The Literature of Neurotransmission

I recently read the French novelist Michel Houllebecq's Serotonin, and my initial reaction was that it would be useful to assign to students of psychotherapy and psychiatry—though I'm pretty sure this will never happen. It will never happen for a few reasons, not least that the novel includes some shocking and frankly abhorrent scenes, of the kind for which Houllebecq is well-known. Nonetheless, reading past or around these scenes, as well as various issues in French politics that tend to animate Houllebecq's work, Serotonin can be read as a melancholy memoir of a certain kind of patient, one who tends not to be prominent in our thinking about psychological treatments, if only because he so rarely shows up.

As its title indicates, the novel is nominally concerned with its narrator's serotonin levels, and in particular with a new (fictional) medication, Captorix, which is supposed to elevate them. As it happens, Houllebecq's novel already feels a touch outdated in this respect. Not long after its publication, a major study (Moncrieff et al. 2022) cast doubt on the hypothesis that low serotonin is the primary culprit in depression, and on whether standard anti-depressants actually increase serotonin levels anyway. So, as a work of psychiatry, Houllebecq's novel may be already superseded. But, on further consideration, this novel—despite its title—was never really about serotonin, or medication at all.

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I do not mean that the novel is concerned with larger issues of politics and modern despair, though this is true. I mean that, even considered as a straightforward memoir of depression, it is one in which medicine and medication have a quite marginal role to play. Indeed, I think that may be a key lesson of Serotonin—how random and ineffective are the narrator's encounters with psychiatry and how little effect they have on his depressive trajectory.

The book's narrator, Florent-Claude Labrouste, is first prescribed Captorix by a psychiatrist who warns him of potential serious physical side-effects, and requires frequent repeat visits for blood-monitoring. Labrouste accepts and fills the prescription, but skips the monitoring. Indeed, even before he has left the psychiatrist's office, he decides that he will never return. Why not? Primarily because the psychiatrist seems to Labrouste supercilious and not especially intelligent. Labrouste goes on taking Captorix, without apparent physical effects, though also without notable effects on his mood, and he later on finds another psychiatrist. This one speaks frankly with Labrouste about sex and life, and smokes cigarettes in his office. Labrouste likes this one a lot better.

There are a couple of lessons that might be drawn from these vignettes, though I am not sure that they are the right ones to draw. One is about exercising caution in prescribing medications that require follow-up, due to the purportedly impulsive nature of psychiatric patients. Prescribers are already very cautious about these matters, and this may be one reason why lithium—a real and effective medication, which does require follow-ups—is under-prescribed, according to some experts. Another is a point about "bedside manner," though here, too, there is the temptation to learn the wrong lessons. It is the first psychiatrist whom Houllebecq visits who seems the most likely to be studiously attempting to interact with his patient in an approachable way. The second psychiatrist seems to be utterly unconcerned with what others think of him while also caring deeply about his patient's survival—a far harder skill to learn.

The lesson that I drew from these encounters was how little they mattered in light of the other things that were happening in Labrouste's life. In the course of the novel, he goes through a checklist that seems almost a design for depression. Without giving away too much of the plot (most of this happens in the beginning of the novel), he quits his job, leaves his long-term partner, moves into a hotel, purchases a gun, and spends a significant amount of time perseverating over old relationships and visiting ex-girlfriends. (Sometimes, Serotonin reads like a depressive French version of Nick Hornby's High Fidelity). This is not a recipe for mental well-being, regardless of what medications he is taking.

He also drinks alcohol, a lot of it, and more or less constantly. I was never quite sure if Houllebecq intended to emphasize his narrator's drinking or if this was just taken as normal background noise (a lot of the people he encounters also drink a lot). Regardless, the copious amounts of alcohol he is ingesting make the psychiatrist's fine-tuning of the latest groundbreaking anti-depressant feel a bit superfluous. No matter what dosage of Captorix the narrator happens to be taking, the predominant influence on his mood is presumably the more ancient effect of alcohol.

In this way, the larger lesson of Serotonin echoes the psychiatric literature more broadly: the scientific precision and innovation of its title and plot devices are overwhelmed by the more basic tidal forces of despair, isolation, and alcohol. One value of the book is that, since these forces are ones that, by their nature, drive people away from psychiatrists and other potential providers, it gives us a perspective into what a descent into the further reaches of depression looks like from the inside. The psychiatric trappings of this journey turn out to be far less influential than they may at first glance seem to be.