Medication and Its Discontents

Blue Dreams: The Science and the Story of the Drugs that Changed Our Minds BY Lauren Slater. Little, Brown and Company. Hardcover, 576 pages. $30

It’s hard to say exactly when her depression began, Lauren Slater tells us, but she has a memory from the summer of her sixth or seventh year. She and her sister were sitting on their stoop, sweltering in the heat, when they were approached by a sweaty man in a dark suit. “His face perspired heavily as he knelt by my sister and me and asked if we would like to see his monkey dance,” she writes. “He was so close I could smell his cinder breath and then I saw his hand, or rather his lack of a hand, how one empty cuff just hung down, the skin at the knob of his bony wrist marbled and seamed.” Suddenly, a monkey leaped out, “a little creature with fur the color of driftwood and a tiny triangular hat on his tiny head.” The man sang, the monkey danced, the child looked on in horror.

That night she had a dream: “I was trying to call someone but despite looking everywhere could not find my hand and thus could not complete the call.” She woke up the next morning in a state of extreme anxiety, the room dissolving around her. Things eventually came back into focus, but she had the sensation that her body had grown heavier and that an object had become lodged in her stomach. “Something,” she says, “was wrong.”

Memories like this one—urgent, vivid, surreal—are of special interest to psychoanalysis. They are thought to preserve, in distorted form, other memories, or even fantasies, that have succumbed to the forces of repression. One could imagine hearing this from a patient and wondering if the marbled, seamed, fleshy stump surrounded by a loose sheaf was an exaggerated memory of the father’s penis, or if the flash of tan fur with a tiny triangular hat on its tiny head was a childish impression of the mother’s exposed genitals. Similarly, one could imagine hearing all this and wondering if that encounter on a sweltering summer afternoon had stirred up memories of waking from a nap some other hot afternoon and catching the parents in flagrante; if the dream was about the anxious feeling that her body was missing something; if the object in her stomach was not a stone, as she tells us, but an imaginary baby.

Then again, maybe her serotonin levels were just off. I, for one, look forward to the day when the mind-body problem is solved once and for all (I can just see the headline now: “Philosophers and Scientists Reach Historic Settlement”). As it stands, when it comes to something like depression, we can’t even agree on what we’re curing, let alone how we’re going to cure it. A clinical psychologist, science writer, and memoirist, Slater is best known for Prozac Diary (1998), which, like Blue Dreams, explored her experiences with psychiatric medication. She’s also the author of Opening Skinner’s Box (2004), a book about twentieth-century psychological experimentation, some of which she subjected herself to; Lying (2000), a memoir, or maybe pseudo-memoir, about epilepsy, or maybe pseudo-epilepsy; and a half dozen other titles. The books have not been without controversy, including accusations that she has gotten facts wrong (which happens to all of us) and that she fabricated quotes (which doesn’t). I have no way of knowing whether these accusations are justified, but I would add that some of the methods in her earlier work, like feigning mental illness in emergency rooms, and alcoholism at AA meetings, have never sat well with me (“The whole thing is done in a lighthearted way,” she told the New York Times).

In her latest book, Slater introduces us to some of the most significant psychiatric medications of the past hundred or so years, including chlorpromazine, lithium, and antidepressants, as well as to some of the latest trends, notably psychedelics and drugs designed to enhance or erase memories. Mixing memoir, history, and medical reporting, she brings a deep appreciation of all the hope that has gone into these drugs, both among those who make them and those who take them. She also brings her ambivalence, based on her own experiences with several of the medications she explores. “Thanks to psychiatry’s drugs, I have a mind that can appreciate the beauty around me,” she writes, “but then, thanks to psychiatry’s drugs, I am dying faster than you are, my body crumbling as side effect after side effect sets in.”

Take chlorpromazine, better known by its trade name, Thorazine, which revolutionized the treatment of mental illness when it was introduced in the 1950s. If Slater’s story of the man and his monkey feels a lot like a Tom Waits song, her account of Thorazine could be the “Prisoners’ Chorus” from Fidelio. Patients who had been catatonic for years were suddenly able to speak, laugh, receive visitors, go on outings, and, in some cases, return to their homes. The number of inpatients in mental wards plummeted. Lobotomies, shock therapies, and similar treatments were largely relegated to the medical-waste bin of history. “Within a decade, the drug had been taken worldwide by fifty million people,” Slater writes. It remains on the World Health Organization’s list of essential medicines. But the side effects were not trivial. Many patients on Thorazine developed tardive dyskinesia: blinking eyes, protruding tongue, grimacing mouth, awkward gait. In popular culture, this came to be known as the “Thorazine shuffle.” To be sure, drugs like Thorazine are not unique, or even unusual, among medications in having unintended consequences (the Greek pharmakon meaning both “remedy” and “poison”). But in psychiatry the costs are much easier to describe than the benefits, which tend to be intangible. Is it worth risking diabetes to control delusions? Massive weight gain to limit aggressiveness? Sexual dysfunction to relieve depression?

These are intensely personal decisions, and Blue Dreams is at its best when it portrays people, first and foremost Slater herself, struggling to make them. This comes across most powerfully in the chapters on antidepressants. Much of what she has to say will be familiar to anyone who has taken an interest in the topic; for those who have yet to, this is a fine place to start, less because her account reflects the latest research—for that, readers should look elsewhere—than because it humanizes the issues involved. Slater tells us she took Prozac, in increasing doses, for nearly two decades, until it stopped working for her and she moved on to other medications. If Thorazine reflected a certain postwar optimism, Prozac was all about late-capitalist cynicism: rapacious corporations, conflict-ridden researchers, overworked doctors, patients with nowhere else to turn. Which doesn’t mean it didn’t help, though perhaps not as often, or as much, as was claimed.

Indeed, for a book that puts so much emphasis on the question of efficacy, it includes surprisingly little recent research on the topic. Blue Dreams often feels oddly out of date. Nowhere is this more evident than in Slater’s discussion of psychotherapy, where she relies almost entirely on a single book, Daniel Moerman’s Meaning, Medicine, and the “Placebo Effect” (2002), and its secondhand account of studies published twenty, thirty, even forty years ago. This gives rise to a number of claims that are either inscrutable, like when she writes that “those who receive psychotherapy of some kind are on average more psychologically well than 75 percent of people who don’t,” or outright misleading, like when she tells us it makes no difference at all what form of therapy one chooses, they all help equally. There are many more recent, and far more rigorous, studies that contradict this claim. For example, a 2015 study sponsored by the British National Health Service found that chronically depressed patients who received eighteen months of once-a-week psychoanalytic psychotherapy were significantly more likely to get better, and stay better, than patients who received the usual brew of counseling, cognitive-behavioral therapy, and medication. There was a great article about it in The Guardian. It’s not even behind a paywall.

The book’s later chapters focus on recent interest in the therapeutic potential of psychedelic mushrooms, LSD, MDMA, and ketamine. Slater describes, for example, how physicians at several universities in the US and Europe have started offering hallucinogens to terminally ill cancer patients to help ease the anxiety of death with what sounds like some success. Slater writes of a woman who had hallucinated a cartoon crustacean during a psilocybin study at Johns Hopkins: “Through the crab, with the crab, Vincent saw that her illness and death were not nearly the big deal that she had made them out to be.” Meanwhile, other researchers have been experimenting with MDMA, better known as Ecstasy, to treat depression, post-traumatic stress disorder, autism, and even marital conflict, thanks to its tendency to promote feelings of connectedness. Slater makes no mention of the microdosing phenomenon, though it would have fit nicely. “Our next golden era of psychopharmacology,” she predicts in the book’s final pages, “will be with psychedelics, drugs not discovered but rediscovered, drugs so pure and powerful that they crack the thin veneer we call reality and show us a show the likes of which we do not forget.”

Is it just me, or does this not feel a bit like that memory of the dancing monkey? The repressed always returns. Psychedelics may indeed expand consciousness for a few hours, but the unconscious will be waiting, and will have to be reckoned with. “In some strange way,” she writes of these drugs, “they reunite us with the father of psychoanalysis, Sigmund Freud, who believed that awareness was the vehicle by which we could be cured of our ills.” But this wasn’t quite what Freud believed. In general, awareness comes easily. Most patients show up with it. The hard part is understanding, and then figuring out what to do with that understanding. Drugs may be able to help this process, but they will never be able to replace it.

Ben Kafka is an associate professor in the department of media, culture, and communication at New York University and a psychoanalyst in private practice in Lower Manhattan.