In Defense of Happy Pills
Why talk to a shrink if Prozac or Zoloft will do the trick?
The first time I did heroin, it was a Listening to Prozac moment. Like the patients that psychiatrist Peter Kramer describes in his 1993 book, I felt the way I wished to be, but better than I'd thought possible.
Moments before, I'd been insanely jealous: I'd found out my boyfriend had been with another woman. I was shouting at him in a grotty New York welfare hotel. I was filled with self-hatred. I'd been suspended from college because of my involvement with cocaine. I thought I had ruined my life. I was about as miserable and low as could be. And then I wasn't.
I was sitting in a dingy room with peeling paint and crooked furniture. My boyfriend and the couple who lived there desperately wanted me to shut up: He had large quantities of cocaine, they had large quantities of heroin, and neither wanted to attract attention. I'd always resisted heroin because from what I'd read, I knew I'd love it. But my anger got the better of me, and I impulsively snorted the huge line they offered in the hope of quieting me.
Suddenly every atom of my being felt nurtured; every ounce of my essence felt well and light. My jealousy no longer bothered me. I also felt very nauseated--but didn't mind. Nothing could touch me. If I'd been able to feel even close to this naturally on even a semi-regular basis, I thought, I'd never have gotten into such trouble. For once, I wasn't a raw nerve, vulnerable to every tiny stimulus. For once, all the voices in my head that said I was worthless, that told me I was irreparably selfish and vile, had shut up. For once, I felt everything would be OK.
Needless to say, I soon added heroin to my cocaine habit. Although most people don't respond to opioids with the kind of rapture I felt, for me it was love at first sensation.
During the next three years, I deteriorated rapidly, to the point where I found myself injecting both cocaine and heroin up to 40 times a day, broke, and begging a man I detested for heroin. I knew then that I had to stop. The impulse I had to try to seduce him to get the drug broke through my rationalizations about "not really" being an addict. But when I quit heroin that day at age 23, having asked my parents to take me to a hospital detox program for help, I thought I was doomed for life to my vicious internal milieu.
Fortunately, through 12-step programs, I was able to dramatically reduce the crime rate in my mental neighborhood. Using techniques they share with cognitive therapy, my groups taught me, for example, that when I thought others didn't want me around, that was my own, possibly flawed perception--not necessarily the truth of the situation. By behaving like someone I would want as a friend and cutting off the internal debate over whether or not this was "authentic," I was able to gradually stop torturing myself. By doing estimable actions, I gained self-esteem. This made escape with drugs much less attractive.
But these cognitive techniques did not eliminate my bouts of depression, during which all that self-hatred would return furious as ever--and during which I was unable to feel any joy or relief. Twelve-steppers insisted that pain, as the founder of Alcoholics Anonymous put it, was "the touchstone of all spiritual progress," that my depression was telling me something I needed to hear.
No Pain, No Gain
Few would dispute the notion that painful experience can build character, just as stressing muscles by lifting weights increases strength. But it's also clear that most people most of the time prefer to avoid pain. The tension between these facts has led to a curious situation in mental health: Unlike in any other area of medicine, treatments that reduce pain and suffering, rather than being welcomed as miraculous breakthroughs, often are denigrated as "quick fixes." They're viewed as band-aids that cover up, but do not solve, the real problem--only marginally more acceptable than illicit drugs. "I oppose the use of heroin for the same reason I oppose the use of Prozac," the psychologist Jeffrey Schaler writes in his 2001 book Addiction Is a Choice. "I think relying on these is an existential cop-out--a way of avoiding coping with life."
Peter Breggin, a longtime critic of psychiatry and author of the 2000 book Your Drug May Be Your Problem: How and Why to Stop Taking Psychiatric Medications, expressed a similar sentiment in a 1994 Psychology Today article. "When so many Americans feel depressed and hopeless," he wrote, "we are dealing with a social phenomenon. The very idea that drugs are the answer suggests a moral, psychological, or spiritual vacuum." From this perspective, psychiatric medications treat symptoms, not causes. Unless someone is getting to the root of the problem with talk therapy, according to this view, drugs are anesthetics that kill pain and temporarily improve function but allow patients to avoid necessary emotional struggles.
The influence of this critique was illustrated by the cover story of the November 2004 issue of Forbes magazine. Under the headline "Just Say No: How America Could Kick Its Prescription Drug Habit," the article clucked, "The 1990s made pill-popping for happiness an acceptable therapeutic alternative for millions of even mildly depressed patients." Forbes approvingly quoted a patient who said, "Drugs just mask the problem." A psychologist moaned, "Psychotherapy just can't compete with drug company advertising. We get crushed."
Anxieties about antidepressants, magnified by the ongoing debate over their side effects, extend beyond mental health professionals who face competitors with prescription pads. They also show up in the qualms of psychiatrists who worry that these drugs can be dangerous short cuts and in the public statements of regulators who suggest they're overused. Most important, the backlash against antidepressants may discourage people they would help from trying them by reinforcing the sense that there is something fundamentally suspect about turning to drugs for assistance in coping with life. Although the critics of drug therapy raise some valid points, the premise that pills are bad because they're easy is pernicious and needs to be challenged.
If a drug were discovered that could eliminate the need for arduous physical therapy following stroke or spinal injury, it would be hailed by patients and physicians alike, even though patients would lose the character-building opportunity of agonizing rehabilitation exercises. But when someone suggests giving Prozac without psychotherapy to an adult who suffered severe trauma as a child, many therapists wail that this "easy way out" will merely postpone the necessary painful reckoning with the past. Giving shy people medication to ease socializing is dismissed either as pathologizing normal human variation and creating greater conformity or as helping the socially awkward avoid the hard work needed to overcome their fears.
But why should someone who suffered trauma have to suffer more to overcome it, if there's a less difficult, equally safe, and effective alternative? Why shouldn't the shy be on a level playing field with the naturally outgoing if that is what they want? Why is it easier for us to let go of the idea that physical suffering is a message from God that we should bear in order to temper our souls than it is to shake the idea that emotional pain must be endured for our own good?
Considering these questions has helped clarify my thinking about how to deal with my own psychological problems and how to think about the wide variety of psychoactive substances available in our society. As a journalist who covers neuroscience and who has personally experienced some of the brain's aberrant states, I confront these issues almost every day. My chief conclusion is that while psychotherapy validated by research has its place, there is no convincing reason why it should be considered inherently superior to drugs.
Like Myself Again
I began taking antidepressants seven years after I kicked my heroin and cocaine addictions. Both my self-help groups and my individual therapist had discouraged medication, and I'd followed their advice. Twelve-steppers had warned me that avoiding my pain with drugs--any drugs--would only lead back to compulsive behavior.
But in 1996, when I sunk into a depression so profound that I was unable to feel the tiniest spark of pleasure, I began to question this position. A publisher had rejected the manuscript for my first book after paying me an advance, and I became so depressed that nothing felt right.
Having decided that the unstructured life of a freelancer was bad for my mental health in such circumstances, I got myself a good job, as an associate producer on a Barbara Walters AIDS special. I thought achieving simple goals like getting to the office would make me, at the very least, less anxious, and working to fight AIDS had energized me in the past.
Before the book was killed, even when I'd felt low, I could usually improve my mood by easing up on myself or seeking social support. I could use my cognitive techniques to recognize when I was grandiosely "catastrophizing"--for example, seeing one obstacle as a sign that everything else in my life was going to collapse. But the new job and the cognitive techniques failed me now. Even love from friends and family didn't help. I knew I'd lose all motivation, even to get out of bed, if meaningful work and socializing didn't at least reduce my dread.
Talking to people or thinking differently couldn't restore my ability to feel good. Even the best of news or most tender expressions of affection didn't interrupt for long the dull terror I felt. When I couldn't stop crying at the office, I finally went to a psychiatrist, who prescribed medication.
The first day I took Zoloft, I was reminded of my earliest recreational drug experiences. Before I'd tried hard drugs, I'd taken many psychedelics, and what I felt after popping that first pill was similar to a feeling I well remembered from using LSD: a sense in the pit of my stomach that things were about to get strange. Soon, in fact, I was having mild hallucinations: complicated, brightly colored geometric patterns when I opened or closed my eyes. I called my psychiatrist, who told me to halve the dose but recommended sticking with the drug, saying the images would pass.
Two days later, the psychedelic patterns were indeed gone, but the depression and pleasurelessness were as strong as ever, and I found myself missing the hallucinations. At that point, I understood for the first time part of why I'd continued using cocaine long after it had ceased to be at all enjoyable. The distraction of experiencing something, anything, was better than consistent anhedonia.
Ten days in, I felt the first therapeutic effects. I noticed that I wanted to write and that I felt better after writing. That tiny reward gave me more optimism.
When the medication fully kicked in, I again felt transformed, as I had in that welfare hotel a decade before. Unlike heroin, Zoloft did not make me euphoric, but it provided a similar sense of comfort and safety. I felt like "myself again," as one of Peter Kramer's patients puts it in Listening to Prozac. With antidepressants, I wasn't "better than well"; I was the way I am when I'm OK.
In other words, I stopped fearing encounters with friends and dreading the phone. I took pleasure in simple accomplishments. If something awful happened, I felt appropriately upset; the difference was that now I no longer cried uncontrollably while watching families reconnect in AT&T commercials. I began to discover that I wasn't wildly jealous when my (new) boyfriend spoke to another woman--or at least I now had the self-control not to act on those thoughts. I felt competent and far less needy. The reassurance I'd sought from 12-step meetings and phone calls for support didn't seem necessary any more. I could hate myself less because my selfish needs and intrusive worries were genuinely less pressing.
Paradoxically, what the drug gave me was greater control over my own thoughts and behavior and more self-sufficiency. I could still choose to act impulsively when irritated, but I could more easily choose not to. And unlike heroin, the Zoloft did not cause the craving that had ultimately led to obsessive, life-disrupting addiction.
Which was more "real"--my new equilibrium or my previous imbalance? It didn't matter, I decided, because on medication I was better not only to myself but to others as well. I became less needy, less self-centered, less demanding. I will never be a mellow person, but I was certainly calmer. The only downside was greater impatience with people who refused to get help for depression, who still exhibited the flaws I'd hated in myself.
Suicidal Strategy?
During my transformation, I began to recognize that, although the drug companies clearly have an agenda in pushing their view of psychiatric medication, psychotherapists do too. If pills really could overcome depression and addiction without endless digging and talking, they'd be out of business. Just as the "brain chemical imbalance" that supposedly causes depression is part of the pharmaceutical companies' sales pitch, as exemplified by those Zoloft commercials in which a blob with a face turns his frown upside down, the idea that talk is better and deeper and more humanistic is part of the therapists' sales pitch (no matter how much they sincerely believe it).
Each perspective, taken in isolation, relies on an outdated, dualistic view of the mind and brain. The drug companies portray depression as a biological defect that leaves people vulnerable to getting stuck in sadness; the therapists say our thinking and emotional histories trap us there. But neither view precludes the other; both can be right simultaneously because all experience must ultimately be coded by processes in the brain. Given this reality, if the easier, faster way is just as effective, why not use it?
Studies repeatedly find that on their own, drugs and certain talk therapies are about equally effective, with a combination of the two often superior. But the talk therapies which have been proven to work are hard to find. As Vanderbilt University psychologist Steven Hollon puts it, "The treatments shown in clinical trials to be specifically effective for depression are still not widely available."
Antidepressant opponents such as Peter Breggin argue that drugs can have terrible side effects, so even unproven talk therapies are preferable. Recently, for example, evidence about the relationship between suicide and selective serotonin reuptake inhibitors (SSRIs) such as Prozac and Zoloft has begun to emerge. Not only can they increase suicidal behavior among depressed people, but a study published in 2000 in Primary Care Psychiatry found that some normal people given these medications become suicidal. In clinical trials, suicide rates are two and a half times higher in subjects given SSRIs than in those given placebos, according to David Healy, a psychiatrist at Cardiff University. He estimates that up to 5 percent of the population may have severe negative reactions to SSRIs that can, in the worst cases, lead to suicide.
But that doesn't mean the drugs don't help others. For the majority of patients, SSRIs seem to reduce suicidal thoughts and suicide itself. Suicide rates in the U.S. have declined since the introduction of these drugs. Given that at least 50 million Americans have taken SSRIs since Prozac was approved in 1987, if their main effect was to increase suicide, the opposite should be true. Further, several studies that have compared local SSRI prescribing rates with corresponding suicide rates have found that the medications are linked with fewer, not more, self-inflicted deaths.
Other SSRI critics--such as Harvard psychiatrist Joseph Glenmullen, author of the 2001 book Prozac Backlash--note that SSRIs don't seem to have much advantage over placebos in clinical trials. This argument, like the suicide warnings, overlooks the importance of individual variations. Nearly every psychiatrist who has used SSRIs has stories similar to mine and those in Listening to Prozac. When you match the right person to the right medication, the positive change is remarkable and unmistakable. David Healy's research has shown that certain personality traits are associated with extremely positive (and others with extremely negative) reactions to these drugs.
The fact that good matches occur only in a small subset for each drug--and that bad matches occur as well--means that clinical trials wash out the contrast between the drug and placebo groups. Most people have a small positive effect, some are transformed, and some are made worse; grouping them together obscures these differences. Which is why Healy, the author of the 2004 book Let Them Eat Prozac: The Unhealthy Relationship Between the Pharmaceutical Industry and Depression, still prescribes SSRIs and does not want them banned.
Side Effects of Talk Therapy
When it comes to side effects, it's also important to recognize that drugs are not the only treatments that can cause harm. Some forms of psychotherapy can be at least as damaging.
It is now clear, for example, that hundreds if not thousands of families were split, many irrevocably, by false memories of incest created in "recovered memory" therapy. Some people received lengthy prison terms as a result of false accusations; many simply lost the invaluable emotional and health benefit of having a close, loving family. Others (including children) were hospitalized for years, tied to beds, and told they had to release "alter" personalities implanted during Satanic rituals in order to be healed. This sort of thing happened in mainstream hospitals such as Chicago's Rush Presbyterian as recently as the early '90s. "The entire history of the recovered memory phenomenon, each and every example, is an example of harmful therapy," says Richard Ofshe, a University of California at Berkeley sociologist and co-author of the 1999 book Therapy's Delusions: The Myth of the Unconscious and the Exploitation of Today's Walking Worried.
Other talk side effects come from therapies that rely on cult-like tactics or become actual cults. Synanon, the Northern California?based drug rehab organization, forced men to get vasectomies and pregnant women to have abortions if they wanted to remain part of the group--and told them they would return to their addictions and die in the streets if they left. Members were made to split up with their spouses or partners and rematched with others by the cult's leader.
To this day, the largest addiction treatment providers in the U.S., Daytop and Phoenix House, base their care on the confrontational "attack therapy" of the Synanon system, and program graduates trained in Synanon's methods staff and run many programs. Although some programs have tried to eliminate the excesses of this approach, reports of humiliating treatment are still common despite research showing it is harmful.
Both Synanon and the Los Angeles?based Center for Feeling Therapy often beat patients; the New York?based Sullivanian therapy cult resulted in numerous bitter child custody cases. And then there is "rebirthing" therapy, which in 2000 killed a 10-year-old girl in Denver. The "therapy" was an attempt to improve her difficult relationship with her adoptive mother by smothering her while trying to replicate the conditions of birth.
It's not just wacky therapies that can harm. According to research by Yale psychologist Susan Nolen-Hoeksema, depression can be exacerbated by focusing obsessively on "the causes and consequences" of personal problems. Therapies that encourage people to ruminate on the origins of their depression thus can make the condition worse. According to a 1999 study published in the Journal of Personality and Social Psychology, many commonly used anger management treatments, which urge clients to "get it out" by yelling and hitting inanimate objects, actually increase rage.
Then there is the matter of all the time and money spent on therapy that could be used for more productive pursuits. Ofshe, who distinguishes between life problems that can be helped by counseling and support and major mental illnesses such as schizophrenia and clinical depression, tells me "all the evidence for years and years has shown that people who practice using psychodynamic techniques, all the therapies derived from Freud, every time anyone tried to treat any real mental disorder, it was a waste of time and money and when real treatment [was developed], they were diverted from something that could be helpful."
Many see such side effects as less problematic than those resulting from drugs, because the patient has a choice whether to follow the therapist's guidance, whereas drug side effects are involuntary. Yet talk therapies cannot work as their proponents intend if the patient doesn't comply, and noncompliance in addiction treatment can result in incarceration, so in that sense the side effects derive just as directly from the treatment.
As Healy points out, talk therapy can "wreck families, can wreck lives just as much as pills can.
People tend to see the risks from pills. They think if they [do] talk therapy, there can't be any risk. But no one ever got raped by a Prozac pill."
Although there is no way of knowing how many rapes are committed by mental health professionals, a survey of 1,320 psychologists by researcher Kenneth Pope, published in the journal Psychotherapy in 1991, found that at least half of therapists reported treating one or more patients who'd had a sexual relationship with a prior therapist. The respondents believed more than 90 percent of the patients had been harmed by the relationships. Earlier surveys found that between 7 percent and 12 percent of male therapists (including psychiatrists, social workers, and psychologists) admitted to engaging in a sexual relationship with a client at least once.
Amotivational Syndrome
Even if drugs outperformed both placebos and talk and had no side effects, there would still remain the complaint that these medications kill pain rather than address its cause. In a 2001 letter to the Archives of General Psychiatry, for instance, a psychiatrist described an alcoholic who kept drinking because Prozac made him feel better, leaving him less determined to get sober. The letter also mentioned a woman who lost her resolve to leave an abusive boyfriend after taking Paxil for several weeks.
But while the data from clinical trials of SSRIs in treating addictions are mixed, the findings are either positive effects in reducing alcohol and other drug use or no effect, not reduced recovery. And while some people may remain in abusive relationships because antidepressants dull their desire to get out, others find the courage to leave after being treated with SSRIs. Without better research focused on this issue, it's impossible to know which reaction is more common.
My own experience suggests that whether a drug paralyzes or activates you has as much to do with where you start emotionally as with the drug itself. Some heroin addicts find that the drug (or a maintenance substitute such as methadone) allows them to be kinder and more open to others because it reduces their overwhelming feeling of vulnerability and oversensitivity; others find it makes them stone cold and numb. It depends on where they begin: If they are too self-conscious and anxious to socialize, lowering the volume of those sensations can help; if they are already indifferent, the drug will make that worse.
Antidepressants are similar. Although they don't offer the unearned euphoria that so disturbs anti-drug crusaders, they do, like heroin, strengthen the voice that says it's going to be OK, which is so important for getting through tough times and which some people may not be able to access without chemical help.
It's the same with physical pain: Too much agony can be as life-destroying and consciousness-contracting as too much anesthesia, and the determination of how much is too much depends both on the original level of pain and on how the drug changes it. Just consider whether you are more agreeable to and nurturant of your loved ones when you have a ferocious toothache, or when the pain has been properly medicated. One cannot discuss a good or a bad drug--only a good or bad drug for a specific person and purpose.
The notion that emotional pain and difficulties inevitably lead to growth and maturity is a largely unexamined assumption with deeps roots in Western religion. Almost everyone can name individuals who believe their painful challenges made them into better people. This is part of why "tough love" approaches to emotional problems continue to thrive and why "easier, softer" approaches such as medication are so often dismissed. As Fox News Channel commentator Sean Hannity put it in 2002, "I've had a criticism of [psychiatrists] for a long time. I think they're too quick to overprescribe drugs and offer chemical solutions. They totally discount the spiritual side of the human nature."
But such critics rarely consider how often pain truly leads to growth--and how often it leads to stagnation, self-destructive escape attempts, and greater emotional damage. Few question whether the anecdote of the survivor made stronger is more common than that of the victim devastated. Most people can easily cite examples of both. Since pain is so common, however, we want to think it's essential to growth. We want it to mean something--and don't like to imagine we could learn to be happier, better people without it.
Being Jim Carrey
Focusing on the value of pain misses the critical role of pleasure in learning. Probably the most difficult task facing human babies is learning to speak, yet it occurs almost completely without punishment. Babies learn to talk because babbling feels good and earns them smiles and praise, and because speaking lets them get what they want far more efficiently and comfortably than they do by crying. They don't learn language by being hurt when they get a word or phrase wrong or hit for not talking; they grow into speaking by basking in love.
"In most cases," says Bruce Perry, a child psychiatrist and expert on childhood trauma, "the acquisition of any new piece of information is much more related to repetition than to anything else, and the most powerful biological source that fuels repetition is pleasure." People learn most lessons better when the experience engages and excites them, not when it's dull or painful. While overcoming challenges is part of the process, if there is no sense of reward and competence early on, most people are far more likely to quit than persevere. In fact, according to Perry, threatening and potentially painful situations make people behave less intelligently because their actions are guided by the lower, more reactive parts of the brain.
For the mental health professions, these findings mean the ability to feel joy--or at minimum, to feel OK--is at least as important to recovery from depression and anxiety as discovering the origin of the pain. In fact, in many cases restoring the ability to feel pleasure may be all that is needed. The source of the trouble could be some misfiring neurons, stuck in the angst of 20 years ago or simply signaling for no emotional reason at all. Regardless of the origin of the problem, if you fix the neurons, the distress is gone. A number of studies indicate that effective depression treatments, whether talk or drugs, lead to regrowth of neurons in an area of the hippocampus that is often damaged by emotional trauma.
While this phenomenon might be unsettling if, as in the movie Eternal Sunshine of the Spotless Mind, drugs made these changes by erasing the memories that make us who we are, there's no evidence that antidepressants do that. And those who argue that we should be able to impulsively act out our prickly, irritable, depressive characteristics to provide human variety are not usually the ones who have to live with those who do so.
One final argument for preferring talk to drugs is fear of dependence. Some antidepressant drugs do produce painful withdrawal symptoms, and it is unconscionable that some patients are given these medications without appropriate warnings and without first having tried other, less problematic treatments. But there's also no doubt that some talk therapies create dependence every bit as worrisome. Therapy cults aside, just think of those analysands who have therapy four hours a week and never make a decision without first consulting their shrinks.
While it's always better to have fewer needs, physical dependence on medication, in and of itself, needn't be a problem if the drug is readily available and safe. If the drug improves one's ability to work and love, who is being hurt? We're all dependent on air, food, and water, and maintenance medications will become a fact of life for most of us as we outlive the ages which our bodies evolved to reach. Whether the medication treats high blood pressure, pain, or depression shouldn't matter.
Suffering Is Not All It's Cracked Up to Be
This is not to say we have anything close to perfect medications--and for many people, the tradeoff between side effects, risks, and benefits weighs against taking those currently available. In this connection, full disclosure of the data on current drugs and more research and openness on those in development is critical.
Nor do I believe there is never lingering emotional distress that needs to be understood and conquered, or that there is no role for talk therapy or self-help. Many studies, including a 2002 review in the American Journal of Psychiatry and a more recent head-to-head trial published this year in the same journal, have found that certain talk therapies are just as effective as drugs. A 2003 study published in the Proceedings of the National Academy of Sciences even found that for people with childhood trauma, one such therapy was more effective.
But evidence-based therapy is hard to find outside university research studies. The therapy that helped the childhood trauma victims more than drugs, for example, was a cognitive-behavioral treatment that focused on dealing with current problems, not searching for their roots in the past. It wasn't the kind of "depth" treatment talk therapy proponents usually advocate.
Few patients outside of studies get therapy based on what the research finds effective; most practitioners ignore the data and do what their "clinical experience" suggests. Recognizing this gap, government agencies such as the Substance Abuse and Mental Health Services Administration have distributed literature and sponsored initiatives aimed at bringing "research into practice." But while the situation is far better than it was 10 or even five years ago, both researchers and patients say there's a long way to go. For talk therapy to be a genuine alternative or supplement to medication, the methods covered by insurers should be proven safe and effective, just as the Food and Drug Administration requires for drugs. Mental health advocates have long called for "parity" between coverage of mental and physical illnesses, but it makes no sense to cover talk unless therapists practice proven treatments.
In addition to insisting on evidence of effectiveness, mental health professionals need to understand that suffering isn't necessarily good for the soul. My own experience has shown me that therapy, self-help, and medication all have value. It has also shown me the pitfalls of each. Both depression and addiction have biological, sociological, and psychological dimensions that vary in importance depending upon the individual and his or her situation. This complexity means that no one solution will work in all cases and that the right approach for any given person may change over time.
I can say this: Painful talk therapy isn't morally superior to medication or to therapy that doesn't go "deep." Pleasure can be just as important for emotional recovery and growth as pain, if not more so. That's why drugs sometimes are the better fix.?
