's troubles in the brain and think less about the relationship between the brain and the community that that brain exists in and the way in which mental illness is a kind of relationship between like a person and the community in which they live. And not just the mental illness, but also like the way that a community responds to the illness also shapes the trajectory of that person's life.

Today's show was produced by Miles Bryan and edited by Matthew Collette. It was engineered by Paul Robert Mounsey and fact-checked by Laura Bullard. I'm Noelle King. It's Today Explained. you