Nonfiction: A Reckoning With an Imperfect Science in ‘Blue Dreams’

The story of Slater’s attempts to get and stay well weaves throughout “Blue Dreams: The Science and the Story of the Drugs That Changed Our Minds” and provides some of the book’s most poignant and lyrical writing. Just as important, her experience makes her a convincing travel guide into the history, creation and future of psychotropics. She is, understandably, not an uncritical cheerleader. But she resists the facile role of hard-charging prosecutor. And no wonder, really, given that the drugs have allowed her to have two children, write nine books, marry (and divorce) and hold dear friendships.


Credit Alessandra Montalto/The New York Times

So, when she takes us back to the 1950s and the story of Thorazine, she doesn’t just give us a “One Flew Over the Cuckoo’s Nest” bag of horrors, but also a glimpse into doctors’ excitement when the drug quelled patients’ delusions and hallucinations and the once-comatose resumed living. A former barber, who had been in a haze for years and for whom all previous treatments failed, returned to shaving (his first customer: the doctor who gave him Thorazine). A juggler asked for billiard balls and began juggling again. And people on one psychiatric ward picked up musical instruments, used drills and saws, held conversations that had been unthinkable shortly before.

In what becomes a through-line in the book, no one fully understood how the drug worked (nor do we know what happened to the juggler or barber once they left the asylum). It was simply enough that it seemed to be working. And yet, in high doses and over the long term, patients often experienced tardive dyskinesia, which includes tongue thrusting, lip smacking, restlessness, involuntary movements of arms and legs, which become twisted like pretzels. When Slater wonders aloud to a psychiatrist why the new class of antipsychotics is really so much better than the old ones, he says: “You have to pick your poisons. Which would you rather be in two years — a circus freak or a diabetic?”

She takes us on similar journeys into lithium and MAO inhibitors, each bringing hope and problems. And then, in the late 1980s there’s the arrival of serotonin reuptake inhibitors, known as SSRIs, and their promise to be different from the antidepressants of the past. The standard explanation is that Prozac, Celexa, Zoloft and other SSRIs boost serotonin levels. But studies have never proved that depressed people suffer from low serotonin (some do, some have normal levels and others have high levels). And SSRIs often fare no better than placebos for mild to moderate depression. Still, doctors tend to talk about depression as if the science is settled, often telling patients: If you’re diabetic you take insulin; if you’re depressed you take a pill. The analogy, of course, doesn’t hold. There is no blood test, no X-ray, no urinalysis that pinpoints depression. It is a field, Slater writes, “still stuttering, with at best a slippery grasp on the science behind its pills and potions, a legion of medical men and women who can help you in one way but hurt you in another.”

Hope does arrive in the second half of “Blue Dreams,” when Slater walks us through emerging interventions. Unfortunately, by this point she’s taken us through so much material and still has so far to go — including brain stimulation and memory drugs — that the journey begins to feel too wide-ranging and, occasionally, too thin on details about what we’re passing along the way.

Still, several of the up-and-coming treatments — many of them not new at all — shift our focus from unmediated pill popping. Among them are placebos, which don’t work for all patients and have no effect on those with Alzheimer’s. But, as Slater rightly notes, numerous studies show their amazing potency, which remains too untapped by a psychiatry field still enthralled with drugs.

Like placebos, hallucinogens also aren’t new, of course, but researchers are repurposing them in promising ways. Studies show that psilocybin, the active ingredient in so-called magic mushrooms, curbs smoking addiction, as well as relieves anxiety and depression for people with end-stage cancer. And in clinical trials, psychotherapy combined with MDMA (the chemical more commonly known as ecstasy) offers significant relief for PTSD sufferers. The drug, which creates feelings of empathy and euphoria, allows traumatized victims to recall their terrors in a calm state of mind and establish deep trust with their therapists — ingredients that pave the way for psychological change.

One of the keys for MDMA, psilocybin and some placebo therapies is the connection between patient and provider. And connection is exactly what vanishes during Slater’s own depressive states. Her primary feeling, she writes, is “the loss of love — my people falling away — and the loss of language, my words dwindling so low that my thought seems to move without rhythm or reason.”

It’s no surprise that Slater goes searching for relief among these new treatments. She tracks down a therapist who uses MDMA in her practice. And in the cozy office painted in calming colors, Slater tells the therapist her history and lists her prescriptions. MDMA won’t work for Slater, the therapist tells her; her current medications would block the drug’s effects. Slater knows from past experiences that she can’t risk weening herself from the prescriptions that keep her stable. Her dependency on our terribly imperfect drugs has ruled out her candidacy for more promising ones.

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Well: Early Puberty in Girls Raises the Risk of Depression


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When girls come in for their physical exams, one of the questions I routinely ask is “Do you get your period?” I try to ask before I expect the answer to be yes, so that if a girl doesn’t seem to know about the changes of puberty that lie ahead, I can encourage her to talk about them with her mother, and offer to help answer questions. And I often point out that even those who have not yet embarked on puberty themselves are likely to have classmates who are going through these changes, so, again, it’s important to let kids know that their questions are welcome, and will be answered accurately.

But like everybody else who deals with girls, I’m aware that this means bringing up the topic when girls are pretty young. Puberty is now coming earlier for many girls, with bodies changing in the third and fourth grade, and there is a complicated discussion about the reasons, from obesity and family stress to chemicals in the environment that may disrupt the normal effects of hormones. I’m not going to try to delineate that discussion here — though it’s an important one — because I want to concentrate on the effect, rather than the cause, of reaching puberty early.

A large study published in May in the journal Pediatrics looked at a group of 8,327 children born in Hong Kong in April and May of 1997, for whom a great deal of health data has been collected. The researchers had access to the children’s health records, showing how their doctors had documented their physical maturity, according to what are known as the Tanner stages, for the standardized pediatric index of sexual maturation.

Before children enter puberty, we call it Tanner I; for girls, Tanner II is the beginning of breast development, while for boys, it’s the enlargement of the scrotum and testes and the reddening and changing of the scrotum skin. Boys and girls then progress through the intermediate changes to stage V, full physical maturity.

In this study, the researchers looked at the relationship between the age at which children moved from Tanner I to Tanner II — that is, the age at which the physical beginnings of puberty were noticed — and the likelihood of depression in those children when they were 12 to 15 years old, as detected on a screening questionnaire.

“What we found was the girls who had earlier breast development had a higher risk of depressive symptoms, or more depressive symptoms,” said Dr. C. Mary Schooling, an epidemiologist who is a professor at the City University of New York School of Public Health, and was the senior author on the study. “We didn’t see the same thing for boys.” Earlier onset of breast development in girls was associated with a higher risk of depression in early adolescence even after controlling for many other factors, including socioeconomic status, weight or parents’ marital status.

Other studies, including in the United States, have shown this same pattern, with girls who begin developing earlier than their peers vulnerable to depression in adolescence. Some studies have found this in boys, though it’s not as clear. But there is concern that girls whose development starts earlier than their peers are at risk in a number of ways, and across different cultural backgrounds.

“Early puberty is a challenge and a stress, and it’s associated with more than depression,” said Dr. Jane Mendle, a clinical psychologist in the department of human development at Cornell University. She named anxiety, disordered eating and self-injury as some of the risks for girls. In her studies of puberty, she has found associations between early development and depression in both genders in New York children. In boys, the tempo of puberty was significant, as well as the timing; boys who moved more rapidly from one Tanner stage to the next were at higher risk and the increased depression risk seemed to be related to changes in their peer relationships.

Before puberty, Dr. Mendle said, depression occurs at roughly the same rate in both sexes, but by the midpoint of puberty, girls are two and a half times more likely to be depressed than boys.

Some of these children may already be at risk; Dr. Mendle said that early puberty is more common in children who have grown up in circumstances of adversity, in poverty, in the foster care system. But some of it is heredity and some of it is body type and some of it, probably, is chance.

Researchers have wondered about hormonal associations with depression; Dr. Schooling pointed out that their study found that depression was associated with early breast development, controlled by estrogens, but not with early pubic hair development, controlled by androgens. “There is no physical factor that we know about that would explain this; estrogen has been eliminated as a driver of depression in earlier research,” she said in an email. “We probably need to explore social factors to seek an explanation.” They also plan to follow up with their study population at age 17.

The biological transition of puberty, of course, occurs in a social and cultural context. One very important effect of developing early, Dr. Mendle said, is that it changes the way that people treat you, from your peers to the adults in your life to strangers. “When kids navigate puberty they start to look different,” she said. “It can be hard for them to maintain friendships with kids who haven’t developed, and we also know that early maturing girls are more likely to be harassed and victimized by other kids in their grade.”

Parents should be aware of the difficulties that children may experience if they start puberty earlier than their peers, but lots of children handle early development with resiliency, and even pride.

Children who start puberty early – say, 8 instead of 12 — are faced with handling those physical changes while they are more childlike in their knowledge and their cognitive development, and in their emotional understanding of what goes on around them.

Parents should keep in mind that the same protective factors that help children navigate other challenges of growing up are helpful here: All children do better when they have good relationships with their parents, and when they feel connected at school. And we should be talking about the changes to their bodies before they happen, and make it clear that all of these topics are open for discussion.


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Dave Duerson Found to Have the Brain Trauma He Suspected

Although the precise motivations behind Duerson’s suicide remain unknown, he had complained of headaches, blurred vision and a deteriorating memory in the months before his death.  His final note to his family finished with a handwritten request: “Please, see that my brain is given to the N.F.L.’s brain bank.”

The N.F.L. does not run the Boston University research group but did donate $1 million to its financing last year, after the league acknowledged long-term effects of football brain trauma.

C.T.E., a condition previously associated mostly with boxers and manifested in behavior more commonly known as dementia pugilistica, is a degenerative and incurable disease that compromises neural activity and is linked to memory loss, depression and dementia. Although groups at Boston University and elsewhere are pursuing tests for living patients, the condition can currently be detected only after death, by brain autopsy.

“We hope these findings will contribute more to the understanding of C.T.E.,” the N.F.L. said in a statement. “Our Head, Neck and Spine Medical Committee will study today’s findings, and as a league, we will continue to support the work of the scientists at the Boston University Center and elsewhere to address this issue in a forthright and effective way.”

DeMaurice Smith, the executive director of the players association, said in a telephone interview that Duerson’s having C.T.E. “makes it abundantly clear what the cost of football is for the men who played and the families.”

He added: “It seems to me that any decision or course of action that doesn’t recognize that as the truth is not only perpetuating a lie, but doing a disservice to what Dave feared and what he wanted to result from the donation of his brain to science.”


Dave Duerson in 1988. Credit NFL Photos, via Associated Press

Duerson’s death rattled players both active and retired, who after years of news media coverage are more aware that the damage done to their brains could be permanent. Pete Kendall, a recently retired offensive lineman, said, “The whole issue of C.T.E. is something that players young and old have no choice but to think about.”

Duerson’s former wife, Alicia, attended the Boston news conference with their four children. Their son Tregg, 25, made a brief statement, saying, “It is our hope that through this research questions that go beyond our interest may be answered — questions that lead to a safer game of football from professionals to Pop Warner.”

He added with regard to his father, “It is my greatest hope that his death will not be in vain and that through this research, his legacy will live on and others won’t have to suffer in the same manner.”

Duerson was an all-American defensive back at Notre Dame before spending most of his 11 N.F.L. seasons with the Bears. He played safety on the famed 46 defense that fueled their Super Bowl championship in the 1985 season, and he won the 1991 Super Bowl with the Giants.

Duerson retired after the 1993 season and became successful in the food-services industry before his businesses collapsed, his marriage failed and he went bankrupt. He began showing symptoms of repetitive brain trauma, including memory loss, poor impulse control and abusive behavior toward loved ones.

Another son, Brock, 22, said that the diagnosis of C.T.E. provided an explanation for his father’s decline and final act.

“I don’t want people to think just because he was in debt and broke he wanted to end it,” he said. “C.T.E. took his life. He changed dramatically, but it was eating at his brain. He didn’t know how to fight it.”

Duerson’s case is unique beyond the circumstances of his suicide. Since 2006, he had served on the six-member panel that considered claims for disability benefits filed by former N.F.L. players. Although individual votes are kept confidential, that board has been sparing in awarding benefits, including those for neurological damage.

Duerson himself told a Senate subcommittee in 2007 that he questioned whether players’ cognitive and emotional struggles were related to football.

However, Duerson’s legacy will almost certainly be how he apparently came to believe he had C.T.E., acted upon it and requested that his brain tissue be examined for confirmation and contribution to science.

Dr. Robert Stern, along with McKee a co-director of the Boston University research group, cautioned that C.T.E. could not explain all of a player’s actions.

“When it comes to suicide and chronic traumatic encephalopathy, it is possible that in some individuals the combination of C.T.E.-related symptoms of poor impulse control, depression and cognitive impairment may indeed lead to suicide,” Stern said. “However, we can never clearly point to any cause-and-effect relationship in any one case.”

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