The Problem With Pills
Antidepressant drug use has increased dramatically over the last few decades. In the United States they are now the most commonly prescribed drugs in all of medicine. Doctors write more prescriptions for antidepressants than for the treatment of hypertension. Three times more antidepressants were prescribed between 1999 and 2000 than between 1988 and 1994, and between 1996 and 2005 there was a 75% rise in antidepressant prescriptions.
There are many reasons for this escalation in the use of antidepressants. Most importantly, since Prozac’s introduction to the market antidepressants have been safe to use and therefore easier to prescribe. They do not lead to accidental or intentional death as the earlier generation of antidepressants did. A month’s supply of pre-Prozac antidepressants taken at once could be fatal. Not so with the newer antidepressants. This is clearly a good thing. If the greater use of antidepressants means that more people suffering from depression receive safe and effective treatment, then that is a positive step forward.
The rise in number of prescriptions parallels the rise in the rate of diagnosis of depression as a psychiatric illness. There are estimates that one in four people will develop depressive illness during their lifetime. This means that given an average family size of four people, you could say that every family will have at least one person with depression and that every family will therefore know the mental illness called depression. When you consider that the word “decimation” refers to one in ten people being afflicted, then something that afflicts one in four seems awfully high.
Depression is decimating us.
There are a number of interesting possible explanations for the rise in the rate of diagnosis of depression as a mental disorder, and I will write about it in a later post.
For now let’s just consider the role of self-esteem in depression, as this may shed light on whether depression is accurately diagnosed as an illness or whether it is being mistaken for something else, since not all feelings of depression are pathological signs of an illness. In fact depression is a common and necessary human emotion. Without the capacity for sadness, it would not be possible to form attachments to others and to things that please us. If we don’t feel sad and depressed when we lose something of value, we would not be reacting normally to the loss.
We psychiatrists normally understand low self-esteem to be a symptom of depressive illness. However, because the diagnostic system we use considers only symptoms and not causes in the diagnosis of psychiatric illness (including depression), it does not take account of the role that low self-esteem plays as a cause of depression. When the source of unhappiness is not considered, it is much more difficult for doctors to tell healthy depression apart from unhealthy depression.
Failed low self-esteem is depressing.
In order to appreciate the role that low self-esteem plays in causing unhappiness and depression, it is necessary to understand how low self-esteem comes about. Self-esteem arises naturally and spontaneously when we are between three and five years old. It emerges in the form of low self-esteem, and does so in response to two separate, unrelated and unavoidable influences.
The first influence is the experience of becoming overwhelmed when our needs go unmet because our primary caregiver, typically our mother, happens to be unavailable when we need her. Even though it is not her intention to be absent when we need her, when we are very young we nevertheless experience her absence at those random times that we just happen to need her as abandonment, and this abandonment is traumatic and threatening to us. And, as human beings, we deal with threat through thought. (We are Homo sapiens, after all, sapiens meaning “wise.”) And it is a specific aspect of our thought that is the second influence that gives rise to self-esteem.
The earliest stage at which we are able to make sense of our experience is when we are cognitively or intellectually egocentric, according to Jean Piaget, the founder of the school of cognitive development, and this is generally before the age of seven. In this egocentric or narcissistic stage, the only way we are able to make sense of our experience is from our own point of view. That is, we cannot put ourselves in anyone else’s shoes and see things from their point of view. We cannot understand or know that our mother’s absence is for her own reasons and that it has nothing to do with us. She may be at work or stuck in traffic or busy with any of a vast number of things, all reasons that are not about or because of us and have nothing to do with us. But that is not how we understand her absence. We only understand her absence from our point of view, and what we conclude (incorrectly, as it turns out) is that her absence means that we are not important, that we do not matter and that we are not worth caring about. In other words, our cognitive narcissism misinterprets her absence as being about us, and through this distortion we mistakenly reach the conclusion that we are not worth caring for, that we are not worth being kept alive and that we are worthless. This is the origin of our deep-rooted conviction that we are inherently worthless and is the source of our low self-esteem.
The combination of abandonment and intellectual narcissism leads to low self-esteem.
The experience of both abandonment and cognitive narcissism is universal. All of us (almost without exception) experience it, as we all do the state of low self-esteem that results from these two experiences. The conclusion that we are worthless provokes in each and every one of us the drive to make our mothers care for us, which we do by pleasing them. We learn to please our mothers, along with the other adults upon whom our survival depends, as a way of inducing them to care for us. As long as they actively care for us and meet our needs, then to our narcissistic minds we are worth being cared for and we are worthwhile. In other words, the only way we can feel worthwhile or valuable is by having someone else care for and about us. As long as someone else values us, we are valuable. This is how we are able to feel worthwhile and the only way we are able to experience positive self-esteem.
We all experience low self-esteem as our default position. To the degree that we are able to make others value us, we have the experience of successful low self-esteem (or what we commonly refer to as positive self-esteem), and that feels good. And this reliance on others for positive self-worth remains with us through our childhood and follows us into adulthood, even though on one level we are able to provide for ourselves and see to our own physical survival and are able to see some things rationally and objectively as we develop beyond our intellectual narcissism. But even as adults we all continue to rely on others and on the outside world in general to validate and value us.
However, when for whatever reason the world stops validating and affirming us or threatens to stop caring for us and it seems that no one values us, then what we feel is that we are worthless. In other words, we experience failed low self-esteem. When we regress to our original state of feeling worthless, this experience of feeling worthless is exquisitely and often unbearably painful. When we cannot do anything to alter this state, when we cannot find new ways to make others value us, we get stuck in a state of failed low self-esteem, which seems as though we are at the bottom of a deep pit and we feel understandably miserable, hopeless and despairing. This state of failed low self-esteem is the state that many doctors regard as an illness and treat with antidepressants.
Antidepressants can reduce our feelings of distress and to some extent can numb our pain. Perhaps by numbing our pain pills enable us to think more effectively about other ways of re-engaging the world to affirm us again, and sometimes the pills free our energies to try new ways of inducing the world to value us.
Pills numb us; they don’t change us.
What antidepressants cannot do for us is change our circumstances and make the world value us again. Nor can they teach us how to overcome our reliance on others as our source of positive self-esteem and become our own source of self-worth. This is the problem with antidepressants: they cannot teach us anything, and specifically they cannot teach us what we need to know in order to be worthwhile.
The most effective and lasting way to deal with the problem of failed low self-esteem is giving up our reliance on others, on external sources, and becoming our own source of self-worth. When we are stuck in the state of failed low self-esteem, we need to know that we can replace others as the source of our self-worth. We also need to know how to become our own source of self-worth. There is specific information we need in order to accomplish this shift, and we need to learn how to apply this knowledge. It is very important to appreciate that it is comfortably within the grasp of all of us to learn everything we need to know about how to become our own source of self-worth.
I will write about how we can learn to replace others as the source of our self-worth in a later post.