The Mind and the Moon: My Brother’s Story, the Science of Our Brains, and the Search for Our Psyches, by Daniel Bergner (Ecco, 320 pp., $28.99)
The specter of mental illness haunts America. A tourist is pushed onto a New York subway track. A madman running through Times Square knocks a nurse to the ground, killing her. Hundreds sleep in the streets of San Francisco’s Tenderloin neighborhood, under the Manhattan Bridge, or in a beat-up Chevy Nova across the street from the Los Angeles County Museum of Art. A young man enters a school, a church, or a movie theater, kills innocents, and perhaps then himself.
Earlier this summer, mass shootings claimed the lives of 36 people, including 19 children in Uvalde, Texas. The recently passed Bipartisan Safer Communities Act expands access to mental-health services at schools and may prevent some mass shootings, but the challenge is far larger. Over the same period, for example, an estimated 930 young men in the throes of depression killed themselves with guns.
Addressing the intersection of mental illness, suicide, and gun violence was not Daniel Bergner’s intent in writing The Mind and the Moon, but the book, a compelling memoir-cum-history published on May 16, two days after the Buffalo supermarket murders, is timely.
With each passing year, fewer people recall the horrors inflicted on patients at institutions like Willowbrook. Geraldo Rivera is known today as a talk radio and cable news host—not a crusading muckraker whose 1972 exposé contributed to federal laws granting civil rights to the mentally unwell. Forgetful of the past, we ask why such people aren’t locked up.
Like many who have not experienced mental illness directly, I believed that medication helps. Buying a gun ought to be as hard for an 18-year-old as buying a car, I thought—but if we medicated at-risk kids, we’d address much of this awful problem. The people I saw wandering the streets and subways needed only to take their pills, I figured. “If it were only so simple,” as Solzhenitsyn wrote.
Bergner, the author of five deeply reported nonfiction books and numerous magazine essays, recounts the history of psychiatry, from Bedlam to Zoloft, via profiles of three individuals dealing with mental illness: Caroline, David, and Bob (the author’s brother). While by now, most recognize the limits of Freudian analysis, our faith in the chemical solutions that often replace talk therapy is similarly misplaced, writes Bergner. He explores alternative approaches and hints that religious faith might work in concert with, not in opposition to, medical science.
The three profiles put a much-needed human face on those who struggle with psychosis. Equally important, Bergner details the scant evidence for various drugs’ positive impact. Since the 1960s, psychiatry has explained depression, psychosis, and other maladies as arising from chemical imbalances—in particular, from norepinephrine production. Bergner presents copious evidence of the woeful simplicity of this theory, which, in any case, the American Psychiatric Association never actually endorsed, and which new research gives further grounds to doubt.
Researcher Donald Goff is one of Berger’s leading experts. In an early Zyprexa trial, his patient made miraculous progress, throwing off crutches and walking freely for the first time in years. Looking back, Goff explains that “your opinion of a drug is formed disproportionately by the first patient you treat with it.” But when Harvard’s Irving Kirsch undertook a meta-analysis of all the studies psychotropic drugmakers had submitted to the FDA, it was clear that pills rarely outperformed placebos. Because of a “widespread need to believe in the drugs,” Bergner explains, Kirsch fielded attacks from numerous critics. Leading the charge was psychiatrist Peter Kramer, author of the best-selling Listening to Prozac, who, according to Bergner, privileged his personal experience and “clinical wisdom” over the data.
Four years ago, the FDA expanded Kirsch’s 1999 analysis to include 73,000 participants, some from as recently as 2016, across 230 trials. Their conclusion was nearly the same: 15 percent of sufferers do benefit from antipsychotics, but the FDA found no way of identifying them in advance.
Even worse, psychotropic drugs have side effects that, while not as awful as the lobotomies and involuntary commitments that they replaced, are often punishing. To name a few: weight gain, gynecomastia, tardive dyskinesia, headaches, dry mouth, loss of sex drive. These side effects often continue even if the patient stops taking the drug. One understands why many patients stop taking medication and try to manage on their own. As The New England Journal of Medicine declared, “We are facing the stark limitations of biological treatments.”
Public ignorance about this reality arises partly from clinicians trusting their beliefs over empiricism, but also from pharmaceutical giants that deny discomfiting data while peddling promises like “you should always feel happy” (Pfizer’s pitch for Zoloft) to potential patients and uninformed generalist physicians. In 2009, the firm paid $2.9 billion to settle illegal marketing charges. Eli Lilly paid close to $3 billion in fines and settlements for deceptive marketing of its antipsychotic Zyprexa. The penalties are a fraction of the $60 billion in Zyprexa sales over several decades or the $3.3 billion worth of Zoloft that Pfizer sells in a good year.
Mount Sinai researcher Eric Nestler tells Bergner that “30 to 40 percent of college students are treated with psychiatric medication at some point in their college years and there is no way that their incidence of mental illness approaches forty percent.” As author Andrew Solomon observed nearly three decades ago, “We now identify as pathology many things that were previously accepted as personality.”
Bergner’s narrative is upsetting to many. Freddie deBoer, a cultural critic who takes lithium to control bipolar disorder, thinks Berger’s book is malpractice. He rejects the idea that a psychotic disorder is “an identity or some magical superpower [a patient should] love.” Responding to an excerpt about Caroline’s work with the Hearing Voices Network, deBoer poignantly declares, “I don’t need to be accepted when I am behaving psychotically. I need someone to stop me from doing the things I would do.” He acknowledges lithium’s awful side effects and his desire for better treatments but insists that “involuntary treatment saves lives.”
So how do we move forward in this vital policy debate? Tentatively. With humility. And by accepting that not every question about our minds will yield an answer.
Neither benzodiazepine nor psilocybin mushrooms nor transcranial magnetic stimulation ameliorates David’s depression. Bergner’s descriptions of his growing detachment from the important civil rights work that previously grounded him, a wife who loves him, and a child who needs him is heartbreaking. In his case, we cannot yet offer an answer.
Caroline, on the other hand, learns to tolerate the voices she hears. She has come to understand that atypical is not the same as abnormal. Her nascent program centers on peer therapy and tolerance of psychiatric difference. In some ways this approach echoes the beliefs of Thomas Szasz, an influential psychiatrist whom Bergner profiles. In the late 1950s and early 1960s, Szasz challenged the classification of mental illnesses as diseases, becoming “the biggest of the antipsychiatry intellectuals,” according to Edward Shorter, a historian of psychiatry.
Freud’s theories have fallen from favor, discredited by subsequent research and the often-false promise of drugs. Cognitive Behavior Therapy (CBT) is a talking cure that appears effective for many, but Bergner addresses it only briefly. By naming harmful thoughts and judging their accuracy, CBT can help patients challenge and overcome their fears. Solomon called depression “a disease of self-obsession” which suggests that looking outward helps. Jordan Peterson, a psychologist focused on behavioral therapy, authored the best-selling 12 Rules for Life, which urges readers to “treat yourself like you are someone you are responsible for helping” and “compare yourself to who you were yesterday, not to who someone else is today.”
DeBoer’s and Solomon’s experiences show that drugs are sometimes a solution. But echoing Solomon’s concerns about over-prescribing, Mount Sinai’s Nestler tells Bergner, “We could do with much less medication.” He lists several alternatives: “Exercise. Better sleep. Mindfulness, the belief in something bigger than yourself. Religion if you’re religious.”
Nestler’s reference to religion surprised Bergner, but the author’s brother Bob felt called while meditating in Montreal Park. After nearly two decades in and out of hospitals, he stopped taking medications and rejected the bipolar label that was attached to him in his thirties. He leads an Episcopalian congregation in Connecticut and works to destigmatize mental illness and side effects like homelessness.
According to the Pew Research Center, studies over the past three decades “have found that religious people tend to live longer, get sick less often and are better able to cope with stress.” In the Handbook of Religion and Health, Duke professor Harold Koenig and coauthors note that religious faith is associated with fewer signs of psychoticism (“characterized by risk taking and lack of responsibility”) in 16 of 19 studies.
Prescribing religious belief to those who do not already embrace it will be no more effective than Xanax. But whether it comes from a hope for life everlasting or fear of eternal damnation, the idea of sublimating oneself to a broader purpose could help. Robert Putnam’s Bowling Alone identified isolation and the loss of community as societal risks. While the root causes of conditions like depression and schizophrenia are more complex than mere alienation, it seems intuitive that a philosophical view that connects oneself to the larger world and physical structures that connect one to a larger community can help. As Solomon writes, “Syndrome and symptom cause each other: loneliness is depressing, but depression also causes loneliness.”
Bergner doesn’t claim that pre-Enlightenment religious faith will save us, but he wonders “about the cost of our belief in biological psychiatry . . . the cost of our centuries-old faith . . . in the potential of science and medicine to right our minds.”
Our failure to achieve progress is not a reason to abandon science, however. In some cases, for reasons we still can’t understand, chemicals relieve some sufferers of the worst effects of their condition. But Jordan Peterson’s recent battle with depression and withdrawal from benzodiazepine remind us that they don’t always work, and side effects are a real concern.
Because the brain is our most energy-hungry organ, we have evolved to use as little of it as possible. Psychologist Daniel Kahneman won the Nobel Prize for cataloging the ways we avoid thinking—how we trick ourselves into ignoring data that we find inconvenient or believe the story we heard most recently. We dream of silver bullets, extrapolating universal solutions from personal experience, falling victim to the narrative fallacy over and over. Discussing his book at a Brooklyn synagogue, Bergner observed ironically that it is this same inefficient, imperfect organ that we use to develop models of our brain.
Adamant atheists in the progressive precincts of Park Slope may dismiss religion. Aggrieved academics can dismiss Peterson as a peddler of nostrums. Neither mushrooms, nor LSD, nor the Hearing Voices Network will work for everyone. But there is no surefire solution to preventing the next Uvalde or saving the lives of the estimated 125 people who will kill themselves in America every day. The hard work of addressing this crisis starts by acknowledging the limits of our current knowledge and developing nuanced responses to mental illness—not misspending billions on ineffective and harmful medications.
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