Ordinarily Well by Peter D. Kramer

Author:Peter D. Kramer
Language: eng
Format: epub
ISBN: 9780374708962
Publisher: Farrar, Straus and Giroux

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Elaboration

I HAVE MENTIONED the theory that antidepressants restore resilience and permit recovery to proceed. Much of the support for this view comes from animal studies and parallel research on human brains. Depression seems to hamper the brain’s ability to generate new nerve cells or elaborate connections between existing ones. Antidepressants reverse these impediments. But how does that renewed flexibility translate into people’s becoming “unstuck”? What happens in the person?

For years, the official line was that antidepressants take two to four weeks to bring relief. Clinicians knew better. Kuhn spotted improvements in the first days of treatment. When I prescribed imipramine, I started with tiny doses and inched up to realistic levels; patients might notice nothing for some time. But with drugs such as Zoloft, where the initial dose can be the final, therapeutic dose, patients will report an immediate, if vague, response. The foreboding recedes. They’re not slogging through molasses.

Thanks to the work of researchers such as Philip Cowen, an Oxford University psychiatrist, we know now that medications have a quick impact. In an experiment whose results appeared in 2009, Cowen gave either a placebo pill or a half dose of an antidepressant to patients with mild-to-moderate depression. Asked to assess emotional expressions in images of faces, patients on placebo had difficulty recognizing happiness. They were also slow to recall positive events in their lives. Patients on medication recognized happiness and recalled positive events—and the normalization was apparent three hours after the administration of the first pill. The early improvement predicted a fuller response down the road.

If their helpful effects can be detected immediately, why do medicines take weeks to calm depression? Cowen finds that antidepressants act right away to correct flawed emotional processing, counteracting negative slants in perception. Long before the depression remits, patients on antidepressants see themselves and their surroundings in a warmer light. Part of what happens next may be social and psychological. Cowen writes:

According to this view, effects of antidepressants on emotional bias are seen rapidly, but the translation of these changes into improved subjective mood takes time as the patient learns to respond to this new, more positive social and emotional perspective of the world. An increased tendency to interpret social signals as positive may not immediately lead to improved mood but could reinforce social participation and social functioning, which over repeated experience improve mood and the other symptoms of depression.

This psychological sequence may not tell the whole story. Sometimes, antidepressants seem to act directly, ending a bout of illness. Occasional patients follow the “unique” pattern that Fred Quitkin observed. Three weeks in, they feel better abruptly and stay well. And as we shall see, certain medicines still being tested for depression seem to reverse the syndrome in hours or days.

Also, even where our current antidepressants act as catalysts, the change that they bring about goes beyond attitude. The medications induce actual resilience to stress—protecting cells from certain forms of biological injury—and allow for greater possibility of learning. Probably, antidepressants work on two levels, lifting despair and making the brain more responsive.

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