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Neko Case is best known as a lead vocalist for the Canadian indie-rock band the New Pornographers and a solo career that doesn’t quite fit any genre (“country noir” and “odd rock” are two labels she has suggested). Her songs feature unusual protagonists, many of whom are animals, and critics and fans have been puzzling over her lyrics for years. Recently, Case published a memoir, The Harder I Fight the More I Love You, which suggests possible source material for her vivid and sometimes alarming imagination. In the memoir, she writes mostly about her experience growing up as the child of teenage parents who, in her telling, never came around to wanting a child. And about finding an alternative home in the music scenes of the American Northwest and Canada.

In this episode of Radio Atlantic, we talk with Case about men, music, her own sliding sense of gender, the impossibility of being a musician in the age of streaming, and most important, how not to suffer for your art. After a lifetime of thinking about her parents, she also has good advice on when not to forgive.

The following is a transcript of the episode:

Hanna Rosin: Just a quick note: This episode contains some cursing that you might not usually hear on this show.

Neko Case is one of those musicians that people have really strong personal attachments to, especially indie music lovers of a certain generation. Like, I know two people who have named a child after her.

Neko Case is a lead vocalist of the indie-pop collective the New Pornographers, and she’s also had a long solo career. But what’s most distinct about her are her lyrics, which are often oblique. Like, a song seems to be about a car crash, but maybe it’s really about incomplete grief. You have to listen a few times before you get closer to it.

[“Star Witness,” by Neko Case]

Rosin: And then there are lots of times when Case seems to be writing about herself, but it’s not entirely clear.

[“Things That Scare Me,” by Neko Case]

Rosin: This is Radio Atlantic. I’m Hanna Rosin.

Last month, Neko Case peeled back some of the mystery. She’s written a memoir called The Harder I Fight the More I Love You, which shares part of the same title as one of her albums from 2013.

She writes about growing up poor and neglected. Her parents were teenagers when they had her, and her guess is that neither of them ever wanted a child. By the end of her sophomore year in high school, she asked her mom for emancipation. She writes: “She couldn’t sign it quickly enough; she didn’t even have to think it over.”

And so Case hid a lot behind her music.

[Music]

Rosin: One of my favorite scenes is you as a kid in the school library. Like, you remembered that the beanbags were corduroy. The image was so perfect. It was such a perfect image from that era. And you were hiding out with your headphones on. I think you mentioned listening to “Atomic,” by Blondie.

Neko Case: Over and over and over and over, like only a neurodivergent ADHD kid can do.

Rosin: Right. Right. (Laughs.) Like, just a million times. Do you have words for what that was like for you? Because it felt like, Okay, that’s the moment that she discovers the power of music. In a movie, that would be the scene in which you discover what music is for and what it does to you.

Case: Music was always just there. And I took it for granted, but I also leaned really heavily into it. I did not make a connection that music was something I would want to do or I would do, because I was just a girl. And I did not make a connection between myself and Blondie, or myself and the Go-Go’s. I just knew I really loved them.

Rosin: So why did it take so long, do you think, for you to open your mouth and sing? You played in bands, but you didn’t really sing for a while.

Case: Well, I was raised to be female in the United States of America so, you know, I wasn’t raised with a lot of self-confidence.

Rosin: So what was the point where you were like, Oh I can do this?

Case: It wasn’t so much deciding I could do it. It was just that I couldn’t help but to do it, because the desire was so intense.

Rosin: Now, the desire is the desire to make music, to write music, to sing? What was the desire?

Case: Even just to sit near it. Anything. Anything I could have.

Rosin: In the book, you complain about your voice. You write that it was neither pretty nor powerful. And that’s—

Case: Oh that’s not a complaint.

Rosin: It’s not a complaint. Okay, okay, okay.

Case: No, no, no. It’s not powerful, and it’s not pretty. Like, those are things that—you know, I wish it were powerful. I don’t care that it’s not pretty. I very much enjoy hearing women singing in ways other than being pretty. And singing is an incredible physical feeling. It’s like your mouth is a fire hose, and you can twist your insides and make a powerful thing come out to the point where your feet levitate ever so slightly off the floor.

[“I Wish I Was the Moon,” by Neko Case]

Case: It gets so physical. It is so athletic, and there’s nothing else like it.

[“I Wish I Was the Moon,” by Neko Case]

Rosin: Well, even in this just few minutes that we’ve been talking, you describe a little journey from a point where the world gives you a set of expectations and tells you, you can and can’t do things. And you seem to sort of find your way out of that, either through your voice or how you experience music, or even the way you write about institutions. Like, you write the country-music institution was limiting in some ways.

Case: Oh it’s straight up misogynist and racist and hateful. We don’t even have to sugarcoat that one. The current country-music scene of radio music in Nashville is absolutely heinous. And I watch young women try to get in there, and I love them so much, and they’re trying, and I’m like, Don’t even bother. Let that thing die. That thing is poison. Come over here. Let’s make the other thing.

Rosin: And is the other thing, like, you inventing your own genres? You’ve given them names over the years that are—“country noir” or “odd rock,” and things like that. Like, is that the way out? Is that what you tell women?

Case: I think that what it is, is the gatekeepers of country music are absolutely terrified that it might evolve, whereas the gatekeepers of rock and roll don’t have a problem with evolution. But there’s something very white supremacist about how country music works. And they’re really, really dialing down on it now.

Rosin: So you don’t mean just then. You’re talking about then, and now there’s a resurgence. Because there was a great moment—

Case: I think it’s worse now. I think it’s far worse now than it has been in a long time.

Rosin: I mean, there was a good moment for women—it was a brief good moment for women in country music.

Case: There have been a couple.

Rosin: Yeah.

Case: Sometimes, people are so talented that they’re undeniable, and not even the gatekeepers can keep them out.

Rosin: Well, it’s good Beyoncé made that country album then.

Case: We’re lucky to have Beyoncé doing a lot of things. That’s all I’m saying.

Rosin: That’s true. That’s true. (Laughs.) I think reading your memoir, for me, changed how I heard your music, and I wasn’t sure if that was the right thing or not the intended thing. Is that something you explicitly thought you were doing? At times, I almost read it like, Oh this is a key to some lyrics, and I wasn’t sure if that was correct or not correct.

Case: I tried to not give away the songs as much as possible. Like, there was a couple times where I kind of went into them, but I don’t like to ruin songs for people. You know how you will hear the lyrics of a song one way, and then you find out it’s not the lyric that you thought it was, and then you’re like, Oh. It’s not as good anymore?

If you think you know what a song’s about, and it makes you feel connected emotionally to it, and it becomes a little chapter heading in your life, you don’t want to ruin that for people.

Rosin: Yeah. But I don’t know if it’s ruin it. I think it’s just complicate it. I’ll give you an example—and maybe just indulge me, and you can walk me through the process. I’m the listener. You’re the singer. When I read the book title, of course, I immediately thought of your 2013 album—

Case: Yes.

Rosin: —The Worst Things Get, the Harder I Fight, the Harder I Fight, the More I Love You, for obvious reasons. Because of the song “Nearly Midnight, Honolulu,” which has run in my head for 10 years—

[“Nearly Midnight, Honolulu,” by Neko Case]

Rosin: —which starts with the kid at the bus stop, and then the perspective is quickly shifting, so it’s hard to keep up with who’s the you and who’s the me.

[“Nearly Midnight, Honolulu,” by Neko Case]

Rosin: And then that kind of devastating line about, “My mother, she did not love me.”

[“Nearly Midnight, Honolulu,” by Neko Case]

Rosin: In your mind, is that line related to the book in any way?

Case: Well, that song was a real event. I was really at a bus stop in Honolulu, fleeing Hawaii. And I saw it happen, and I just felt so helpless.

Rosin: You felt helpless to protect the kid?

Case: Yeah. But the kid, also, was being very resilient, and she was entertaining herself. She was very spunky and cute. And her mom was just an asshole.

Rosin: I mean, reading your book, I did think, Oh that line resonated with Neko for a reason, because of struggles with your own mother. Do you mean for people to read the memoir that way?

Case: Well, I mean, I told the story. I just—I’ve never written a book before, and I didn’t set out to write a memoir. I wanted to write fiction, but it was at the height of the pandemic, and Hachette said, We’ll pay you to write a memoir, though. And I was like, Okay. A memoir it is. And that’s not a complaint or, you know, they didn’t hold my heels to the fire or anything. I just thought, Okay, well, it’ll just be a little challenging, because, you know, talking about yourself or writing about yourself to yourself isn’t the most exciting thing ever.

You spend a lot of time with yourself. So I don’t think of myself as like, Oh people are really going to want to know this. So I mean, that’s one of the reasons I tried to pick more interesting stories from childhood that were scenes, maybe, of good things, too, because I didn’t want it to just be, Oh poor me, especially because it’s not unusual. It’s most people’s experience.

I mean, my situation with my mother is pretty bizarre. But neglect or abuse or things like that—those are most people’s experiences. Or growing up really poor—that is most people.

Rosin: I think your experience is actually pretty unusual.

Case: Yeah. It’s pretty damn weird.

[Music]

Rosin: “Pretty damn weird” it is.

When Case was in second grade, her father told her that her mother had died of cancer, which was surprising because Case didn’t even realize she was sick. And then a year and a half later, her dad said to her one day: I don’t want you to think your mom’s a ghost, but she came home.

As Case recalls in her memoir, the story was that her mother had had terminal cancer and gone to Hawaii to recover but didn’t want Case to see her so ill. And Case—who, remember, was a little kid—believed her. She had her mom back. She was happy.

It only occurred to her later—after many, many years and another disappearing act from her mother—that she might never have been sick in the first place.

Rosin: It’s one of the weirdest stories I’ve ever heard. I mean, it is a little shocking and hard to forget. And I’m not sure if you knew that or recognized it in that way.

Case: I didn’t know that until I was in my early 20s, and I told somebody I knew that my mom faked her death. And then they were like, That’s the weirdest fucking thing I’ve ever heard, and I was like, Oh yeah. That is actually pretty weird, isn’t it? But you know kids. Kids just think what’s happening to them is what happens. So it didn’t occur to me.

Rosin: So where did it register for you? Because now I see that what I am assuming about that song isn’t actually how you move through the process. I just assumed you had that in your head when you wrote the lyrics, “She did not love me.”

Because that lyric is haunting, even the way you sing it and the pacing of it. I just assumed you had that in your head, but maybe you didn’t. Maybe you just had it in your subconscious somewhere.

Case: It’s in me all the time. And, you know, it’s just not my fault.

[“Nearly Midnight, Honolulu,” by Neko Case]

Case: She didn’t love me. And it’s just the fact.

[“Nearly Midnight, Honolulu,” by Neko Case]

Rosin: When you work out memories and pains in song, is cathartic a banal word to use here? Does it do something for you to work it out and learn?

Case: Only in a super-nerdy, kind of neurodivergent-slash-Virgo way where I’m like, Oh! I’m taking all the things, and I’m organizing them in this box. And so now I can put this box over here like a hard drive, so my brain has more room in it. And it’s all color-coded, and I know where it is. That’s, like, Virgo organization.

Rosin: Interesting.

Case: Yeah.

Rosin: Because I feel like one glib way to read a memoir like this is, Oh from family trauma and a mother who didn’t love you comes immense creativity. How wonderful! What’s wrong or right about that interpretation?

Case: Well, the mythology of people needing to suffer to make beautiful things or just art or creative things, in general, is not true.

Rosin: You mean they don’t need to suffer? Because it feels like, reading this book, your suffering is related to how you think and work through things and organize things.

Case: No. If I had had a supportive upbringing, I would be able to read music and play instruments and would probably be a lot further along. You don’t need that.

Rosin: So to you, it just feels like pure baggage. It’s, like, a thing you’ve had to tolerate, but you could have been a singer some other way.

Case: Oh it’s an absolute trunk of shit.

Rosin: (Laughs.)

Case: The things that I admire about myself are despite those things. You know, like, I still am a trusting person. I still really want to see the good in people, and sometimes I will make mistakes and trust people I shouldn’t. And I could beat myself up about that, or I could just go, No. You still want to believe people are good. And I think that’s a more important quality than whether or not you’re wily enough to spot a jerk a mile away—you know what I mean?

Rosin: Yeah, I was more thinking, like, you had this life, and you had to escape this life and find your family elsewhere, and you had a huge, strong motivation to do that, and so you found music.

Case: Yes.

Rosin: But that’s just another way of saying trauma made you a great musician.

Case: No. Music is the only thing that never let me down. But trauma did not make me a great musician. I am a journeyman, at best, and, you know, I’m broke. I don’t know—I think great musicians do other things.

Rosin: Mm-hmm. Wait. Did you just say you were broke?

Case: Yeah.

Rosin: Do you mean financially broke or personally broke?

Case: Financially broke.

Rosin: Really? How is that possible? I think your fans would be shocked.

Case: The confluence of my house burning down, COVID, and streaming—those three things together.

Rosin: Wow.

Case: And I cannot catch up.

[Music]

Rosin: When we come back—more with Neko Case on politics, on forgiveness, and a recent experience with a friend’s death that she said felt like getting on the spaceship to go to the moon.

Case:  I felt absolutely unafraid. And I was seeing an actual moment of grace in life, and I couldn’t believe it.

Rosin: That’s after the break.

[Break]

Rosin: I wanted to ask you about gender, because the way you write and sing about gender is very much the way a lot of people talk about gender now. And I’m curious how you have watched the evolution of how people inhabit and think about gender, like in your lyrics to “Man”—

[“Man,” by Neko Case]

Rosin: —you don’t mean that literally. What do you mean by “I’m a man”?

Case: I do mean it literally.

[“Man,” by Neko Case]

Case: I mean, I am of the species. I am a man. Like, whatever’s going on downstairs doesn’t matter. I have all my faculties. You can call a female or a male lion a lion, and they’re still a lion. I’m a man in that same way.

And I am so thrilled and proud and excited by generations younger than mine who are not backing down from who they think they are and the idea that they get to be who they are. That has been one of the most exciting things I’ve ever witnessed, and it has given me so much more insight into myself because I never felt like a girl or totally a guy. I’m more of a gender-fluid person.

Rosin: And when you say it’s taught you so much about yourself, what do you mean? Because in the book, there is one way in which you very much inhabit the experience of a woman of that generation, just at the hands of careless and arrogant and brutal men, like a teacher, older brothers, fellow musicians. And then there’s a sense, I imagine, of being trapped in that.

So what have you learned about yourself in this era of gender fluidity? How do you think about yourself?

Case: As neither. I am neither. I still call myself she/her. I’m used to it. It doesn’t bother me. And partly because the world hates women so much, I will not abandon it. I just won’t. But I also understand that the world hates gender-fluid people and trans people, LGBTQ people, and I understand the importance of not abandoning that, either.

Rosin: So you see the world as making some cultural progress and how we think of what’s a man and what’s a woman in some corners, but not a lot of progress politically or socially.

Case: Politically, we are fucked. Socially, I don’t think what the president and his people represent, represents the American people. I don’t believe that Americans, in general, have a hatred or a problem with people who are not white, who are LGBTQ, who are immigrants. I just don’t think they do.

Rosin: To shift away from politics, since we get a lot of it over here in D.C., although this is related, the thing—

Case: Well, I mean, a human being’s right to be is—I mean, that’s just everyday life. Like, politics and everyday life just—they just aren’t separate, not that I want to talk about politics, specifically. Because I just refuse to be afraid.

Rosin: Do you feel like that’s something you found at this age? Because you’ve said there are times in your life where you haven’t had self-confidence, you’ve been depressed, or you’ve kind of lost your mind, even, in one section of the book. Is it easier to not be afraid now?

Case: Well, I have really benefited from menopause. And a lot of people who menstruate who don’t anymore have said the same things about, you know, the hormone shift. Like, you don’t care anymore what people think of you.

And also, I just came from seeing one of my best friends die. And sitting with her body for four days as—you know, she was an organ donor, and she had a massive aneurysm. And her partner just heroically did CPR, and then the paramedics came and kept her pulse going and got her to the hospital, and they stabilized her, despite the fact that she had no brain activity.

And you cannot be an organ donor unless you die on a respirator in the hospital. Like, it’s very, very specific. And then you have to wait for all the tests. There are barrages of tests that happened to make sure that you’re healthy and that your organs can really save someone else’s life and not be rejected. And so we spent days just with her and talking about her life and what a selfless person she was. And we joked a lot about how she was going to work, even in death. She was all about service.

And then the day came. Right on the way to the OR, what they do is they do a thing called an “honor walk.” And we went down what seemed like miles of corridors behind her hospital bed, behind the doctors. And the corridors were lined with doctors and nurses and hospital staff honoring her. And it seemed like one of those movies where you see the people going down the corridor in slow motion to get into the spaceship to go to the moon or whatever, and everyone’s saluting them, and it seems so important. And I think I actually saw that in real life.

And I just thought, All those things that I worry about and the injustices—we are so right to fight for them. And I was there watching this incredible thing happen, and these beautiful people from all over the world—many of the doctors are immigrants—and it was a mix of people of all colors from all over the world and all different cultures. And I felt so utterly galvanized against the fear and so utterly galvanized in that joy is the way forward.

Rosin: Mm-hmm.

Case: Loud-ass, exuberant joy.

Rosin: I mean, one of the things I took most from your book is how you write about forgiveness. It’s related to this. I mean, you definitely acknowledge the beauty of forgiveness, but then you say this other thing, and you could read this in a lot of different ways, which is the “trust your contempt” paragraph. Do you remember that? You don’t have the book in front of you, right?

Case: I don’t. But I do talk about this, occasionally.

Rosin: Yeah. Dissect it if you can. If something doesn’t stir anything but contempt in you, then there’s a reason. Don’t canonize your contempt, but don’t ignore it.

This is the part that I love. It’s so good: “Sometimes bad things are just senseless brutality that finds you. You do not deserve or ask for these things. They are not always teaching you a lesson.”

Where would you say you are—you know, you have a lifetime of songs; you have this memoir; it sounds like you have friends—on this path? Is it different for different people? Like, forgiving members of your family, people who have hurt you in the past?

Case: Oh yeah. I mean, relationships with people are all very different, and some are very complicated, and some are not.

Rosin: So you would say you’re at different places with different people?

Case: Oh yeah.

Rosin: What about your dad? I was curious about him because he plays a kind of shadow role in the book, not quite with the extravagant cruelty of your mother. Maybe neglectful—maybe—is the right way to read that.

Case: I have a lot of compassion for my dad and a lot of sadness because I feel like his development was arrested completely. And he had to be an adult man and head of the family and all these things, and he was just a kid inside. And he didn’t know how to handle it. He maintained it with drugs and drinking for a long time, but then it catches up with you.

And the kind of pain from that—he didn’t use what happened to him to manipulate anyone. His forward path was genuine. He wasn’t doing a great job, but he was also a 19-year-old kid when he had me. And he didn’t want me, but he ended up with me.

Rosin: Yeah. And ended up raising you.

Case: Not really.

Rosin: (Laughs.) Right. Ended up housing you under the same roof.

Case: Sometimes.

Rosin: Sometimes. Yeah, there was that moment when you guys reconnect over a car. You speak car talk with each other—

Case: Yeah.

Rosin: —which is very familiar to me. I come from a family of mechanics and car people. And so I found that very peaceful. It was a tiny second of peace in a very rocky journey.

Case: Yeah, it was nice because when I was a little girl, I would have loved to have had him show me how to do things, because he was always fixing the car or the truck or whatever, and it would have been nice to have been included. I mean, when I was a kid, I thought he wanted a boy, and I thought he was really disappointed. But he just didn’t want any kid.

Rosin: You know, I’ve just been nonstop listening to your music to prepare to talk to you and sort of tuning into the different moods of different albums. And I wonder, from you: What’s the song you wrote when you were happiest? Or even when you listen to it now, it makes you happy. Like, it just makes you feel good.

Case: Probably “Hold On, Hold On.” It’s melancholy, but it feels very much like I am in charge of myself. And I make good decisions in it.

[“Hold On, Hold On,” by Neko Case]

Rosin: So it’s, like, a song that makes you feel like all of this pain and trauma—like you can handle it.

Case: Partially. It’s a moment of actually seeing yourself clearly. It doesn’t mean the moment’s going to last.

Rosin: Mm-hmm.

[“Hold On, Hold On,” by Neko Case]

Case: I think I also partly feel that way because I wrote it with the Sadies, and I have such a loving relationship with them. And it’s always made me feel good to play it. And my dear friend Dallas Good passed away a couple of years ago, way too young. And so now it takes on a new sort of heaviness, but it’s a heaviness that feels good to carry somehow.

[“Hold On, Hold On,” by Neko Case]

Rosin: Thanks again to my guest, Neko Case.

[Music]

This episode of Radio Atlantic was produced by Jinae West and edited by Claudine Ebeid. Rob Smierciak engineered, and Genevieve Finn fact-checked.

Claudine Ebeid is the executive producer of Atlantic audio, and Andrea Valdez is our managing editor.

I’m Hanna Rosin. Thank you for listening.

This is an edition of The Atlantic Daily, a newsletter that guides you through the biggest stories of the day, helps you discover new ideas, and recommends the best in culture. Sign up for it here.

The following contains spoilers for some of the episodes mentioned.

Recently, I tasked seven Atlantic writers and editors with selecting a perfect episode of TV. What emerged was a list that spans genres, generations, and cultural sensibilities. Their recommendations, which include the Veep episode “C**tgate” and a SpongeBob episode that examines “the empty promise of the good life,” are proof that identifying good TV is, at its core, a gut instinct. A perfect episode must find a way to burrow itself in the viewer’s mind, ready to be recalled in today’s crowded field of television.

When I posed the same challenge to The Daily’s readers earlier this week, I was met with enthusiasm and exasperation. “This is an impossible question,” Eden wrote back. “It’s like asking for the perfect song, the perfect movie, or the perfect book.” That being said, “I can think of five off the top of my head!”

Eden’s list includes “Forks” from The Bear, “Through the Looking Glass” from Lost, “The Suitcase” from Mad Men, and “Long, Long Time” from The Last of Us. And that doesn’t even cover “Friday Night Lights, or The Wire, or Insecure, or Derry Girls, or The Sopranos, or The Wonder Years, or My Brilliant Friend, or Curb Your Enthusiasm,” Eden added. I can sympathize—the breadth of options is dizzying.

Maybe some criteria would help. Our culture writer Sophie Gilbert wrote that “the thing I love most is when a television series tells a complete story in miniature—a stand-alone short that puts a particular dynamic or relationship or cast member front and center.” Radio Atlantic’s podcast host, Hanna Rosin, argued that, “unlike a perfect movie, a perfect episode of television does not need to surprise you or make you cry. It just needs to move your beloved or loathed characters through the formula in an especially excellent way.” And Suzanne, 59, offered her own formula: “The script must be: (1) tense or funny; (2) warm and loving to the viewers, performers, and crew; and (3) move the overall story forward.”

Of course, the benchmarks for what makes an episode perfect are as subjective and varied as viewers’ selections. But a thorough analysis of The Daily’s reader responses has uncovered some patterns. At least five people named a West Wing episode: Two readers nominated “Two Cathedrals,” which shows “the effects of death on time,” wrote David, from Chicago; L. Hawkins, 70, recommends “Noel,” adding that viewers should “listen for the sirens as the episode fades out.”

“Long, Long Time” from The Last of Us was mentioned by both Eden and Bob—it offers “a lesson that love may find you at any time, any place, and under the most unexpected circumstances,” Bob wrote. Two readers agreed with Atlantic film critic David Sims, who insisted in our recent roundup that “the richest cache [of perfect episodes] to search is the ‘case of the week’ entries of The X-Files.” Lisa, 47, wrote that she was thrilled to see “Clyde Bruckman’s Final Repose” in our list (she also recommends the series finale of Derry Girls).

Other readers highlighted examples of good comedy. In only 22 minutes, “Remedial Chaos Theory” from Community “tells seven different stories, with each timeline building on the last,” E.F., 46, wrote. “The Ski Lodge” from Frasier stands out to Bruce, 52, who said that the episode is “riddled with quotable laugh-out-loud lines.” And L.M., 61, laughed until she cried watching a loopy Steve Martin in Only Murders in the Building’s “Open and Shut.”

For some, a perfect episode tells a story that reverberates throughout their life. Sharon, from California, wrote about an episode she remembers watching on Hallmark Hall of Fame, which follows a grief-stricken child who reads a story about magical silver shoes. To his astonishment, he finds skates that look identical, which he puts on to go skating in hopes of bringing back his dead parent. “As life went on and I became the mother of a child who lost his father in childhood, I’ve recalled the episode more than once,” Sharon wrote. “Now, at 80 years old, it still breaks my heart.”

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By Yasmin Tayag

When I was unexpectedly diagnosed with ADHD last year, it turned my entire identity upside down. At 37, I’d tamed my restlessness and fiery temper, my obsessive reorganization of my mental to-do list, and my tendency to write and rewrite the same sentence for hours. Being this way was exhausting, but that was just who I was, or so I thought. My diagnosis reframed these quirks as symptoms of illness—importantly, ones that could be managed. Treatment corralled my racing thoughts in a way that I’d never before experienced.

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Take a look at these photos of Maha Kumbh Mela, a religious festival in India that’s also the largest gathering in the world.

P.S.

I realize it’d be a bit unfair to make everybody else share their perfect episode without naming mine: the series finale of Fleabag. There are many good things I can point out about this episode—Claire’s mad dash to happiness, Fleabag’s final confession, the Alabama Shakes song that plays over the show’s last moments. But above all else, it moved me, reminding me that love can outlast the person who prompted it.

— Stephanie

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When I was unexpectedly diagnosed with ADHD last year, it turned my entire identity upside down. At 37, I’d tamed my restlessness and fiery temper, my obsessive reorganization of my mental to-do list, and my tendency to write and rewrite the same sentence for hours. Being this way was exhausting, but that was just who I was, or so I thought. My diagnosis reframed these quirks as symptoms of illness—importantly, ones that could be managed. Treatment corralled my racing thoughts in a way that I’d never before experienced.

But knowing that I have ADHD, short for “attention-deficit hyperactivity disorder,” has also opened my eyes to a new issue: Apparently, I am at risk of an early death. According to a study published last week that analyzed the deaths of more than 30,000 British adults, ADHD is linked with a lifespan that’s nearly seven years shorter for men, and about nine years shorter for women. Nine years! The findings suggest that the life expectancy of people with ADHD is nearly on par with that of smokers, and about five years shorter than that of heavy drinkers. When I sent the study to my husband, who also has ADHD, he texted back: “Damn.”

The findings are foreboding for many Americans. As of 2022, about 7 million American children ages 3 to 17  had at one point received an ADHD diagnosis as of 2022—1 million more than that same age group in 2016. And although ADHD may bring to mind kids bouncing off the walls, the number of adults with the condition has surged in recent years. ADHD’s rising prevalence has been met with some dismissiveness. As I wrote in 2023, questions have been raised about the validity of the recent spate of adult diagnoses, some of which were offered through dubious telehealth services that haphazardly doled out prescriptions. And ADHD is widely seen as mild, even mundane: Struggling to focus is hardly the same as say, schizophrenia, which has been linked to declines in life expectancy. But ADHD is “not as innocent as some people think it is,” Margaret Sibley, a psychiatry professor at the University of Washington School of Medicine who is not associated with the new study, told me.

No one dies from ADHD itself. Rather, symptoms such as concentration issues, emotional instability, memory issues, and impulsivity can touch nearly every aspect of life. Researchers have long known that people with ADHD are more likely to engage in risky behaviors, including substance abuse, unsafe sex, gambling, criminal acts, and dangerous driving. They are at a higher risk of depression, anxiety, and suicide. Difficulties keeping up with healthy lifestyle habits, such as eating well and exercising, lead to higher rates of obesity. All of these risks can chip away at a person’s life: Around the world, having ADHD is associated with lower socioeconomic status.

Some of the most life-threatening impacts of ADHD may be the least conspicuous, experts told me. Missing doctor appointments, forgetting to take medications, and struggling to navigate the health-care system can make existing illnesses worse. What leads children to be scolded for poor behavior can snowball into difficulties keeping a job, maintaining healthy relationships, and even staying out of prison. Forgetting to pay rent can lead to eviction; the sudden urge to race down a freeway could end in a crash.

The new study points to these sorts of risks to explain how ADHD can cut someone’s life short. Besides the shocking findings, what makes the research so notable is that it is the first to directly quantify years lost to ADHD. By matching diagnoses with death records, the authors calculated the mortality rate of people with ADHD, which they used to estimate life expectancy. A previous study quantified the effect of a childhood diagnosis on lifespan by extrapolating the effect of known risks and came to similar findings. The new research shows that “we have data related to the mortality of individuals—true data,” Sibley said.

The calculations aren’t definitive. The top-line life-expectancy numbers are part of a range that incorporates a margin of error: 4.5 to 9.11 years lost for males, and 6.55 to 10.91 years lost for females. “The estimate is not super precise,” Joshua Stott, an author of the paper and a clinical-psychology professor at University College London, told me. Nevertheless, even the most optimistic scenario discussed in the paper—a reduction of 4.5 years for men—is “still a big difference” in lifespan, Stott said.

Another caveat, he added, is that the study population may have been skewed toward people with additional health issues, possibly inflating the mortality risk. ADHD underdiagnosis is common in the United Kingdom, so it’s possible that those who had a diagnosis had sought it and were overall more in touch with health services. Perhaps the biggest limitation of the study, however, is that it doesn’t show whether treatment helps. Good data on who in the study was treated just weren’t available, Stott said.

Among the researchers I spoke with, there was no question that treatment would help. In fact, the diagnosis alone is even more important—an idea that transformed my fears into hope. Once people are aware of their condition, they can learn about the risks and adjust their lifestyle accordingly, David Goodman, an ADHD expert and a psychiatry professor at the Johns Hopkins University School of Medicine, told me. If ADHD can be diagnosed and managed, “a lot of this would disappear,” Stott said. Certainly, research suggests that drugs like Adderall can reduce ADHD’s effect on life expectancy. That should provide solace for many Americans: In 2023, two-thirds of American adults with ADHD were on medication or in behavioral therapy, or both.

The earlier a person knows about their disorder and the risks associated with it, the better. In a way, ADHD is like diabetes, Goodman said. When it’s treated early, living a relatively healthy life is doable. The longer it isn’t treated, the more the comorbidities pile up: heart disease, vision problems, nerve damage, kidney disease, and so on. With ADHD and diabetes, treatment can involve both drugs and lifestyle changes.

At first, my diagnosis brought relief. Then anger and remorse—that I had spent nearly four decades feeling drained and frustrated with myself when I could have managed my disorder all along. When I shared this with Goodman, he replied: “You and everyone else who gets diagnosed in their adult years.” Underdiagnoses aren’t limited to the U.K.; globally, they are common, particularly among girls and women. Underdiagnosis partly accounts for the growing number of adult cases. Given Stott’s findings, the uptick in adult diagnoses is a positive thing: It means those people have a chance to claim the years they might otherwise have lost. With diagnosis, “the goal is to diminish the regret that you have in the future, given the information and decisions you make in the present,” Goodman said.

But that requires a new perspective on ADHD. Although it has long been classified as a mental-health disorder, it is often seen as a stage that can be outgrown; eventually, the hyperactive child learns to sit still. The notion that ADHD is a serious lifelong disorder remains underappreciated; it’s relatively new, even in the research community. The condition has a dubious reputation among the general public: Just yesterday, Senator Tommy Tuberville lamented the bygone days when, to manage their child’s ADHD, “parents didn’t use a drug, they used a belt.” It is sometimes seen as a path to the recreational use of stimulants. Some scientists still contest the validity of adult ADHD itself, Sibley said: One recently framed ADHD as a false epidemic sparked by an overmedicalized society and self-diagnosis. Indeed, during the coronavirus pandemic, TikTok creators self-diagnosing ADHD led their followers to do the same; whether their assessments were right is anyone’s guess.

At times, I still question my own diagnosis, wondering whether my attention span is just victim to a maelstrom of forces: Texts, social-media alerts, email notifications, and the endless onslaught of news can make anyone feel chronically discombobulated. But I know now that ADHD is more than just a problem of attention; the relief I experience with treatment—from impulsivity and recklessness, angry outbursts, and frantic thoughts—is undeniable. For people with ADHD, the hope is that diagnosis can help disentangle a serious condition from the frenzied realities of modern life. Both are exhausting, but one, at least, can be controlled.

In a Massachusetts cellar in 1873, Lydia Pinkham first brewed the elixir that would make her famous. The dirt-brown liquid, made from herbs including black cohosh and pleurisy root, contained somewhere between 18 and 22 percent alcohol—meant as a preservative, of course. Within a couple of years, Pinkham was selling her tonic at $1 a bottle to treat “women’s weaknesses.” Got the blues? How about inflammation, falling of the womb, or painful menstruation? Lydia E. Pinkham’s Vegetable Compound was the solution. Pinkham’s matronly smile, printed on labels and advertisements, became as well known as Mona Lisa’s.

Lydia E. Pinkham’s Vegetable Compound was one of thousands of popular and lucrative patent medicines—health concoctions dreamed up by chemists, housewives, and entrepreneurs—that took the United States by storm in the 19th and early 20th centuries. These products promised to treat virtually any ailment and didn’t have to reveal their recipes. Many contained alcohol, cocaine, morphine, or other active ingredients that ranged from dubious to dangerous. Dr. Guild’s Green Mountain Asthmatic Compound was available in cigarette form and included the poisonous plant belladonna. Early versions of Wampole’s Vaginal Cones, sold as a vaginal antiseptic and deodorizer, contained picric acid, a toxic compound used as an explosive during World War I. Patent-medicine advertisements were unavoidable; by the 1870s, 25 percent of all advertising was for patent medicines.

After the Pure Food and Drug Act was passed in 1906, the newly created Food and Drug Administration cracked down on miracle elixirs. But one American industry is still keeping the spirit of patent medicine alive: dietary supplements. In the U.S., vitamins, botanicals, and other supplements are minimally regulated. Some can improve people’s health or address specific conditions, but many, like the medicines of old, contain untested or dangerous ingredients. Nevertheless, three-quarters of Americans take at least one. Some take far more. Robert F. Kennedy Jr., the longtime conspiracy theorist and anti-vaccine activist who’s awaiting Senate confirmation to run the Department of Health and Human Services, has said he takes a “fistful” of vitamins each day. Kennedy has in recent years championed dietary supplements and decried their “suppression” by the FDA—an agency he would oversee as health secretary. Now he’s poised to bring America’s ever-growing supplement enthusiasm to the White House and supercharge the patent-medicine revival.  

The newly created FDA eventually required all pharmaceutical drugs—substances intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease—to be demonstrably safe and effective before they could be sold. But dietary supplements, as we call them now, were never subject to that degree of scrutiny. Vitamins were sold with little interference until the “megadosing” trend of the late 1970s and ’80s, which began after the chemist Linus Pauling started claiming that large amounts of vitamin C could stave off cancer and other diseases. The FDA announced its intention to regulate vitamins, but the public (and the supplement industry) revolted. Mel Gibson starred in a television ad in which he was arrested at home for having a bottle of Vitamin C, and more than 2.5 million people participated in a “Save Our Supplements” letter-writing campaign. Congress stepped in, passing the 1994 Dietary Supplement Health and Education Act, which officially exempted dietary supplements from the regulations that medications are subject to.

Since then, the FDA has generally not been responsible for any premarket review of dietary supplements, and manufacturers have not usually had to reveal their ingredients. “It’s basically an honor system where manufacturers need to declare that their products are safe,” says S. Bryn Austin, a social epidemiologist and behavioral scientist at the Harvard T. H. Chan School of Public Health. The agency will get involved only if something goes wrong after the supplement starts being sold. As long as they disclose that the FDA hasn’t evaluated their claims, and that those claims don’t involve disease, supplement makers can say that their product will do anything to the structure or function of the body. You can say that a supplement improves cognition, for example, but not that it treats ADHD. These claims don’t have to be supported with any evidence in humans, animals, or petri dishes.

In 1994, the dietary-supplement industry was valued at $4 billion. By 2020, it had ballooned to $40 billion. Patent-medicine creators once toured their products in traveling medicine shows and made trading cards that people collected, exchanged, and pasted into scrapbooks; today, supplement companies sponsor popular podcasts, Instagram stories are overrun with supplement ads, and influencers make millions selling their own branded supplements. The combination of modern wellness culture with lax regulations has left Americans with 19th-century-like problems: Pieter Cohen, an associate professor of medicine at Cambridge Health Alliance, has found a methamphetamine analogue in a workout supplement, and omberacetam, a Russian drug for traumatic brain injuries and mood disorders, in a product marketed to help with memory.

Last year, Kennedy accused the FDA of suppressing vitamins and other alternative health products that fall into the dietary-supplement category. But “there is no truth about the FDA being at war on supplements over the last several decades,” Cohen told me. “In fact, they have taken an extremely passive, inactive approach.” Experts have repeatedly argued that the FDA needs more authority to investigate and act on supplements, not less. And yet, Kennedy continues to champion the industry. He told the podcaster Lex Fridman that he takes so many vitamins, “I couldn’t even remember them all.” Kennedy has vocally opposed additives in food and conflicts of interest in the pharmaceutical industry, but has failed to mention the dangerous additives in dietary supplements and the profits to be made in the supplement market. (Neither Kennedy nor a representative from the MAHA PAC responded to a request for comment.)

In an already permissive environment, Kennedy’s confirmation could signal to supplement manufacturers that anything goes, Cohen said. If the little regulation that the FDA is responsible for now—surveilling supplements after they’re on the market—lapses, more adulterated and mislabeled supplements could line store shelves. And Americans might well pour even more of our money into the industry, egged on by the wellness influencer charged with protecting our health and loudly warning that most of our food and drug supply is harmful. Kennedy might even try to get in on the supplement rush himself. Yesterday, The Washington Post reported that, according to documents filed to the U.S. Patent and Trademark Office, Kennedy applied to trademark MAHA last year, which would allow him to sell, among other things, MAHA-branded supplements and vitamins. (He transferred ownership of the application to an LLC in December. Kennedy’s team did not respond to the Post.)

A truly unleashed supplement industry would have plenty of tools at its disposal with which to seduce customers. Austin studies dietary supplements that make claims related to weight loss, muscle building, “cleansing,” and detoxing, many of which are marketed to not just adults, but teenagers too. “Those types of products, in particular, play on people’s insecurities,” she told me. They also purport to ease common forms of bodily or mental distress that can’t be quickly addressed by traditional medical care. Reducing stress is hard, but ordering the latest cortisol-reducing gummy on TikTok Shop is easy. Your doctor can’t force vegetables into your diet, but a monthly subscription of powdered greens can.

Judy Z. Segal, a professor emerita at the University of British Columbia who has analyzed patent-medicine trading cards from the 19th and 20th centuries, told me that supplement-marketing strategies “have not changed that much since the patent-medicine era.” Patent medicines appealed to ambient, relatable complaints; one ad for Burdock’s Blood Bitters asserted that there were “thousands of females in America who suffer untold miseries from chronic diseases common to their sex.” And the makers of patent medicine, like many modern supplement companies, used friendly spokespeople and customer testimonials while positioning their products as preventive care; according to one ad for Hartshorn’s Sarsaparilla, “The first deviation from perfect health should receive attention.”

In 1905, the muckraker Samuel Hopkins Adams lamented that “gullible America” was so eager to “swallow huge quantities of alcohol, an appalling amount of opiates and narcotics, a wide assortment of varied drugs ranging from powerful and dangerous heart depressants to insidious liver stimulants; and, far in excess of all other ingredients, undiluted fraud.” Compounds and elixirs go by different names now—nootropics, detoxes, adaptogens—but if Adams walked down any supplement aisle or browsed Amazon, he’d still find plenty of cure-alls. He could even pick up a bottle of Lydia E. Pinkham’s Herbal Supplement, which is sold as an aid for menstruation and menopause. Pinkham’s face smiles at buyers from the label, though its advertised benefits are now accompanied by a tiny disclaimer: “This statement has not been evaluated by the FDA.”

BBC research finds nearly 400,000 private prescriptions for ADHD were issued in 2023-24.