The Best of Times...

"He knew what this thing was--hysteria, a snake whose scales are tiny mirrors in which the dead world takes on a semblance of life."

Miss Lonelyhearts

One of my early fascinations with psychiatry was the question of whether the problems we face are primarily "the thousand natural shocks that flesh is heir to" or whether they are largely of our own making. Of course, inasmuch as we are natural creatures, our soiling of our own nest is merely another "natural shock," but while this may be a cosmic comfort, the serenity prayer codifies our belief that wisdom is knowing what we can alter and what we can't. And the parallel question of perennial controversy is whether psychiatry itself makes things better or worse overall.

It is a time of extremes (a "bipolar" time indeed). Every generation in history has probably thought of itself as exceptional in some way, but we are different because we really are exceptional (ha). Our 63-year-old awareness that civilization as we know it could end in minutes (see Cormac McCarthy's The Road, but not if you're depressed) has been broadened to the increasingly visceral knowledge of the planet's potential environmental depletion and degradation. And yet by many other measures those who live today, excepting the billion or so of the absolute poor (a dreadful exception I know), enjoy greater comforts and advantages than most who have ever lived on the planet.

The current fascination with happiness and "positive psychology" suggests that we increasingly wonder whether we're better or worse off than our ancestors. It is interesting to me how many patients have brought this up spontaneously over the years. "Are more people stressed out these days?" I answer that many people wonder the same thing, but that no one really knows.

Pysch Central among many others reported on the recent 5% increase in the suicide rate in the U.S. between 1999 and 2005, an uptick that surprisingly occurred chiefly among middle-aged white men and women. Speculative causes that I read about included increased abuse of opiate pankillers (no longer a specialty of the young), the decrease in estrogen use after its risks were shown, and increased depression and PTSD among war veterans. It is discouraging that psychiatry's efforts in this respect make such a modest impact.

Psychiatrist Peter Whybrow, M.D. is reported as opining that our contemporary consumerist lifestyle has hijacked evolutionary drives that were once advantageous but may be no longer (sort of like cotton candy). Much as cocaine affects dopamine systems that were naturally selected for other purposes, our endless craving for more stuff (stoked of course by overheated, and I dare say underregulated, capitalism) only leaves us crashing, empty and wanting more. It is an interesting idea, even if the title of the linked article, "American Dream an Impossibility, Neuroscientist Says," sounds like a headline from The Onion.

Dear Abby has been around for a long time, but recent years have seen a proliferation of celebrity advice-givers and counsellors (for a while there Dr. Phil seemed to be everywhere), who constitute an "alternative" treatment within psychiatry every bit as much as St. John's Wort. One advice-giver I enjoy following is Dear Prudence (Emily Yoffe) at Slate, who almost always is, in fact, as wise as one would wish a therapist to be. Many of the stories people write in with, naturally, are (often ludicrous) family situations, but this week's entry contains a woman who asks for help with "self-loathing" unrelieved by conventional psychotherapy and medication.

To some degree the trend of alternative "therapy" represents dissatisfaction with mainstream psychiatry or even imperfect access to the same, but in a wider sense it could reflect a popular discontent, a feeling that our once common cultural bearings and guideposts are being lost. The most devastatingly satirical look at this phenomenon that I know of is Nathanael West's novella Miss Lonelyhearts, written interestingly in the 1930's (his Day of the Locust was a similarly spot-on treatment of celebrity culture). It is satire as transcendence; if Obama is our FDR (ha), who is our Nathanael West (who died young in a car accident)? Maybe David Foster Wallace? If his Infinite Jest (confessedly, as yet unread by me) could have been compressed to short-novel length, perhaps it could have had the white heat of Miss Lonelyhearts. But where is Wallace when we need him?