Coming of Age on Zoloft (28 page)

Part of the reason he is such a challenging case, James explained, is that he suffers from major depression on top of atypical depression—a more chronic condition, which is marked by symptoms that include oversleeping (James’s record is thirty-one hours straight, though ten to twelve hours a night is normal for him), overeating, and a sensation of heaviness approaching paralysis in the limbs. It is also characterized by rejection sensitivity so extreme that the atypical depressive often avoids forming close social bonds. James told me that although he’s dated women in the past, it is “an unusual thing for me,” and while he is comfortable enough in group social settings, and enjoys them, he has a hard time making friends. “I have one friend,” he said. “He’s an excellent friend. He’s been my friend for six years. I was the best man at his wedding.” For the most part, though, James said, “I’m so afraid of rejection that I don’t make connections.” Over the years, medication would occasionally chip away at the symptoms of James’s major depression, but it always left his atypical symptoms untouched.

James’s low opinion of antidepressants remained unchanged until, in the aftermath of a third suicide attempt at twenty-five, he began seeing a new psychiatrist who quickly hit upon a cocktail of drugs that affected James in ways that he had scarcely believed possible. “I felt
great
,” said James. “Just truly great. I can almost give you the exact dates. I mean, I was still neurotic; the stuff that had happened to me in my childhood was still there, but the physiological aspect of the depression was totally gone. I felt a way I hadn’t felt since I was three. It was miraculous.” His atypical symptoms were banished too; in fact, James first noticed the drugs were working during the holiday party of a company he contracted for. “I suddenly realized I wasn’t nervous,” he said. “There were no barriers. I even flirted with a girl.”

Four months later, James was hanging out at a bar with his cousin when he realized he didn’t feel well. That night, he developed a high fever and checked himself into the emergency room. “When I came out, [the medications] weren’t working anymore,” he said. “They had just stopped. What had been there for four months was gone.” And though he has continued to search even more aggressively for effective medications since then, he has never had a comparable drug effect again.

By now, said James, he has tried every SSRI, every SNRI, and most of the antipsychotics and mood stabilizers. He has used a medication that is not for sale in the United States, which his pharmacologist, who is regarded as one of the best in James’s city, brought back from Europe in his luggage. He pins hope on a handful of medications he hasn’t tried yet, medications I had never heard of; next, he said, he wants to sample an MAOI that is available in a transdermal formulation, like the nicotine patches people use to quit smoking. In the meantime, he attends therapy and copes as best he can. For years he worked part time and went to college at night. He finally finished his undergraduate degree and hopes to attend a professional program someday. When we met, though, James had been receiving disability for several years. He was cycling out of a major depressive episode and hadn’t worked in a while, though he’d recently heard about a part-time opportunity through a family member, which he hoped to follow up on soon.

Given the ratio of success to failure in James’s medication story, you might expect him to be furious with pharmaceuticals, but he isn’t. In fact he’s a vocal believer in the importance of medication (given his failures, he said, “I think drugs are even more important for other people than they are for me.”), and he’s unflinchingly dedicated to continuing to search for medication that will work for him again. In large part, the four months of success when he was twenty-five were the fulcrum around which James’s opinion of medication turned, the conversion experience that solidified his faith in the drug approach. “In some ways, those four months are very good and they’re very bad,” he said. “They show me what I’m missing, but they also remind me what’s possible. I can’t imagine having gotten to forty-seven meds without knowing that it’s possible that they could work.”

But he also attributed his evolved attitude to changes in himself. Part of it was getting older. When he first started Prozac at fifteen, James was preoccupied with what his classmates would think of him. “What you think as a teenager is very different from what you think as an adult,” he said. “I already had fears about being weird or being a nerd; anything extra was scary, and something that I couldn’t allow myself to do or really accept.” For another thing, James came to take his problems more seriously over time. “After the second suicide attempt at eighteen, the idea that I might continue to have suicide attempts was scary,” James said. “When I’m not suicidal, I don’t want to die.” Still, it was years more before he became invested in medication as something he actively felt like he wanted to do, on his own behalf and no one else’s. “Once upon a time, my parents’ approval was ridiculously important to me,” he remembered. “There was a period of time where part of the reason I was okay with meds was because my parents wanted me to take meds, because they were scared of what I could do to myself without them. So that was part of the change.” He went on:

Eventually, the change became all my own, and their opinion stopped mattering. Part of it was those four months, when I was given a taste of what life can be like. Prior to that, I was trying out of fear and out of desire to please my parents. It wasn’t until I was twenty-five that I truly became convinced that at least I need to try. There’s no harm in trying. You get a side effect, it’s a bitch, you get off the drug and it goes away. It’s not the end of the world. And I’ll take the gamble of getting an annoying side effect that I get rid of just by going off the drug, for the potential of one day finding the combination that no longer puts roadblocks in the work I need to do in therapy.

One thing that sank in as I listened to James tell his story was the extent to which the questions that have coalesced around antidepressants for me, and for some of the people whose antidepressant stories I relate to the most, were almost completely irrelevant in his case. For years I’d concerned myself with the relationship of antidepressants to identity, the ambiguity of the border between normal moods and disordered ones, and the issue of need in cases where need might legitimately be considered ambiguous. These weren’t bad questions to ask—they were the ones that experience had brought me, and I knew from my conversations that many had shared them—but in talking to James I realized afresh that they are, in a very real sense, luxury questions. Worrying about the finer points of antidepressant use, like what it means to your sense of self, is a privilege denied to those for whom the pills never fulfill their basic promise in the first place. And they are not likely to be top concerns for people who are dealing with a whole other order of problem. There is nothing like talking to someone who finds it hard to hold down a job or flirt with a girl—someone who, when he says he has trouble getting out of bed in the morning, means something very different from what you have meant, the times when you’ve complained about having trouble getting out of bed in the morning—to make you feel churlish for how much time you’ve spent wondering whether antidepressants have tempered your personality. In James’s presence I started to feel a little like a woman at a fancy restaurant, sending back the soup because there was a fly in it, while people like James were pressing their noses against the window, daydreaming about a square meal. There wasn’t much I could do about the situation except stop to take note of the perspective it offered. James’s experience had made him viscerally sure of the thing it had been my good fortune to be able to dither about; at this point in his life, he felt certain that anything he might have to lose by using medication pales in comparison to what he has to gain.

MANY PEOPLE WHO
came to feel more positive about antidepressants over time talked, in one way or another, about a sense of agency. They began to focus less on their fears about what uncontrollable things medication might be doing to them, and more on the active, empowering dimensions of their choice to use medication in the first place. Denise, twenty-seven, used antidepressants in college and after, for about five years in all, but she said it was a habit she’d always felt ambivalent about. Her family didn’t really approve of medication (“My father is manic-depressive,” she said, “but he won’t take meds because they ‘make his tummy hurt.’ ”), and Denise wasn’t too sure what she thought about them either.

“I think that a lot of my depression comes out of anxiety, and isolation too,” she said, explaining that she had been living independently for a long time; she moved out on her own when she was sixteen and put herself through community college, before transferring to a four-year school. She lived off campus, and her college boyfriend became her connection to the rest of her social life at school. After college and before her move to New York City, Denise recalled becoming “very upset and clingy with friends.” Her doctor gave her a prescription for the antidepressant Lexapro. “It was just my G.P.,” she said, adding that she had wanted him to prescribe Xanax, for anxiety, but that he had seemed unwilling to do so (Xanax is technically a controlled substance). In the end, Denise ended up taking Lexapro for four years, but she never felt that it had a pronounced effect. She knew it was an antidepressant, and she had never considered depression to be her main problem. “I just don’t feel that Lexapro did anything for me, in terms of anxiety,” she told me. Eventually, she took herself off it.

When I met her, Denise had started using antidepressants again just the month before—but this time, she said, her outlook on them was completely different. Earlier that year, she’d gone through a breakup, a familiar trigger for her “separation anxiety and abandonment issues.” “When I’m living on my own, or starting a new job, I’m very self-sufficient, so even though it’s hard, I’ll muddle through,” she said. “But when a relationship doesn’t work, something kicks into gear.” She began to feel anxious, lonely, and sad, and she also started losing weight, which frightened her because she has a history of anorexia and is afraid, every time she begins to shed weight, that she’ll get carried away by the temptation to lose even more.

Getting depressed and anxious on the heels of a breakup wasn’t new to Denise, but she told me that she’d deliberately decided to respond in a new way this time. She said that she was using the end of the relationship as an opportunity to take a good hard look at her life, and make changes. When she was honest, she continued, she had to admit that even though her depressions were often brought on by life events, there was something about life that had felt off in between the crises too. “The best thing about the end of this past relationship is that it’s making me realize how low I’ve been, because that’s what I’ve been attracting into my life,” she said. “As far as the hard part about the end of this relationship, I feel like there’s this huge void, and that void had always been there; it’s just that by burying it in work or in a relationship you sort of forget about it. So it’s made me realize that I’ve always felt pretty low, and that there’s something I need to do to up myself and attract more positive things into my life.” She even told me that she thought taking Lexapro had been abetting her apathy in a way—that it had helped her limp along without addressing the things that were really bothering her. “I think part of the reason I was taking it was that part of me knew I was depressed, but I still wasn’t doing anything about it in terms of therapy or anything like that.”

Denise said that returning to antidepressants was part of a bigger decision to start taking her mental well-being seriously. She began by finding a therapist who helped her locate a new doctor, a specialist with more medication expertise than her old G.P. “This is the first time I’ve seen a psychiatrist where I feel like he’s going to get me on the right meds, and I’m going to report back to him, and if I don’t feel any improvement, he’s going to change things,” Denise said. “He was very concerned about how we got along together, which was great. He wanted to make sure that we had a good rapport, so he could feel like I was opening up to him, and giving him all the right details so that he could recommend the right kind of drugs.”

But Denise also said she was no longer content with a medication-only approach. In fact, she was setting out on an almost gleefully eclectic program to revamp her life, sampling a multitude of techniques for feeling better and intending to hang on to the ones that worked. Medication, therapy, an alternative anxiety-reduction technique called E.F.T., Buddhist meditation classes, a support group for people with mood disorders, a psychic, a new online-dating profile, scheduled social activities with friends—Denise was trying a little bit of everything. While not everyone will agree with the effectiveness of all these approaches, to Denise the important thing was her new sense of resolve. Earlier, she said, she’d been floating along, taking Lexapro “out of habit” and not really facing the problems she knew were there. This time, taking medication felt to her like an active choice, part of a larger personal commitment to taking care of herself as well as she can. When I asked Denise whether she’d ever had negative feelings about antidepressants, her answer illuminated the shift in her thinking. “Yeah, definitely,” she said.

That’s one of the reasons I got off antidepressants this past summer. Because I was feeling like, “Oh yeah, I’m fine.” And there’s a stigma attached to it. I’m from a Scandinavian background, and Scandinavians are very stoic, they tend not to talk about a lot of things. Now I’m feeling like, with my background and my family history, and the way I’m reacting to certain life events, I definitely need to be on them. But it’s more just realizing they’re a tool, not a solution. So I just sort of get my mood up, and I keep experimenting with life and figuring out what makes me happy and how to handle it better. Part of it is me shifting my life philosophy around, but I’m hoping that the meds keep it that way, no matter what happens.