Bashing mental health drugs has become a popular trend of late. But just because some people are taking SSRIs that don't need them doesn't mean the drugs don't work.
The mere title of the new book Coming of Age on Zoloft: How Antidepressants Cheered Us Up, Let Us Down, and Changed Who We Are made me want to put up my dukes. Right there in the sub-title seemed to be the implication that we'd been wronged by these drugs--transformed in sinister ways. The back cover also raised my hackles: "[Author Katherine Sharpe] weighs the cultural implications of America's biomedical approach to moods," it says. Moods? Depression may be a mood disorder, but classifying it as a mood seemed like a way of belittling and obfuscating a serious, often deadly, illness.
If I sound defensive, I have my reasons. As someone whose life was dramatically improved by head meds--improved in demonstrable, physical ways--I have to wonder if some recent media attacks on antidepressants have done more harm than good in the way that they have called into doubt the demonstrable efficacy of the medication, even while raising some valid questions.
I'd never thought my own "moodiness" was serious enough to warrant medication; I had, frankly, scoffed at antidepressants as an easy way out, for the weak. (I preferred to fix my psychological problems the hard way--through therapy; that seemed to me to be a more sustainable and "real" solution.) But then I found myself on the Brooklyn Bridge late one December night, contemplating a swan dive in terrifying detail.
The funny thing is, I thought it was less depression than insomnia that was driving me crazy. For close to a decade, I'd had major sleeping problems; I'd tried everything I could think of to cure myself (cutting out alcohol, cutting out caffeine, practicing better "sleep hygiene," melatonin, etc.); nothing had worked.
I'd given up on finding a cure, by then, and I just felt too tired to keep living. Most days were a trial of exhaustion. My head often seemed to prickle with a pins-and-needly feeling that was half numbness, half pain. Having to force myself through another year of despair, only to surely face one more just like it after I climbed the mountain of days--and then another year of bad sleep, and another after that--held no appeal, to put it mildly.
I'd never thought I was truly depressed before that point. Mopey, maybe; a little screwed-up, sure; in therapy to try to figure out why I had so much trouble with relationships, certainly. But, as it turns out, vividly envisioning your own suicide in the spot where you'd actually go through with it is a quite compelling way to start believing that, yes, you're definitely depressed.
After getting down from the bridge, I went to see my primary care doctor, and told her, in tears, about what happened. She got me started on Celexa--an SSRI, or selective serotonin reuptake inhibitor, that magically solved my sleeping problems. (As she told me during that visit, insomnia can be both a symptom and cause of depression; if I'd heard that before, it had not really registered.) The more rested I felt, the more energy I began to have. Celexa restored me to life, giving me a certain basic sense of well-being that was as physical as it was psychological.
Do I wish I'd started taking antidepressants long before such a terrible idea implanted itself so deeply in mind? I do. Do I wish my psychologist--who was more aware of my sleeping problems than my doc--had urged me to take them? Absolutely. Do I regret taking them? Not a bit. I was on medication for two years (though I eventually switched to Wellbutrin, because Celexa was making me gain weight); when I felt strong again, I went off them--after consulting my doctor--and found, miraculously, I was able to sleep pretty well without them. (About a year after that--when the break-up of a relationship and a few big setbacks hit me all at once--I stopped being able to sleep again, and I returned to Wellbutrin.)
As a result of my experience, my impulse is to proselytize about the benefits of antidepressants. But maybe what antidepressants need, these days, is a defender more than a proponent.
The most high-profile hit job on psychiatric medications--and antidepressants in particular--came last summer, courtesy of Marcia Angell, a writer for the New York Review of Books. In a much-ballyhooed two-part article, Angell drew on three new books as she cautioned that we don't know much about the long-term effects of antidepressants; that, in fact, we don't even know precisely why or how they work. She pointed to some evidence that would suggest they're not much more effective than placebos. She questioned the relationship between the psychiatric community and the pharmaceutical industry. She speculated that psychoactive drugs, which seem to be overprescribed, might "create worse problems than they solve." In conclusion, she called the three books she focused on -- The Emperor's New Drugs: Exploding the Antidepressant Myth, by Irving Kirsch; Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, by Robert Whitaker; and Unhinged: The Trouble with Psychiatry--A Doctor's Revelations About a Profession in Crisis, by Daniel Carlat -- "powerful indictments of the way psychiatry is now practiced. They document the 'frenzy' of diagnosis, the overuse of drugs with sometimes devastating side effects, and widespread conflicts of interest."
Angell makes many excellent points. The lack of long-term studies, for instance, is certainly concerning--although as even the critic Sharpe noted in an email dialogue we had, "SSRIs have been around for 25 years, and anecdotal reports of catastrophic ill effects have yet to emerge."
Angell also argues that doctors should pay more attention to non-pharmaceutical treatments for depression: "Both psychotherapy and exercise have been shown to be as effective as drugs for depression, and their effects are longer-lasting, but unfortunately, there is no industry to push these alternatives and Americans have come to believe that pills must be more potent." And it's true; psychotherapy and exercise can help (as can meditation); patients should try them--and doctors should suggest them--before turning to pharmaceutical solutions. Nonetheless, in some cases--like mine--years of therapy doesn't solve the problem, and neither does daily exercise.
And what Angell doesn't say is that good therapy is often very expensive--far more expensive than most people can afford, particularly because so many health insurance plans provide little or no coverage for it--whereas less-than-excellent therapy can contribute to a sense that one's problems are intractable, that things will never change. (I speak from experience.) Perhaps it's also worth noting that if developing a fitness habit were easy for the average person, then the obesity epidemic wouldn't be the most serious and costly health problem facing our country right now. And many seriously depressed people have a difficult time getting out of bed, to say nothing of going for a thirty-minute jog--though for some of us, like myself, our mental illness happens to come with a degree of obsessive-compulsiveness that often manifests itself at the gym.
Sharpe, whose book goes on sale this week, had an experience that was nearly the opposite of mine. I wish my psychologist had pushed pills on me. Sharpe wishes that the health counselor she encountered during her first year in college had encouraged her to get into therapy instead of starting her on Zoloft--by way of free samples, like some kind of pusherman in a lab coat--after Sharpe basically got seriously bummed out by a hook-up gone wrong. (Or, as she puts it: "I was in a depressive, panicky phase, probably brought on by the transition to college.") Like Angell, Sharpe is concerned about how many prescriptions for psychiatric medication are handed out each year, but her book is less the polemic against antidepressants that I was expecting than a call to be more careful about how we, as a culture, use and understand them.
The latest report from the Centers for Disease Control found that 11 percent of Americans aged 12 and older are taking antidepressants--making them the most commonly used kind of drug for people between the ages of 18 and 44. Sharpe believes those numbers are so high in part simply because so many patients ask doctors for them after seeing them advertised. "Since 1997, we've had direct-to-consumer advertising of prescription drugs, which urges consumers to 'ask your doctor' whether a certain medication might be right for them," she tells me. "And people do: a 2003 report found that a third of adults had asked their doctors about a medication they'd seen advertised, and that four out of five who did ended up receiving a prescription." Hearing that, one has to wonder: How are doctors determining that those people really are depressed? Are they careless or cavalier when it comes to handing out prescriptions? And how many patients ask for antidepressants less because they're actually depressed and more because they've heard that "scattered studies suggest that antidepressants bolster confidence or diminish emotional vulnerability -- for people with depression but also for healthy people," as Peter Kramer, author of Listening to Prozac, noted in the New York Times last year?
But just because some people who are on antidepressants might not need them doesn't mean that no one does--and the problem with a piece like Angell's is how dismissive of psychiatric medication it is. "If we knew that the benefits of psychoactive drugs outweighed their harms, that would be a strong argument [in their favor], since there is no doubt that many people suffer grievously from mental illness," she writes. "But as Kirsch, Whitaker, and Carlat argue convincingly, that expectation may be wrong."
Wait a second, though--don't we know that the benefits of psychoactive drugs outweigh their harms? I think they do, but I know my evidence is anecdotal.
Luckily, I'm not the only one convinced of the good they're doing; many psychiatrists and other mental health care practitioners are, too. As John Oldham, M.D., president of the American Psychiatric Association, put it in a letter to the New York Review of Books shortly after Angell's piece ran: "The bottom line is that these medications often relieve the patient's suffering." Similarly, Carlat, an associate clinical professor of psychiatry at Tufts University School of Medicine, wrote in to agree that "psychiatrists often overdiagnose disorders of questionable scientific validity, they have become overly fixated on medication solutions to life's problems, and many have accepted a steady flow of drug industry money, creating so many conflicts of interest that it is impossible to know who we can trust." But he also noted that "missing from her review is an unequivocal if perplexing truth about psychiatric drugs--on the whole, they work." (Carlat, let us remember, had no axe to grind; Angell had written favorably about his book.)
And in another rebuttal to Angell's piece, Listening to Prozac author Kramer got more specific. "A reliable finding is that antidepressants work for chronic and recurrent mild depression, the condition called dysthymia," he wrote. "More than half of patients on medicine get better, compared to less than a third taking a placebo. ... Similarly, even the analyses that doubt the usefulness of antidepressants find that they help with severe depression."
While I'm certain that antidepressants helped me, Sharpe is more ambivalent about the decade she spent taking Zoloft. "I can't say that antidepressants ruined my life, and for all I know they may have made it better," she says. "Still, I don't feel that my problems were so very unusual, and I believe that I could have gotten by without medication--and I wish that I had at least tried to do so." She tried to get off Zoloft a number of times over the years. "It never seemed to work well," she says. "I'd always seem to end up back in some state that reminded me of the first time I went on them, and back I'd go again. I don't know what was happening there: maybe I just got depressed without them. Maybe the fear of living without them became a kind of self-fulfilling prophecy. Maybe, as I've heard some people say, the brain habituates to SSRIs and reacts with depression-like symptoms when they are withdrawn."
She didn't have any medical guidance in trying to figure out when and how she should get off antidepressants--and she's concerned that experiences like her are all too common. "Doctors [seem to be] much more comfortable putting people on antidepressants than discussing how long they should expect to stay on them or how they might get off," she notes.
Sharpe's book reminds us that there are significant questions we should be asking about who needs antidepressants, why doctors prescribe them, and how the insurance industry approaches mental illness. But that, of course, doesn't mean that antidepressants are dummy pills that have no real effect; and it's crucial that depressives--many of whom are suspicious of medication--realize that.
"With a higher frequency and stronger potency than what we see in the literature, [antidepressants] seem to help," as Kramer writes. "[I]t is dangerous for the press to hammer away at the theme that antidepressants are placebos. They're not. To give the impression that they are is to cause needless suffering."