My morning pills consist of a multivitamin which I’m pretty sure is useless except for making nutrient-rich urine, an antidepressant which can have the unfortunate side effect of making me happy, and a mood stabiliser whose side-effects include an alarming number with the word “necrosis” in them. I swallow them every day, possibly less diligently than I should, and I guess I’m doing OK. I’m no longer skittering along a dangerous path into alcoholism, I don’t spend every day either sleeping or weighing up the benefits of suicide. Sometimes I even believe I have some kind of future and I’d even go so far as to say I’m often happy. I still sometimes wake in the night, screaming into the dark, but I suspect that’s just an active metaphor for most people’s experience of life. So I guess the drugs are doing OK.
I’d possibly be dead without them.
As I say, the antidepressant can on occasion make me a little too happy - or rather, hypomanic, which can be happy but can also be angry, spiteful and black. My last psychiatric consultation we discussed this, discussed bringing my dose down, eventually maybe stopping. Nobody wants to take drugs. There’s a good possibility that manic and hypomanic states can cause damage to the brain and - besides - they definitely cause disruption to my life. We talk about the mood stabiliser, maybe an increase in dose? We’ll have to keep an eye on my bloods, make sure nothing untoward is happening - “multi organ system failure” for example, which makes me sound like an exceptionally buggy copy of Windows Vista. We run through other options - counselling? Group therapy? She looks almost sheepish as she mentions “mindfulness? It’s the in thing at the moment”.
It is indeed the in thing; promoted by the NHS and at GP surgeries, and subject to numerous newspaper pieces, mindfulness-based cognitive therapy is suffering the fate of many promising psychiatric treatments - hype and over application. Based on a sliver of Buddhist practice - especially Zen Buddhist practice - MBCT attempts to engender both a spirit of detached observation and increased emotional and physical awareness. This can be achieved through meditation or through less intense practice of ‘being in the moment’; individuals become more sensitive to incipient mood disruptions and can avoid being caught in plunging, self-reinforcing mood cycles. The therapy has a decent evidential base and I’ve engaged with it a few times, I believe to my benefit. So it’s possible that MBCT has shot to fame entirely on its own merits, but it’s hard to avoid the suspicion it appeals to cultural discomfort with psychiatric medication and a desire to fix things ‘naturally’.
This discomfort isn’t unreasonable - it’d be nice to be able to sort my head out without having to worry about a list of side-effects. But fixing things “naturally” is no guarantee there will be no unwanted side-effects - it turns out St Johns Wort, which is possibly useful for mild depression, can have some nasty effects involving disruption of contraceptive drugs. But surely meditation is different? Sitting calm and simply observing thoughts is hardly going to lead to anything involving system failure, is it?
But if a treatment has an effect, it will also have side-effects.
MBCT was never meant to treat depression - at least, not immediately. Recognising that asking depressed individuals to observe their thoughts would generally lead to them getting more depressed, mindfulness is instead meant as a prophylactic. Meditation and “being present” might help you avoid depression, but not resolve it. However, as MBCT has become more popular, this is often forgotten. To us patients it can often seem that it is being offered as a quick cure all; a sticking plaster which doesn’t stick. Charlotte Walker, a mental health advocate who blogs as Bipolar Blogger, tells me “I have heard of staff saying to people, often in crisis, “Have you tried mindfulness?” like it’s completely uncomplicated... the staff member really doesn’t understand what they are talking about”. Behavioural approaches such as MBCT need to be actively engaged with, something a profoundly depressed individual simply cannot do.
Further, it is becoming increasingly apparent that not all of meditation’s effects are necessarily benign, and that it is indeed possible to have too much of a good thing; meditators sometimes report feelings of depersonalisation or derealisation, as the self and the world take on a strange, fake or staged quality. I’ve experienced this mildly, as a symptom of the bipolar; while not painful it is certainly worrying and distracting. Applying such a treatment to psychologically unstable individuals - even those whose symptoms are in remission - should be approached with the same degree of caution as a prescription for a new drug.
My psychiatrist was about to move on - next appointment date, blood test form, check address details - when I agreed to the mindfulness. It is indeed the “in thing”, probably over hyped and over prescribed and now suffering the beginnings of a backlash. But we shouldn’t throw out the Buddha with the bathwater. The consistently reported side-effects of mindfulness meditation give me confidence that the treatment is no placebo. Walker is also willing to fight its corner - telling me of her frustration that a potentially effective treatment is suffering a backlash thanks to poor education and inappropriate implementation. And the more worrying effects - depersonalisation, panic - seem to follow a dose response curve, arising from intensive meditation. Much as with my mood stabiliser, it might be best to start low, and increase if it feels right; to watch out for system failure.
A perennial debate - one which has recently resurfaced - is the appropriateness of pharmacological treatments for psychiatric disorders, given their known side-effects. This is an important ongoing conversation and these questions apply to all disorders and all drugs - but mental health often seems to be singled out. We are happy for people to take pills for blood pressure or diabetes even as we know that exercise and diet can play a huge role in these domains. Conversely, for depression, OCD and even schizophrenia, society can seem actively aggressive toward the drugs used, despite the fact these disorders can be not only debilitating, but deadly. All effective treatments - all – will have side-effects, and behavioural interventions should not be given a free pass. I’ll continue to swallow my pills, and will continue to talk with my psychiatrist, watching my treatments for signs they need adjusting, or signs they’re doing me harm.
Philip Hoggart is on Twitter as @anandamide