Q: It seems so many depressed and variously troubled people have thought of pills as "cheating." Yet no one ever worries that drinking alcohol is cheating, and many of those same people drink or drank heavily. Why do you think that is? Alcohol, of course, has been around nearly forever, and pills are relatively new, so perhaps culture hasn't fully caught up with the concept as being a legitimate way to create mental or emotional change?
RB: There are a lot of issues at play here: culture, stigma, control, trust, education, access to care, and individual biology, to name a few. But we do need to keep in mind that while alcohol is a commonly used psychoactive substance, the antidepressant and antianxiety medications account for billions of dollars in market share and are among the most commonly prescribed medications in the United States.
When I was writing the introduction for Poets on Prozac, I was fascinated by the higher rates of antidepressant and antianxiety medication being prescribed in the United States as compared to Japan. The Japanese place a much higher cultural value on suffering as a stimulus for growth and change than Americans. Of course, the Japanese also pay a price with a higher suicide rate. And so much of our cultural view of psychoactive substances is based on arbitrary legal definitions rather than pharmacology: alcohol, tobacco, and prescription drugs are defined as legal, while marijuana and a host of others are illegal.
The legal issues overlap with stigma. People in our culture who suffer from psychiatric disorders are a highly stigmatized group and have reduced access to care compared to people who experience a medical disorder. Just take a look at health insurance coverage which either limits or tries to exclude mental health treatment.
Cultural values and stigmatization erode trust, and the disturbing overlap between the medical profession and Big Pharma also makes people uncertain about who to trust. As a doctor, I have become increasingly uncertain about how to interpret the results of studies which receive funding from drug companies or the reliability of researchers who garner huge honoraria for speaking and promotion. We now have the terrible situation in which doctors are uncertain about how to educate themselves, and that makes it difficult to educate our patients.
Which brings us back to alcohol, which is legal, cheap, "natural," easily accessible, does not require a prescription, and provides short-term relief, even if its long-term effects are potentially devastating. However, "natural" remedies, including alcohol, are part of a billion dollar industry, are promoted heavily, and have a complicated pharmacology. What I tell my patients is that we have medications that have been studied for safety and effectiveness, and other medications that have yet to be tested. For example, St. John's Wort came to the United States with a long track record of use in Germany, but the treatment studies in our country have been pretty lukewarm in terms of actual benefit when compared to a placebo.
For the poets who wrote essays for Poets on Prozac, a key element in successful treatment was their relationship with their psychiatrists, psychologists, or therapists.
SO MANY MEDS, SO LITTLE TIME
Q: Why is individual response to particular medications so various? Seems like many of your poet/essayists have tried or are on quite a number of different meds. Is this a necessary aspect of treatment?
RB: Unfortunately, the variety of the poet/essayist responses to medications is a common problem in treatment. We still don't have a single psychiatric disorder which can be diagnosed with a biological test, and we still don't understand the fundamental biology at play. For example, people know that Prozac increases a neurotransmitter called serotonin.
But serotonin is one of hundreds of neurotransmitters, and an increase in brain serotonin usually takes a few weeks to work. For roughly half the people who take this type of antidepressant, there is no beneficial response. And everyone's body handles medications differently: I see patients who have immediate effects from very low doses of medication and others whose dosing has to go way beyond the usually recommended limits in order for them to benefit.
This brings us back to the doctor-patient relationship. Most of the time, we can find a medication or combination of medications that can be helpful, but alas, the process is one of educated guess-work and trial and error. The doctor needs to create a context of hope and trust, and be an active guide through the entire process.
Q: On the subject of regaining or retaining or accessing one's creativity, how vital is the talking part of the "cure," compared to the medicinal part?
RB: When I was a medical student, psychiatry appealed to me because the profession combined all the fascinating aspects of medicine and neuroscience with the intense interpersonal aspects of psychotherapy. I trained at a time when psychoanalysts and the "talking cure" were highly valued, and when "biological" psychiatrists were just starting to have a major impact. As a result, I developed expertise in both the psychotherapeutic and psychopharmacologic interventions, and this has always informed my practice.
What is really interesting is that recent studies demonstrate that the combination of psychotherapy and medication tends to have a better outcome than either treatment alone. And perhaps most interesting of all, actual scans of the brain show changes in the same areas when patients respond to either medication or psychotherapy.
LEFT, RIGHT, WHOLE BRAIN
Q: Can you talk about the interaction and communication between brain hemispheres as that relates to creativity? In my own research with poets and novelists, I became convinced that the whole right/left brain distinction is too simplistic. (As I said in my dissertation: "Ordinary consciousness would be a subset of the larger mind, with flow allowing all the walls in the mind to disappear so the writer has access to an 'omnimax' of consciousness.")
RB: I agree. The right brain/left brain distinction is too simplistic. Alice Flaherty, MD, a neurologist, has a wonderful discussion of this issue in The Midnight Disease: The Drive to Write, Writer's Block, and the Creative Brain. The right/left brain distinctions are based on studies of people with certain types of seizures who had their corpus collosum severed to prevent the spread of seizure activity from one side of the brain to the other (the corpus collosum is the band of fibers that connects the two sides of the brain). But these "split brain" patients actually have lower rates of creativity. The brain hemispheres need to communicate with each other to generate the creative flow.
Q: Is it true that, as suggested by at least one of your contributors, poets really are more sensitive? That they see, hear, and feel more intensely, and are thus more hyperaware (the opposite of depression), which makes them better poets but more challenged in getting through life easily?
RB: As a poet, I would like to see myself as more sensitive, intense, and hyperaware. Paying acute attention and making careful, accurate observations work well for doctors, too! Since no one has ever put this question to the test of controlled research, my hunch is that this is part of a Romantic myth—the sensitive poet, suffering in the tower. Virginia Woolf had been described just this way, and then people concluded she had bipolar disorder.
Q: I get the impression that as creative linguistically as these poets are, they aren't above-average in their creativity when it comes to psychological issues, in that they "think they've tried everything," or "feel they have no other choice," that sort of thing. A matter of resilience, perhaps?
RB: Being ill and suffering really narrow a person's viewpoint and resilience. In people with psychiatric disorders, an additional component is the distortion in world-view: people who are depressed tend to see things as hopeless, including the possibility of recovery, and people who experience delusions and hallucinations in bipolar disorder or schizophrenia often don't even see themselves as "sick." So yes, people become less resilient, but that may be due to the state of being ill rather than an enduring trait.
Q: Is there really such a thing as "creative gestation" that happens during deeply depressed episodes? Does the brain need that sort of "rest"?
RB: Two of the poet/essayists write about their "creative gestation." Gwyneth Lewis discusses her severe, recurrent episodes of immobilizing depression this way, and David Budbill compares his periods of depression to the cycles of growth and rest we see in the natural world.
I also remember reading Bertrand Russell's description of how he solved complex mathematical problems: he would work on the problem with his full attention, and then he would take a break. After he had given himself enough rest, the solution would appear. This is consistent with the old adage of "I need to sleep on it."
The image at the top of this post is a photo (taken by Kristine Kisky) of art by Renee Lynn Haggart, more of whose work can be seen here.
Copyright (c) by Susan K. Perry, Ph.D.