My own experience, of course, involves ample exposure to both drugs and other therapies, often in concert. Starting when I was 11, I saw the same psychiatrist once or twice a week for 25 years. Dr. L. was the psychiatrist who, when I was taken to McLean Hospital, administered my first Rorschach test. When I started therapy with him, he was approaching 50, tall and lanky, balding a little, with a beard in the classic Freudian style. Over the years, the beard came and went, and he lost more of his hair, which turned from brown to salt-and-pepper to white. Trained at Harvard in the 1950s and early 1960s, Dr. L. came of professional age in the late stages of the psychoanalytic heyday, when Freudianism still dominated. When I first encountered him, he was a believer both in medication and in such Freudian concepts as neurosis and repression, the Oedipus complex and transference. Our first sessions, in the early 1980s, were filled with things like Rorschach tests and free association and discussions of early memories. Our last sessions, in the mid-2000s, were focused on role-playing and “energy work”; he also suggested during those latter years that I sign up for a special kind of yoga program, later alleged to be a brainwashing cult by some former members, though their claims were never proved.
Here’s some of what we did in our sessions together over a quarter century: looked at picture books (1981); played backgammon (1982–85); played darts (1985–88); experimented sporadically with various cutting-edge psychotherapeutic methods of an increasingly New Age complexion, such as hypnotism, eye-movement desensitization and reprocessing, energy-systems therapy, and internal-family-systems therapy (1988–2004). During this period I also moved, in tandem with prevailing pharmacological trends, from one class of drugs to another, in often overlapping succession: from antipsychotics to benzodiazepines to tricyclic antidepressants to MAOI antidepressants to SSRI antidepressants back to benzodiazepines again. I was the beneficiary, or possibly the victim, of seemingly every passing fad in psychotherapy and psychopharmacology.
Medication has more reliably soothed my anxiety than various other forms of therapy have. (Without Thorazine and imipramine and Valium, I don’t know that I could have gotten through seventh grade.) Yet the case for medication, I can also tell you, is complicated by drawbacks and side effects that range from sedation to weight gain to mania to headaches to digestive and urinary troubles to neuromuscular problems to dependency and addiction to, some say, brain damage—and that’s leaving aside withdrawal symptoms that, in the case of many drugs, can be far worse than the side effects. While lots of people will testify that drugs have helped them, lots of other people will testify (and often do, in court filings and before Congress) that medication has ruined their lives. Though plenty of studies, and many individual experiences, suggest that drugs can be highly effective in treating anxiety, the benefits are at the very least not clear-cut.
Sigmund Freud relied heavily on drugs to manage his anxiety. Six of his earliest scientific papers described the benefits of cocaine, which he used regularly for at least a decade, beginning in the 1880s. Only after he prescribed the stimulant to a close friend who became fatally addicted did Freud’s enthusiasm wane. Much of the history of modern psychopharmacology has the same ad hoc quality as Freud’s experimentation with cocaine. Every one of the most commercially significant classes of antianxiety and antidepressant drugs of the past 60 years was discovered by accident or was originally developed for something completely unrelated to anxiety or depression: to treat tuberculosis, surgical shock, allergies; to use as an insecticide, a penicillin preservative, an industrial dye, a disinfectant, rocket fuel.
Prozac and other, similar selective serotonin reuptake inhibitors are currently the medications of choice for many psychiatrists, and have been for more than two decades. Given how completely SSRIs have saturated our culture and our environment, you might be surprised to learn that Eli Lilly, which held the U.S. patent for fluoxetine (the generic name for Prozac), killed the drug in development seven times, in part because of unconvincing test results. After examining the tepid outcomes of fluoxetine trials, as well as complaints about the drug’s side effects, German regulators in 1984 concluded, “Considering the benefit and the risk, we think this preparation totally unsuitable for the treatment of depression.” Early clinical trials of another SSRI, Paxil, were also failures.
I’ve been on one or another SSRI pretty much continuously for going on 20 years. Nevertheless, I can’t say with complete conviction that these drugs have worked, at least for long—or that they’ve been worth the costs in terms of money, side effects, drug-switching traumas, and who knows what long-term effects on my brain.
After the initial flush of enthusiasm for SSRIs in the 1990s, some of the concerns about drug dependency and side effects that had attached to tranquilizers in the 1970s began clustering around antidepressants. “It is now clear,” David Healy, a historian of psychopharmacology, wrote in 2003, “that the rates at which withdrawal problems have been reported” on paroxetine, the generic name for Paxil, “exceed the rates at which withdrawal problems have been reported on any other psychotropic drug ever.”
Even leaving aside withdrawal effects, there is now a large pile of evidence suggesting—in line with those early studies of the ineffectiveness of Prozac and Paxil—that SSRIs may not work terribly well. In January 2010, almost exactly 20 years after hailing the arrival of SSRIs with its cover story “Prozac: A Breakthrough Drug for Depression,” Newsweek published a cover story about the growing number of studies that suggested these and other antidepressants are barely more effective than sugar pills. A large-scale study from 2006 showed that only about a third of patients improved dramatically after a first cycle of treatment with antidepressants. Even after three additional cycles, almost a third of patients who remained in the study had not reached remission. After reviewing a host of studies on antidepressant effectiveness, a paper in the British Medical Journal concluded that drugs in the SSRI class—including Prozac, Zoloft, and Paxil—“do not have a clinically meaningful advantage over placebo.”
How can this be? Tens of millions of Americans—including me and many people I know—collectively consume billions of dollars’ worth of SSRIs each year. Doesn’t this suggest that these drugs are effective? Not necessarily. At the very least, this massive rate of SSRI consumption has not caused rates of self-reported depression to go down—and in fact all of this pill popping seems to correlate with substantially higher rates of depression. Meanwhile, the relationship between low serotonin levels and anxiety or depression (once, and to some extent still, the theoretical reason SSRIs, which boost serotonin, should work) now seems less straightforward than previously thought. George Ashcroft, who, as a research psychiatrist in Scotland in the 1950s, was one of the scientists responsible for promulgating the chemical-imbalance theory of mental illness, abandoned the theory when further research failed to support it. “We have hunted for big, simple neurochemical explanations for psychiatric disorders,” Kenneth Kendler, a co-editor of Psychological Medicine and a psychiatry professor at Virginia Commonwealth University, conceded in 2005, “and have not found them.”
Some drugs work on some people, but the reasons are murky, and the results sometimes fleeting. Of course, studies have generally not found the response rates to nonpharmacological forms of treatment to be better than the response rates to antidepressants or any other drugs. Some recent studies have found that the effects of cognitive-behavioral therapy are more enduring than drug treatment. But as a general rule of thumb across many types of therapy, patients tend to split pretty evenly among those who see long-term improvement, those who see only transient benefits, and those who see no improvement at all. (That’s generally true of placebo treatments as well.) And so, just as I find it difficult to endorse most of these treatments, I am also reluctant to condemn them. Like medication, they clearly do help some patients. This is a fact I can vouch for personally.
On the Sunday in the autumn of 1995 when my mother announced to him that she might want a divorce, my father, desperate to save the marriage, and in a gesture that was completely out of character, acquiesced to emergency couple’s counseling. When that didn’t work, and my mother left him, he became unmoored, and soon began seeing Dr. L., my psychiatrist. For years before that, my father, despite footing the bill for my sister’s and my shrinks, had disdained psychotherapy. “How was your wacko lesson?” he’d ask jeeringly after I’d had an appointment. He did this so often that the term became a part of the family’s lingua franca, and eventually my sister and I were referring without irony to our wacko lessons. (“Mom, can you give me a ride to my wacko lesson on Wednesday?”)
And yet, there he was, suddenly sharing a therapist with me. My own sessions with Dr. L. came to be dominated by the therapist’s questions about his new star patient, my father. I couldn’t blame Dr. L. for finding my father the more interesting patient. After all, while he’d been seeing me for more than 15 years, he’d been seeing my dad for only a few months. My dad entered therapy emotionally wrecked by his separation, profoundly shaken, and newly sober. He completed therapy less than two years later, happy, productive, remarried, and deemed (by himself and by Dr. L.) to be much more “self-actualized” and “authentic” than he had been before. He was in and out of therapy in 18 months. Whereas I was entering my 18th year of therapy with Dr. L. and was still as anxious as ever.
At some level, it is adaptive to be reasonably anxious. According to Charles Darwin (who himself seems to have suffered from crippling agoraphobia that left him intermittently housebound for years after his voyage on the Beagle), species that experience an appropriate amount of fear increase their chances of survival. We anxious people are less likely to remove ourselves from the gene pool by, say, frolicking on the edges of cliffs or becoming fighter pilots.
An influential study conducted 100 years ago by two Harvard psychologists, Robert M. Yerkes and John Dillingham Dodson, laid the foundation for the idea that moderate levels of anxiety improve performance: too much anxiety, obviously, and performance is impaired, but too little anxiety also impairs performance. “Without anxiety, little would be accomplished,” David Barlow, the founder and director emeritus of the Center for Anxiety and Related Disorders at Boston University, has written.
The performance of athletes, entertainers, executives, artisans, and students would suffer; creativity would diminish; crops might not be planted. And we would all achieve that idyllic state long sought after in our fast-paced society of whiling away our lives under a shade tree. This would be as deadly for the species as nuclear war.
Even if I can’t fully recover from my anxiety, I’ve come to believe there may be some redeeming value in it.
Historical evidence suggests that anxiety can be allied to artistic and creative genius. The literary gifts of Emily Dickinson, for example, were inextricably bound up with her reclusiveness, which some say was a product of anxiety. (She was completely housebound after age 40.) Franz Kafka yoked his neurotic sensibility to his artistic sensibility; Woody Allen has done the same. Jerome Kagan, an eminent Harvard psychologist who has spent more than 50 years studying human temperament, argues that T. S. Eliot’s anxiety and “high reactive” physiology helped make him a great poet. Eliot was, Kagan observes, a “shy, cautious, sensitive child”—but because he also had a supportive family, good schooling, and “unusual verbal abilities,” Eliot was able to “exploit his temperamental preference for an introverted, solitary life.”
Perhaps most famously, Marcel Proust transmuted his neurotic sensibility into art. Proust’s father, Adrien, was a physician with a strong interest in nervous health and a co-author of an influential book called The Hygiene of the Neurasthenic. Marcel read his father’s book, as well as books by many of the other leading nerve doctors of his day, and incorporated their work into his; his fiction and nonfiction are “saturated with the vocabulary of nervous dysfunction,” as one historian has put it. For Proust, refinement of artistic sensibility was directly tied to a nervous disposition. Dean Simonton, a psychology professor at the University of California at Davis who has spent decades studying the psychology of genius, has written that “exceptional creativity” is often linked to psychopathology; it may be that the same cognitive or neurobiological mechanisms that predispose certain people to developing anxiety disorders also enhance creative thinking.
Many of history’s most eminent scientists also suffered from anxiety or depression, or both. When Sir Isaac Newton invented calculus, he didn’t publicize his work for 20 years—because, some conjecture, he was too anxious and depressed to tell anyone. (For more than five years after a nervous breakdown around 1678, when he was in his mid-30s, he rarely ventured far from his room at Cambridge.) Perhaps if Darwin had not been largely housebound by his anxiety for decades on end, he would never have been able to finish his work on evolution. Sigmund Freud’s career was nearly derailed early on by his terrible anxiety and self-doubt; he overcame it, and once his reputation as a great man of science had been established, Freud and his acolytes sought to portray him as the eternally self-assured wise man. But his early letters reveal otherwise.
No, anxiety is not, by itself, going to make you a Nobel Prize–winning poet or a groundbreaking scientist. But if you harness your anxious temperament correctly, it might make you a better worker. Jerome Kagan says he hires only people with high-reactive temperaments as research assistants. “They’re compulsive, they don’t make errors,” he told The New York Times. Other research supports Kagan’s observation. A 2013 study in the Academy of Management Journal, for instance, found that neurotics contribute more to group projects than co-workers predict, while extroverts contribute less. And in 2005, researchers in the United Kingdom published a paper, “Can Worriers Be Winners?,” reporting that financial managers high in anxiety tended to be the best, most effective money managers, as long as their worrying was accompanied by a high IQ.
Unfortunately, the positive correlation between worrying and job performance disappeared when the worriers had a low IQ. But some evidence suggests that excessive worrying is itself allied to intelligence. Jeremy Coplan, the lead author of one study supporting that thesis, says anxiety is evolutionarily adaptive because “every so often there’s a wild-card danger.” When such a danger arises, anxious people are more likely to be prepared to survive. Coplan, a professor of psychiatry at the State University of New York Downstate Medical Center, has said that worrying can be a good trait in leaders—and that lack of worrying can be dangerous. If people in leadership positions are “incapable of seeing any danger, even when danger is imminent,” they are likely, among other poor decisions, to “indicate to the general populace that there’s no need to worry.” (Some commentators have suggested, based on findings like Coplan’s, that the main cause of the economic crash of 2008 was politicians and financiers who were either stupid or insufficiently anxious or both.) Studies on rhesus monkeys by Stephen Suomi, the chief of the Laboratory of Comparative Ethology at the National Institutes of Health, have found that when monkeys genetically predisposed to anxiety were taken early in life from their anxious mothers and given to unanxious mothers to be raised, a fascinating thing happened: these monkeys grew up to display less anxiety than peers with the same genetic markings—and many also, intriguingly, became the leader of their troop. This suggests that, under the right circumstances, some quotient of anxiety can equip you to be a leader.
As always, all of this comes with the proviso that anxiety is productive mainly when it is not so strong as to be debilitating. But if you are anxious, perhaps you can take heart from these findings.
I’ve come to understand that my own nervous disposition is perhaps an essential part of my being—and not just in ways that are bad. “I hate your anxiety,” my wife once said, “and I hate that it makes you unhappy. But what if there are things that I love about you that are connected to your anxiety?
“What if,” she asked, getting to the heart of the matter, “you’re cured of your anxiety and you become a total jerk?”
I suspect I might. Military pilots, by reputation, at least, are famously unanxious. And one small-scale study from the 1980s found that nine out of 10 separations and divorces among Air Force pilots were initiated by wives. Perhaps the two are linked. Low baseline levels of autonomic arousal (which can correspond to low levels of anxiety) have been tied not only to a need for adventure (flying a fighter plane, say), but also to a certain interpersonal obtuseness, a lack of sensitivity to social cues. It may be that my anxiety lends me an inhibition and a social sensitivity that make me more attuned to other people and a more tolerable spouse than I otherwise would be.
The notion of a connection between anxiety and morality long predates the findings of modern science or my wife’s intuition. Saint Augustine believed fear is adaptive because it helps people behave morally. The novelist Angela Carter has called anxiety “the beginning of conscience.” Some research into the determinants of criminal behavior suggest that criminals tend to be lower in anxiety than noncriminals. (On the other hand, different studies have found that high levels of anxiety, especially in youth, correlate with delinquent behavior.)
My anxiety can be intolerable. But it is also, maybe, a gift—or at least the other side of a coin I ought to think twice about before trading in. As often as anxiety has held me back—prevented me from traveling, or from seizing opportunities or taking certain risks—it has also unquestionably spurred me forward. “If a man were a beast or an angel, he would not be able to be in anxiety,” Søren Kierkegaard wrote in 1844. “Since he is a synthesis, he can be in anxiety, and the greater the anxiety, the greater the man.” I don’t know about that. But I do know that some of the things for which I am most thankful—the opportunity to help lead a respected magazine; a place, however peripheral, in shaping public debate; a peripatetic and curious sensibility; and whatever quotients of emotional intelligence and good judgment I possess—not only coexist with my condition but are in some meaningful way the product of it.
In his 1941 essay “The Wound and the Bow,” the literary critic Edmund Wilson writes of the Sophoclean hero Philoctetes, whose suppurating, never-healing snakebite wound on his foot is linked to a gift for unerring accuracy with his bow and arrow—his “malodorous disease” is inseparable from his “superhuman art” for marksmanship. I have always been drawn to this parable: in it lies, as the writer Jeanette Winterson has put it, “the nearness of the wound to the gift,” the insight that in weakness and shamefulness is also the potential for transcendence, heroism, or redemption. My anxiety remains an unhealed wound that, at times, holds me back and fills me with shame—but it may also be, at the same time, a source of strength and a bestower of certain blessings.