Emotional Choices

What story you choose to believe about antidepressants reveals a deeper truth about who you are.

In modern life, we each get to choose how to act and whom to be. This freedom can also be a curse, because we must make our choices based on approaches to doing and being that may be persuasive but are often in conflict. Our choices are centered on the stories we tell ourselves and the stories we are told; our challenge is to find good ways to choose among contradictory stories.

Such decisions are among the most basic challenges we face, because they become the foundation for a succession of other choices we make throughout our lives, often with no clearly right answers yet with long-term consequences. When we want to make the "right" decision about education, child rearing, or medicine, we must first sort out conflicting claims about what is true.

But while modern life offers us an abundance of compelling stories about what is best for us to do, it offers little guidance for finding our way through a thicket of equally plausible but often mutually contradictory points of view.

There are as many compelling illustrations of this issue as there are choices to make. The example I will use centers on a personal medical decision, but it involves far broader issues: social norms, approaches to choice, even identity. It is about mood medication.

Mother's Little Helper

I'm a prime candidate for such medication -- female, entering menopause, with a full-time job and two active children. I've long been prone to bouts of sadness and lethargy. I usually answer yes to most of the depression screening questions found in women's magazines and drug company pamphlets. On top of my symptoms of depression, I have lots of anxiety; I'm definitely a worrywart, imagining disasters of many kinds befalling me, my loved ones, and the world.

Plenty of experts have tried to convince me that I need mood medication. In the last 10 years my primary care physician, my gynecologist, and even my allergist's assistant have offered to get me prescriptions. I'm also being targeted by pharmaceutical companies with magazine and TV ads that describe me exactly and tell me that I can greet the dawn with gusto, romp with my children, smile at myself in the mirror, and be productive, cheerful, and optimistic ("like myself again") if I take their drugs. Why am I resisting taking mood medications, an option that millions of my fellow citizens have already chosen?

One reason I'm hesitant to take Prozac, Zo-loft, Xanax, Celexa, Wellbutrin, or their like involves a related but complicating issue: alcoholism. Years ago, I quit drinking because I believed I was an alcoholic, and if this is true it makes taking even doctor-prescribed drugs problematic. When I was first struggling to control my alcohol use, I strongly resisted the alcoholic label. But my resistance was interpreted by a counselor as denial, which is a key element in the diagnosis of alcoholism. And as with those depression screening questions, I could answer yes to well over the minimum number of questions required for an official diagnosis of alcoholism.

Since even with my best efforts I was unable to control my drinking, I finally adopted the language and beliefs -- what we in academic life call the discourse -- of alcoholism recovery, including the conviction that the only way to control my addiction was to abstain completely from alcohol and other mood-altering substances. I've successfully abstained from these, one day at a time, for more than 20 years.

Many in 12-step recovery circles believe that mood medication -- 20 years ago it was Librium, Valium, and tricyclic antidepressants -- is just alcohol in pill form. In the 1980s, lots of recovering alcoholics (more women than men) considered themselves dual addicts because they both drank and took pills. Recovering addicts were therefore considered to be one drink or drug away from active addiction. So if these beliefs are true, antidepressants are (for me, if I am indeed an addict) not useful medicine but dangerous drugs. Even everyday medicine -- cough syrup, pain pills -- could lead me back into active addiction, at least according to some members of the 12-step recovery community. So perhaps I am right to be especially wary.

Yet today many recovering alcoholics make exceptions for doctor-prescribed medications. Even as they consider themselves recovering alcoholics, they are taking and feeling better on mood medication such as Prozac and stimulants such as Ritalin (taken for "adult attention deficit disorder"). These people believe they are treating medical conditions, not feeding their addiction. They believe prescription medication, taken when recommended by a doctor to treat a real illness, is not dangerous and does not lead to relapse.

Are they right? Previous generations of doctors happily prescribed the tranquilizers and pep pills -- the Mother's Little Helpers -- that brought many women into what they defined as active addiction. In my early sobriety, I heard harrowing tales of how hard it was for these women to learn to live without the pills that their doctors had prescribed for the same kinds of symptoms I struggle with today. And it turns out that today's new and improved mood medications are also difficult to quit, requiring a gradual weaning process much like other addictive drugs. How are Paxil, Zoloft, and Xanax any different from Miltown, Librium, and Valium, the pills many critics now denounce as addictive drugs used to keep women of the '50s and '60s passive and complacent?

Coming Down Again

If you believe the media coverage of the 1990s, the newer selective serotonin reuptake inhibitors (SSRIs) are unlike the drugs of the past because these new medications treat a chemical imbalance that causes the diseases of depression and anxiety. Many who take these medications believe they are correcting a brain chemical deficit. But this is a marketing model that misrepresents what neuroscientists currently know about brain chemistry and the reasons these drugs may work. On top of that, depression, anxiety, and even alcoholism aren't diseases like cancer or diabetes, even if it may be helpful to think of them this way.

There is plenty of controversy about whether alcoholism even exists or, if it does, if it really is a disease. The original use of the term disease in Alcoholics Anonymous was metaphorical, aimed at destigmatizing the condition and describing its relentless course if untreated. But alcoholism, along with anxiety and depression, has come to count as a disease in the diagnostic manuals used by psychotherapists and physicians. This means that, at least for prescription and insurance purposes, they are diseases. Yet this pathologizing of elements of human experience begs the question: What makes heavy drug or alcohol use, long-term sadness, or heightened anxiety a disease?

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