One sunny afternoon a week before Christmas I met a gifted young woman at a neighbourhood party. Her thoughts and feelings were lavishly on display, flashing like the sunlight on the sea below, sometimes blinding, sometimes obscured by the tumble of associations welling up around her theme. She was visiting relatives and would return to Sydney the following day.
I observed her over a few hours and we talked for a time. By early evening she had squandered her ration of happiness and was more than a little drunk.
It was impossible not to notice the healed scars on her arms, or to miss her references to Sylvia Plath, suicide and Zoloft.
As the party wound down, she claimed the seat beside me. She’d been listening at a distance when I answered a few questions about work I’d done in drug education. I guessed that she wanted to ask me something personal, about medication. I imagined her overwrought state to be concern over mixing dubious chemicals with the prescribed kind, the quandary many of us find ourselves in. I had no idea she’d already stormed that barricade.
During my leave-taking she stayed close, saying something about wanting to stretch her legs. We walked slowly along the cliff road together and she told me stories about her life, love affairs, elations and frustrations (“the usual mixed bag of angsty 22-year-old stuff and then some”), all the while crying unselfconsciously and wiping her nose and eyes with her forearms.
Not wanting to turn her loose I invited her into my house, found a box of tissues, and listened. Should she stay a slave to a drug like Zoloft because she got a bit messy now and again? What did I think? Her friends who, like her, grew up with the 1994 memoir Prozac Nation, were “quite divided on medication”. Some disdained antidepressants “partly because of the zombifying effect” or because “they’re now seen as a bit tacky or clichéd”; other friends – who were scared by her self-harming – “seemed reluctant to argue against the drug” because they could see she needed help.
“It’s the postmodern girl’s dilemma,” she concluded. “We all know the drugs fuck with your brain, but you need them to get on with your life.”
Angie, as I will call her, had just won a fellowship to study overseas, an opportunity she saw as a meaningful turning point. Grasping at the symbolism of renunciation, she wanted to clean her slate of old ways, including medicating her sorrows. She sought a quick answer and I gave one. I advised her against stopping the drug. It was the same advice I might give in the clinical setting of my professional life; follow the prescription, but if in doubt, go back to your doctor, the tame dove answers of my white-coat training.
What follows is the longer, vastly more digressive version of a reply I’ve been formulating for this young woman since she flew off to New York and fell in love with a skyline.
Do I really need the drugs that were prescribed for me? Do I have the right to question medical authority? Am I paying a long-term price for short-term peace of mind? The questions are valid and increasingly common. Our intellect, which likes to assert itself when faith demands we keep silent and take our medicine, will keep on shaping these questions, even in the face of competent reassurance, even when we are told the drugs will save our lives.
Angie’s very individual story, which I will come to later, is one of several million Australian stories which lead to the same punch-line: a prescription for antidepressant tablets. In 2004, twelve million prescriptions for this group of drugs were dispensed through the Pharmaceutical Benefits Scheme (PBS), a figure that contains both newly initiated scripts and monthly repeats of established regimes and equates to well over a million annual users. More people than ever before in the history of Australia are taking antidepressants. Five million PBS scripts in 1990, 8.2 million in 1998, twelve million last year, 250,000 of which were written for patients under twenty years old.
It is not surprising within one’s own circle to discover that your postman, your bank manager, your best friend, three of your nieces, the surly boy in the next street and even the cat you offer to “sit” while your colleague is away are all on SSRIs. Selective serotonin reuptake inhibitors. Or the newer SNRIs, or NaSSAs. The acronyms matter little beyond the borders of medical jurisdiction. We take the drugs on faith, reassured by the certainties of hard science that seem to beep like text messages from their chemical aliases.
Collectively, these drugs are called psychoanaleptics. They restore, amplify, even (it is claimed) invigorate our impoverished supplies of happy-making brain chemicals. Worldwide, antidepressant sales recently topped twenty billion US dollars annually. From anybody’s perspective, this is an impressive expression of faith.
At a time when more and more of our citizens are drawn to the narrowband evangelical message of a personal god who watches over our wellbeing if we dose up regularly on the approved scripture, it is tempting to conceive of mood-altering drugs as secular fetishes for unhappy souls. Except that the potential for harm from prescribed drug-taking is demonstrably higher than it is from handclapping and shut-eye singing in a Pentecostal church.
After a ten-year love affair with “happy pills”, we are beginning to see flaws in some of the hard science underpinning our beliefs about the safety of these drugs, and to recognise the disguised motives of those who bring the drugs to market. Researchers are questioning the wisdom of medicating 10 per cent of the population with potent molecules when (many argue) other, less encroaching strategies might work just as well. Doubt is not a comfortable place for the growing membership of the second-wave Prozac nation, who are beginning to wonder whether they’ve jumped aboard a bandwagon for no good purpose.
The counter view to this concern, championed and buttressed by most physicians and all drug companies, is an appeal to our collective sense of perspective: the increase should not be couched in terms of over-prescribing but as a “catch-up effect” after decades of under-diagnosis and under-prescribing. By 2020, we are told, depression is expected to constitute the biggest burden on health spending in the Western world.
Looking back at the last decade, it now seems as if an epidemic has slipped in under the usual radar screens and multiplied, secretly. Twelve million prescriptions for antidepressants in a population of less than twenty million? If the number of prescriptions truly reflects the numbers who are depressed, then we may need to re-design our tourist brochures. The sun-bronzed Aussie optimist with his no-worries attitude to calamity might be an outdated caricature. We may need to position our national larrikin on a bleak promontory, hands deep in his pockets, hood pulled over his head, contemplating a leap into oblivion.
And yet, glancing around the new psychopharmacologised neighbourhood, it would seem that all was well. The postman is whistling, the bank manager is back at work, the best friend is taking yoga classes, the nieces are crying less and the cat has stopped licking itself into hairlessness.
Overlooked, perhaps forgotten, in the neighbourhood snapshot above is the surly boy in the next street. About him, we should worry. He is eighteen and he is not whistling. His symptoms are so severe, so disabling, so manifestly black that he can’t get off his bed. He may have already attempted suicide, he will certainly be hospitalised again in the near future. At the outset of this essay it is important to reserve a front-row seat for the severely depressed patient, drowning, in William Styron’s words, under a “toxic and unnameable tide that obliterate[s] any enjoyable response to the living world”. This boy is not representative of patients who want to feel “better than well”, the Prozac warcry. He is someone who cannot remember what “well” feels like, he is the patient for whom the mood-enhancing drugs were invented, but who (curiously) represents only a small proportion of the millions of users.
Is alarm the correct response to this increase in prescription numbers? If drugs make our citizens happy and functional, what’s all the fuss about? Alarm is a response to threat, and like many Australians who have been alerted to perceived threats in recent times, I am curious about this strange beast haunting the neighbourhood.
After many years of working in pharmacies and around pharmacology, it has taken me a few years of reduced involvement (working two days, then one day a week) to notice that on balance I have become the air I breathed in thirty years of dispensing, to acknowledge that a kind of pharmaceutical ectoplasm has stuck to my skin, that allopathic rhetoric has colonised my thinking and left me with an acquired pro-drug bias.
And I am not alone in almost involuntarily associating illness with a drug cure. Many ask if the antidepressant epidemic has been inadvertently conjured up by doctors reaching too quickly for their prescription pads.
Others blame the tactics of the big drug companies who have been selling the message that depression is underdiagnosed. “A lot of money can be made from healthy people who believe they are sick,” is the message of Ray Moynihan’s comprehensive work on the phenomenon he calls “selling sickness” and author Lynn Payer called “disease mongering”. Are commercial pressures and drug company profiteering driving the escalation in prescription numbers? Could the answer be so simple?
Or, is another perspective required? Do we need to turn our gaze back upon ourselves, the patients who knowingly walk into the surgery with a prescription-outcome in mind?
Australians are avid supporters of drug therapies. In 2004 we spent three billion dollars on prescription drugs. Of the top fifty most-prescribed drugs on the Pharmaceutical Benefits Scheme to June 2004, four were antidepressants: citralopam (Cipramil) 16th, sertraline (Zoloft) 25th, paroxetine (Aropax) 27th, venlafaxine (Efexor) 46th. Zoloft was top of the pops for nearly a decade but is coming off patent this year and, like an ageing star, has had to make way for younger, hotter rivals.
In fact, rather than rising and rising, we are witnessing the teetering (some say, about to crash) crest of a wave of SSRI use, a wave that assumed its massive shape and rose skywards from 1990, as antidepressant use increased by 352 per cent over a decade, then levelled out. Market saturation may be a factor in the slowdown (the SSRI market is young relative to the tricyclic boom that came before it). Alternatively, the absence of a new blockbuster like Prozac (1990) or Zoloft (1996) coming onto the stage may account for the plateau. We may just be waiting for the next star to appear.
Social scientists have been keeping an eye on the depression phenomenon for the past decade. Rapid social change is taking its toll. As a nation we’re profoundly disturbed by the acceleration of change, the shrugging off of methods and manners that have served us well, the feeling that many of us are somehow failing to meet modern challenges, that we have a new malaise called, by Hugh Mackay, “change fatigue”.
The medical profession is well aware of this, but the question is what it thinks it is seeing. The impediments to recognition owe much to the adage about the forest and the trees. A diffuse systemic problem, as physicians know, is often harder to diagnose and treat than a visible affliction.
I want to suggest that this impressive, noticeable increase in antidepressant usage in Australia today has come about through the co-operation of three large but inherently unequal groups: the multinational drug companies; the physicians who write prescriptions; and the public who turn to medicine for answers.
And that driving this closed system (which resembles the hypothesised neural loop that makes us depressed and keeps us there) is uncertainty about the way we are governed, and the impact of world events on our personal resilience.
The epidemic of antidepressant-taking (the phenomenon which alarms us) is analogous to the disease itself. There are gradations, complexities and dimensions to the treatment which must be understood before we look to a solution. We at least have to catch the beast and study its habits before we load up the shotgun.
This is an extract from Gail Bell's Quarterly Essay, The Worried Well: The depression epidemic and the medicalisation of our sorrows. To read the full essay, subscribe or buy the book.
ALSO FROM QUARTERLY ESSAY