What If Life Is Not Worth Living?

He looked different from most of the depressed patients that walk into a psychiatric clinic.  He was 24, thin and spare.  His hair was longer than average and hung loosely over his brow, his clothes were black and macabre –what the young folks call “Goth”.  That style makes everyone look depressed, but I could tell his depression ran deeper than fashion styles.

He was actually a handsome young man, and he had sensibly avoided the face and body piercings that Goths favor.  He was open about his choice of lifestyle, relishing his chance to educate me. But while he was talking, I could see he was so depressed, he could have been the poster child for the diagnostic manual.

But something more was going on here. He told me that he had adopted the Goth look at age 13; that nothing else could express how he felt about life — or rather, how he didn’t feel.

Nothing was pleasurable.  He told me his father was just like him, and generally wore black, too. I asked him when he had last had fun; he said he could not remember. He simply could not understand why other people loved life, or even what the purpose was. He had loved, been engaged to be married, and the young woman had been suicidal. She followed through on her threats, so he was wondering if the “love thing” was worth the trouble. He told me he had spent a lot of time and energy making her want to live, and now it was all lost. The first thing he did — since he had been through the system a lot and hospitalized more than a few times — was assure me he was NOT suicidal.  When he felt that way, he checked himself into a hospital.  He knew, on some level, that staying alive was the right thing to do.

I suppose, he also knew from experience with shrinks, that had I thought he was immediately suicidal, the ambulance would have been there in a heartbeat, and he would have been hospitalized in a secure unit, monitored, unable to do anything destructive, let alone suicide.

So I made him look me in the eye and convince me he was safe.  It was neither religion nor law that kept him alive, but an animal like survival instinct, which I pointed out to him was obviously durable and strong.  He agreed.  We were safe.  Now, what next…. A depressed person often cannot remember the good times.  I often think of depression as a sort of veil that distorts everything you see through it.  But this was more, I thought as I flipped through his chart.

Of course, I would keep giving him the strongest combination of antidepressants I could come up with.  I could buy him some liberty from at least some of his darker feelings. Although anhedonia (a Greek word for a lack of pleasure) is generally regarded as a symptom of depression, it has also been recognized as a result of long-term drug use. Addicts — generally those who come “down” from stimulants and stay there – feel that “normal” life isn’t exciting enough.

The notion of a reward pathway, particularly pathways that involve dopamine, being somehow “worn out” by over-stimulation comes to mind. But the idea of a genetic predisposition was new to me, since he said his father was similar and denied any drug abuse. Although patients often do lie.

Sometimes it is discussed in schizophrenia, relative to a subtype, and somehow related, at least in this article, to a certain type of COMT or carboxyl methyltransferase, an enzyme which breaks down, among other things, adrenaline, which is a “pep up” substance if ever there was one.  This young man had a blood pressure a bit on the low side.  He said that his father did, too. I was happy to find a contribution to the psychiatric literature, albeit a theoretical one, from my own medical school of Amiens, France.  Perhaps anhedonia is somehow a chronic structure that predisposes to and decompensates into depression. But back to the idea of enzymes.  Surely individual complements of enzymes, their subtypes, their qualitative and quantitative differences describe what makes us different.  Easy to have an opinion on, almost impossible to measure, since we all have millions of enzymes that govern every single synthesis or breakdown chemical reaction in our body. I have wondered only recently if the ways we gain and lose weight are due to different complements of enzymes, about which we can only generalize theoretically, maybe from our racial origins?  Wildly theoretical, I know, yet maybe one way to access an amount of data which seems infinite beyond imagination. The father of the anhedonic Goth was of British ancestry. Interesting, but nobody can afford to order a measurement of his enzymes that breakdown adrenaline.  I must continue with the rough tools I have, antidepressants developed by a system that is directed by what works for large numbers of people.  I simply have no weapons to treat an abnormal enzymatic complement, even if I can diagnose it. Here is a link to the most reasonably understandable recounting of the work of Paul Keedwell of King’s College (U.K.) who seems to consider anhedonia the hallmark symptom of depression, and has done some studies suggesting that there is a defect in the reward system of the brain associated with this symptom.  It is almost as if one part of the front of the brain cannot do a very good job of communicating with the back, as far as dopamine circuits are concerned.  If raising dopamine levels of the brain can help with pleasure, than anti-Parkinson medications that raise dopamine ought to be great antidepressants. Someone is actually testing one,  (pramipexole, or Mirapex) but everyone knows neurotransmitters are complex and it takes more than one to get things done.  The role of serotonin in depression is known, for medicines like fluoxetine (Prozac) raise it and work against depression. I kept reminding him that his will to live was stronger than even he could explain, and begged him to cling to it; He promised he would. I would get him the most effective psychotherapy I could, have someone try emotional freedom technique, and supervise them a bit.  I gave this young man a direction to “never give up, never surrender” and got a sort of half-smile from him. Biological psychiatry does not know how to fix this thing, may not be sure what it is, so I give him humanity, spirit, and whatever else I have.