But studies have generally not found the response rates to other forms of treatment to be all that much better. And the psychiatrists and psychopharmacologists on the front lines who consistently say that they have seen these drugs work time after time cannot all have been fatally duped by the drug industry’s marketing campaigns. Sometimes the statistical reality of the randomized double-blind controlled studies says one thing while the clinical reality (what psychiatrists and primary care physicians observe in and hear from their patients) says another. What to make of all this?
I am willing to believe that, for the most part anyway, both sides in these debates are arguing in good faith. The promedication advocates—the Gerald Klermans and Frank Bergers and Peter Kramers and Dr. Harvards of the world—have a compassionate Hippocratic desire to reduce their patients’ anxious suffering with drugs, and they are sincere in their desire to destigmatize anxiety disorders and clinical depression by classifying them as medical problems. The anti-medication crusaders—the Peter Breggins and Dr. Stanfords of the world—are sincere in their desire to protect patients and would-be consumers against what they believe to be the profit-minded rapaciousness of the drug companies and to help patients recover from their anxiety on the strength of their own inner resources, rather than on potentially dependency-inducing medications.
I have sympathy for the more reasonable drug industry critics. I can say based not only on the thousands of studies I’ve pored over but on my own lived experience that in some ways the critics are clearly right—right about the debilitating side effects, right about dependency and withdrawal problems, right to express skepticism about whether these drugs work as well as they’re advertised to, right to worry about what the long-term effects of such a heavily medicated society will be. But in some ways, too, I believe, they are wrong. The drugs, many other studies suggest, can work—yes, only some of the time, in some people, with sometimes rotten side effects and bad withdrawal symptoms and dependency problems. And, yes, we don’t know what long-term damage they’re wreaking on our brains. And, yes, the diagnostic categories have been artificially inflated or distorted by the drug companies and the insurance industry. But I can tell you with hard-won personal authority that there is legitimate underlying emotional distress here, which can be quite debilitating, and which these drugs can mitigate, sometimes only a little, sometimes profoundly.
When I talk to Dr. W. about this, he reports that his own clinical experience comports with what I have been finding in my research: there is enormous variability in how different patients respond to different drugs. He once treated a patient whose parents were Holocaust survivors. This woman was deeply depressed; it was clear to Dr. W. that she had internalized their survivors’ guilt, a common phenomenon. He worked with her for months to get her to recognize this in an effort to dispel her unhappiness. Nothing helped; her devastating depression persisted week after week. Then she tried Prozac. After a few weeks on the drug, she came for her appointment one day and said, “I feel great.” A few weeks later, she deemed herself cured and terminated treatment. Score one for the SSRIs.
But around that same time, Dr. W. had another patient, a man suffering from obsessive-compulsive disorder and low-grade depression. That patient, too, started on Prozac—and within forty-eight hours was in the hospital with acute suicidal ideation. Score one against the SSRIs.d
Dr. W. has a psychopharmacologist colleague with whom he has collaborated for years. Together they have successfully treated many patients with anxiety disorders. Whenever one of their patients gets better, Dr. W. will say to the psychopharmacologist, “It was clearly your drugs that did it.” And he will respond to Dr. W., “No, it was clearly your psychotherapy that did it.” And then they laugh and congratulate each other on another successful case. But the truth is, as Dr. W. acknowledges, they don’t really know what made a given patient recover.
It is much cheaper to tranquilize distraught housewives living in isolation in tower-blocks with nowhere for their children to play than to demolish these blocks and to rebuild on a human scale, or even to provide play-groups. The drug industry, the government, the pharmacist, the tax-payer, and the doctor all have vested interests in “medicalizing” socially determined stress responses.
—MALCOLM LADER, “BENZODIAZEPINES:
OPIUM OF THE MASSES” (1978)
Just because I can explain your depression using terms such as “serotonin reuptake inhibition” doesn’t mean you don’t have a problem with your mother.
—CARL ELLIOTT, The Last Physician: Walker Percy and the Moral Life of Medicine (1999)
Before Donald Klein’s imipramine experiments, interpreting the content of one’s anxiety mattered a lot: What does your phobia of heights or rats or trains mean? What is it trying to communicate to you? Imipramine drained anxiety of much of its philosophical meaning. Developments in pharmacology were showing anxiety to be merely a biological symptom, a physiological phenomenon, a mechanical process whose content didn’t matter.
Yet for philosophers like Kierkegaard and Sartre, anxiety resolutely does have meaning. For them, as well as for psychotherapists who resist reducing brain states to biology, anxiety is not something to be avoided or medicated but rather the truest route to self-discovery, the road to (in the sixties-inflected version of this idea) self-actualization. Dr. W. believes this.
“Go into the heart of danger,” he likes to say, quoting a Chinese proverb, “for there you will find safety.”
For evolutionary biologists, anxiety is a mental and physiological state that evolved to keep us safe and alive. Anxiety enhances our vigilance, prepares us to fight or flee. Being anxious can helpfully attune us to physical threats from the world. Freud believed anxiety attunes us not just to threats from the world but to threats from within ourselves. Anxiety, in this view, is a sign that our psyche is trying to tell us something. Medicating away that anxiety instead of listening to what it’s trying to tell us—listening to Prozac, as it were, instead of listening to our anxiety—might not be what’s called for if we want to become our best selves. Anxiety can be a signal that something needs to change—that we need to change our lives. Medication risks blocking that signal.e
In Listening to Prozac, Peter Kramer engages the work of the novelist Walker Percy, whose writing grapples with how to cope with emotional pain and spiritual longing in the age of biological psychiatry. What gets lost, Percy’s stories and essays ask, when anxiety and anomie are medicated away?
Percy was well situated to tackle these issues. The “hereditary taint” (as Freud called it) of melancholy ran thick through the bloodlines of his Southern family. His grandfather, his father, and possibly his mother (who drove herself off a bridge) committed suicide; two of his uncles had nervous breakdowns. Percy’s father, LeRoy, a lawyer, medicated his depression with alcohol and sought treatment from specialists, traveling to Baltimore to meet with the leading psychiatrists at Johns Hopkins in 1925. But modern psychopharmacology was not yet available, and in 1929 LeRoy succeeded in his second attempt at killing himself, shooting himself in the head with a 20-gauge shotgun.
Walker’s response was to study science. Believing that science would eventually explain everything in the cosmos, including the nature of the melancholy that killed so many members of his family, he decided to become a doctor. His medical training hardened his scientific materialism. “If man can be reduced to the sum of his chemical and biological properties,” as one of his biographers characterized Percy’s reasoning as a young man, “why worry about ideals, or lack thereof?”
But in 1942, Percy contracted tuberculosis and had to drop out of medical school, repairing to a sanatorium in Saranac Lake, New York, to recover. Streptomycin and—note this—isoniazid and iproniazid were still a few years away from being available as tuberculosis remedies, so the prescribed treatment was rest. While at the sanatorium, he fell into a depression and read intensively—lots of Dostoyevsky and Thomas Mann, as well as Kierkegaard and Thomas Aquinas.
Feeling physically and emotionally unwell, he underwent a spiritual crisis in which he determined that science could not, after all, solve the problem of human unhappiness. Eventually, influenced especially by the writings of Kierkegaard, he decided to make a leap of faith and become a Catholic.f How differently might Percy’s life and philosophy have turned out if he had been treated with iproniazid instead of with a curriculum of European novels and existential philosophy? Iproniazid, we now know, would shortly become the MAOI antidepressant Marsilid—a drug that might quickly have both cured his tuberculosis and dispelled his melancholy. He might well have returned to his medical training and never become a novelist. His opinion of biological psychiatry might have become considerably warmer.g
Percy never lost his respect for the scientific method. But he came to distrust the reductionist worldview that claimed science as the philosophical basis of ethics and of all human knowledge. In fact, he came to believe that the high rates of depression and suicide in modern society were owed in part to the cultural triumph of the scientific worldview, which reduced man to a collection of cells and enzymes, without supplying an alternative repository of meaning.
In 1957, Percy wrote a two-part article for America, the weekly Jesuit magazine. By focusing on the biological, he said, psychiatry becomes “unable to account for the predicament of modern man.” Guilt, self-consciousness, sadness, shame, anxiety—these were important signals from the world and from our souls. Medicating these signals away as symptoms of organic disease risks alienating us further from ourselves. “Anxiety is,” Percy wrote, “under one frame of reference a symptom to be gotten rid of; under the other, it may be a summons to an authentic existence, to be heeded at any cost.”h
Many times in his writing, Percy alludes to Kierkegaard’s idea that worse than despair is to be in despair and not realize it—to have anxiety but to have built your life around not experiencing it. “We all know perfectly well that the man who lives out his life as a consumer,” he writes in “The Coming Crisis in Psychiatry,” “a sexual partner, an ‘other-directed’ executive; who avoids boredom and anxiety by consuming tons of newsprint, miles of film, years of TV time; that such a man has somehow betrayed his destiny as a human being.”
If anxiolytic medication mutes our anxiety, deafens us to it—allows us to be in despair without knowing it—does that somehow deaden our souls? Percy would seem to believe that it does.
I believe all of this, as far as it goes. I endorse the philosophical stances of Walker Percy and Søren Kierkegaard. And yet how much credibility do I have? After all, here I am, in my thirtieth year of taking psychiatric medications, with citalopram and alprazolam and possibly still some of last night’s clonazepam flowing through my bloodstream as I write this—my serotonergic and GABAnergic systems boosted, my glutamate inhibited—agreeing with Peter Breggin that drugs are toxic and with Walker Percy that they diminish the soul. Am I not a terribly compromised vessel for delivering this argument?
And yet so, one might say, was Percy, who took sleeping medications for his chronic insomnia. (And with good reason: his father’s brutal insomnia played a large role in driving him to suicide.) Psychiatric medications—for some people, in some situations, some of the time—work. To deny the schizophrenic chemical remission from his psychotic delusions, or the bipolar patient pharmacological relief from his self-endangering manias and crushing depressions—or, yes, the panic-ravaged and housebound individual some medical defense against anxiety—would be cruel. One can be, I believe, skeptical about the claims of the pharmaceutical industry, concerned about the sociological implications of a population that is so heavily medicated, and attuned to the existential trade-offs involved in taking psychiatric medications without being ideologically in opposition to the judicious use of these drugs.
On the other hand, I know I would do well to heed Percy, as well as modern Big Pharma critics like Edward Drummond and Peter Breggin, because the irony of what I have had to ingest in order to write this section on drugs is obvious. I elevated my Celexa dosage, became dependent on Xanax and Klonopin, and consumed heroic quantities of alcohol to keep my anxiety at bay. After forty years of never smoking a single cigarette (because after getting my grandmother to quit smoking in her sixties, I’d promised to never take up the habit myself), I smoked my first one at forty-one. After having been so afraid of recreational narcotics (perhaps an instance of the evolutionary adaptiveness of my innate caution) that I’d never for forty years taken so much as a puff of marijuana nor indulged in any other nonprescribed drug, I resorted in desperation (after reading Freud’s enthusiastic papers about it) to trying cocaine and also amphetamines. Many nights I would begin the evening fueled by caffeine and nicotine, which I needed to propel me out of torpor and hopelessness—only to overshoot into quaking, quivering anxiety. Thoughts racing, hands shaking, I would end the evening taking a Klonopin and then perhaps a Xanax and drinking a scotch (and then another and another) to settle down. This is not healthy.
More constructively, I have tried to draw on Kierkegaard and Percy for backbone and solace, and I have also tried yoga and acupuncture and meditation. I would very much like to unlock my “inner pharmacy”—that repository of healthy, natural hormones and neurotransmitters that can be activated, the antidrug New Age healers say, with meditation and biofeedback and better “inner balance”—but despite my best efforts, I’m fumbling with the keys.
* * *
* The birth of a child ranks high on the famous Holmes and Rahe Stress Scale, which attempts to quantify the effects of various kinds of life stresses on mental and physical health.
† Often, escaping the office wasn’t enough to stem the tide of panic, so I took to walking several blocks to Old North Church, where Paul Revere’s famous one-if-by-land-and-two-if-by-sea lanterns had supposedly been hung in 1775. I’d sit in an austere wooden pew in the back and gaze at the oil painting of Jesus that hangs behind the altar. In that painting, Christ’s face looks kindly, his eyes sympathetic. I am not a hard-core atheist, but nor am I a believer—I’m a who-knows-what-explains-all-this agnostic, a skeptic who out of my usual abundance of caution refuses to brazenly deny that God exists for fear of losing Pascal’s wager and discovering too late that he does. Yet in those desperate weeks in the summer of 2003, I would sit in Old North Church and pray forthrightly to that painting of Jesus. I’d ask it to please give me peace of mind, or a sign that God existed, something I could grab hold of to steady myself against the assault of my nerves. In my quest for succor, I started reading my way through the Bible and a history of early Christianity, trying to see if I could somehow reason my way to faith and the psychic and existential serenity I thought it might provide.
I couldn’t. And while I did find something about the unadorned Puritan simplicity of the church to be calming, my visits there didn’t really help, either, especially during the nadir of my Effexor experience. I’d try to calm my breathing—but then I’d get overwhelmed by claustrophobia and panic and have to rush out of the church. I’d often end up shaking on a park bench, probably looking to passing tourists like a homeless person suffering delirium tremens.
‡ A series of studies in the 1980s found imipramine, the tricyclic antidepressant, to be more effective than Prozac for treating patients with depression or panic disorder. Imipramine also trounced Paxil in two studies in the early 1980s of patients with depression. In 1989, Paxil failed to beat a placebo in more than half its trials. Yet four years later, Paxil was approved by the FDA—and by 2000 it was the best-selling antidepressant on the market, outselling Prozac and Zoloft.
§ Carlsson wanted to pursue chlorpheniramine clinical trials for patients with anxiety and depression, but he never did. His own lab research, as well as subsequent naturalistic observations, showed that chlorpheniramine may, without any modifications, be as effective as any existing SSRI—which is intriguing because chlorpheniramine has been on the market, under the trade name Chlor-Trimeton, as an over-the-counter medicine for
pollen allergies since 1950. In 2006, Einar Hellbom, a Swedish researcher, published a study suggesting that patients diagnosed with panic disorder who took chlorpheniramine for their hay fever experienced a remission of their panic symptoms while on the drug; when the patients went off Chlor-Trimeton, even if they switched to another antihistamine, many of them found their panic attacks returning. Hellbom suggested that perhaps this means an effective nonprescription SSRI antidepressant is sitting on the allergy remedy shelf of your local pharmacy today—even though scarcely any doctors, and certainly no consumers, are aware of its potential in this regard. “If chlorpheniramine had been tested on depression in the nineteen seventies,” Hellbom writes, “it is probable that a safe, inexpensive SSRI drug could have been used some 15 years earlier than [Prozac].… Chlorpheniramine might have been the first safe, non-cardiotoxic and well-tolerated antidepressant. Billions of dollars in the development and marketing costs would have been saved, and the suffering of millions of patients alleviated.”
This is striking to me because I took Chlor-Trimeton regularly each spring throughout my childhood. I had always attributed the lifting of my depression and anxiety in April and May to the lengthening of the daylight and the approaching end of the school year. But Hellbom’s paper leads me to wonder if my brightening mood and decreasing tension each spring were a result of my exposure to Chlor-Trimeton, the accidental SSRI.
‖ The tricyclics and MAOIs, in contrast, were “dirty,” or “nonselective,” in that they affected not just serotonin but also norepinephrine, dopamine, and other neurotransmitters, a fact that was thought to account for their wide range of unpleasant side effects.
a Ironically, the early commercial success of SSRIs owed a lot to the public furor over Valium addiction in the early 1970s, which had driven benzodiazepines out of favor. When the FDA approved SSRIs for the treatment of depression, that caused the number of depression diagnoses to skyrocket, even as rates of anxiety diagnosis fell. But when the FDA subsequently approved SSRIs for the treatment of anxiety, the number of anxiety diagnoses rose again.
My Age of Anxiety: Fear, Hope, Dread, and the Search for Peace of Mind Page 27