To Medicate or Not To Medicate an Anxiety Disorder
Each year, doctors prescribe antidepressants to thousands of young Canadians. Two decades ago, Emily Landau was one of them. Today, she considers how drugs have affected who she is.
When I was seven, I became convinced that my house was about to burn down. Night after night, as I tried to fall asleep, I saw the flames encroach upon my bed. Then, at around 1 a.m., unable to handle the dread, I would go wake my dad. He would walk me through the house, pointing out fire alarms and double-checking that the oven was off. This was our normal. My crippling anxiety started when I was a toddler, I’m told, and only worsened as I approached puberty.
On September 3, 1996-the first day of Grade 6-I suffered a mental breakdown. I’d never been popular, but I had one close friend and that was enough. After a summer apart, I spotted her in the schoolyard and ran up excitedly to say hi. She clipped a quick greeting, then turned her back. I’d spent my childhood stewing in amorphous terror, awaiting some unknown calamity. Maybe this was it. I ran to the administrative office in tears and said I was sick-and I was.
The illness manifested as an all-consuming fear of school. When my parents tried to convince me to return, I cried and hyperventilated. A few times, they managed to get me to class for an hour or two. I’d stare into my lap, chin quivering. I stopped eating and lost about 20 pounds. One day, I announced I’d rather be dead than go back to school. That whiff of suicidal thinking scared my parents so deeply that the next morning, we drove from our home in midtown Toronto to the Hospital for Sick Children in the city’s downtown core.
This was the era of peak Prozac. By the end of its first year on the market, a decade earlier, the drug racked up more than $100 million in sales. Between 1981 and 2000, the number of antidepressant prescriptions in Canada increased by 353 per cent, from 3.2 million to 14.5 million.
But the backlash was as ferocious as the boom. Many patients experienced what came to be known as “Prozac poop-out,” in which their serotonin-induced euphoria dissipated and their depression returned. Doctors worried about potential side effects; some reports pointed to agitation, violence and even suicidal thoughts in users. Patients started complaining that, in addition to alleviating their depression, the drugs also numbed their feelings-a condition known as the “anti-depressed personality.”
For children, medication was practically verboten. At SickKids, my parents and I met with a militant child psychologist who prescribed a course of discipline. My refusal to go to school was merely separation anxiety,he claimed. During each of several subsequent visits, he gave my parents a version of the same advice: roll me into a carpet and carry me into the classroom if necessary. My parents refused. After about a month, it occurred to them that medication might be the only thing that could make me better.
My family doctor referred me to one child psychiatrist, who diagnosed me with a depressive illness, and then another, who pinpointed it as generalized anxiety disorder. He prescribed 250 milligrams of Zoloft, even though Health Canada hadn’t approved the drug or any other antidepressant for patients under 18. Almost 20 years later, tens of thousands of young Canadians are taking antidepressants. (A recent study from researchers at the University of Saskatchewan and the University of Ottawa, for example, suggests that 15 out of every 1,000 Saskatchewanians under the age of 20 have been prescribed antidepressants.) Yet the old fears persist. What do these medications do to the developing brain? The most pervasive fear is that antidepressants will somehow alter the patient’s essential identity.
When I was initially diagnosed with a depressive illness around age 11, my doctor explained that I was suffering from a chemical imbalance. At the time, the medical community believed that depressive disorders were primarily caused by a deficiency of monoamine neurotransmitters, which help regulate moods. The new drugs were thought to stall reabsorption of serotonin into nerve cells and allow it to linger instead in the synapse between cells, where over time it may help transmit the “happy” message.
I did improve. Over the next few months, by the time I turned 12, my sadness lifted. I switched schools, made new friends, and slowly, cautiously, returned to normal life. The drugs buoyed me up from cataclysmic depression to relatively stable, low-boiling anxiety. But they came with side effects. I picked the skin on my face and limbs, creating welts and sores. I also developed a facial tic, wherein I’d scrunch up my nose until it ached. My doctor prescribed even more drugs.
My parents weighed the potential risks of this cocktail against what they imagined would happen if I continued along my destructive path. My doctor, meanwhile, hoped that by staving off anxiety and depression at an early age, my brain might be able to lay down permanent pathways to combat patterns of dysfunctional thinking. No one knew what to expect.
We still don’t really know anything about the effects of antidepressants on adolescent development. There have been no long-term studies, partly because of logistics, and because the U.S. Food and Drug Administration and Health Canada require companies to prove only that their medications are better than placebos over the short term. One study found that extended exposure to fluoxetine (the generic form of Prozac) in young mice led to anxiety-like behaviour recurring in the mice as adults.
One of the paramount tensions of mental illness is the blurred line between pathology and personality. It is a fear that metastasizes in the context of adolescence-a period we mythologize as a stage during which a person carves out his or her identity. Some people argue that adding antidepressants to this primordial soup could thwart the development of a predestined selfhood. Katherine Sharpe, an American journalist who started taking antidepressants at 18, reflects on this issue in her 2012 book, Coming of Age on Zoloft: How Antidepressants Cheered Us Up, Let Us Down, and Changed Who We Are. “When I first began to use Zoloft, my inability to pick apart my ‘real’ thoughts and emotions from those imparted by the drug made me feel bereft,” she writes. “The trouble seemed to have everything to do with being young.”
Geoffrey Cohane, a clinical psychologist in Concord, Mass., studied adolescent antidepressant use in his 2008 dissertation. Issues of identity, he found, were chief among the psychological barriers to seeking medication. Existential angst isn’t the exclusive domain of those with mood disorders. From time immemorial, humanity has been preoccupied with questions of identity. Philosophers trace this obsession back to Plato, who espoused what is known as the strict theory of soul-the idea that we all have a wispy, incorporeal core that persists independent of the body.
Yet long after many of us have shed the notion of the inextinguishable soul, the desire to label ourselves continues. We scour horoscopes for insights into our astrological constitutions. We worry ourselves with Myers-Briggs psychometrics, trying to nail down our Jungian archetypes-all in the quest to know who we are in this world. But what happens when that question is rigged from the outset?
According to one popular psychological theory, the five-factor model, “personality” depends on a fixed set of qualities: openness to experiences, conscientiousness, extraversion, agreeableness and neuroticism. In adolescence, these traits become more consistent and predictable. When I was a teenager, I never had the opportunity for my personality to settle into that equilibrium. In the years immediately following my breakdown, the pills allowed me to pick up where I had left off-except, in place of the friendly, albeit anxious, kid I had been was a sensitive, prickly preteen. In high school, the surliness softened, but my social fears intensified. The friends I’d made in middle school, a group of funny, eccentric girls, began to act like teenagers. I was a bookish introvert with a mood disorder; not surprisingly, adolescent hedonism made me uncomfortable. Despite my friends’ kindness and patience, I couldn’t trust them. If I hadn’t spoken to them that day, I became consumed with the fear that they were mad at me. Other times, I was buoyant and confident. It all depended on the time of year, or the time of day, or if I’d taken my Zoloft in the morning or with dinner.
When I was 16, after more than five years on the medication, I decided the cons outweighed the pros. My appetite had increased, and I was gaining weight. It caused heartburn and digestive issues. More than anything, perhaps, I wanted to know who I was off the drugs. The first couple weeks after quitting, I felt great. My anxiety was manageable. Then, seemingly overnight, it all came rushing back: the nausea, the blind panic, the intense social anxiety that escalated into free-floating dread. By summer’s end, I was on Celexa, a newer drug that my doctor hoped would help me avoid the side effects I’d experienced while on Zoloft.
I realized then that I’d likely be on some form of antidepressant for the rest of my life. And I have been-about six different kinds. For the first few years on a new medication, my sensitivity ripens into empathy, while my anxiety keeps me active and conscientious.
Inevitably, however, the meds stop working. After more than a decade of navigating this unpredictable landscape, I had two major insights. First, I realized I couldn’t rely on drugs alone and began cognitive behavioural therapy, or CBT, building my mind’s capacity to discern and defuse negative thoughts. Second, although I developed my trademark tastes-Victorian novels, dogs, Diet Coke-I found that my personality had settled into impermanence. I comfortably alternate between introvert and social butterfly, solemn and ebullient, confident and insecure.
James Giles, a Vancouver-born philosopher and psychologist currently based in Denmark, and the author of the 1997 book No Self to Be Found: The Search for Personal Identity, argues that consciousness is a fickle constant-people forget things, invent new memories, rewrite history.
He champions something he calls the “no-self theory,” which is not really a theory about the self, but rather a dismissal of all such theories as “inherently untenable.” Its roots run deep. “The Buddha was the first person who rejected the idea of the self as a delusion,” Giles tells me. “People create the idea of a permanent self, which causes us to grasp at things that are transient. He suggested that once we relinquish the notion of the permanent self, we’re able to let go of things like self-pride, embarrassment and vindictiveness.”
While I’m not on that particular path, it does sound familiar. “I have thoughts, but I am not my thoughts,” is a typical refrain in CBT. And, as in Buddhism, the reward for doing your homework is ostensibly greater happiness. I can’t speak to the viability of that contract-not yet, anyway. What I do know is that if I had subscribed to popular notions of essentialized selfhood, my true identity would look like a feverishly anxious mass of phobias and self-loathing. Had I stuck with that girl, I’d be either in a padded cell or dead.
I’ve simply had to accept that I am a bricolage of my experiences: my happy (albeit anxious) childhood, my prepubescent breakdown, my fraught teen years and my evolving adult personality, with antidepressants being merely another cog in the wheel. To others, I might argue that there are a billion possible selves, just as there might be a billion possible universes. It’s conceivable that my 18 years of antidepressants have made me a different person, changed the way I think and feel and relate. Luckily, that’s the person I want to be.
© 2015 By Emily Landau, The Walrus (March 2015). thewalrus.ca