My father, a rheumatologist, routinely prescribes drugs such as prednisone and methotrexate—he’s a believer in up-to-date medicine. Yet he’s skeptical of the fact that I have been on Celexa, a popular antidepressant and anti-anxiety medication, for 13 years. When a young relative of ours fled college two weeks into freshman year, undone by the anxiety that had plagued her all her life, he wasn’t impressed. “Why don’t they just tell her she has to stay?” he demanded. (Actually, he preceded it with “Jesus Christ!”)
The point is, even among doctors, there’s still a stigma about mental illness—and about the necessity of treating it with psychoactive drugs. The notion lingers that we all should be able to pick ourselves up by the proverbial bootstraps, that anyone who can’t hack life without a pill has a moral or character flaw. This, even though today in this country one in eight adults takes an SSRI (Prozac, Zoloft, Lexapro, Celexa) or a similar SNRI (Effexor, Cymbalta) or NDRI (Wellbutrin). The rates are almost double that for women in their forties and fifties.
Though I feel zero shame about my own reliance on SSRIs—maybe because so many of the smart, original artist types I know tend toward depression, and more than a few swear by these drugs—I worry I may have contributed to the stigma myself, with an article I wrote for this magazine nine years ago. So I’m here to set the record straight: to come clean about, well, not coming clean.
In my November 2008 piece, “Club Med,” I wrote about the backlash against SSRIs, which were then as now the most commonly used drugs to treat depression and anxiety, and the ones with the least—and least deleterious—side effects. Yet books with titles like Medication Madness and Comfortably Numb were arguing that Americans had medicated away normal emotions under the spell of evil-genius pharmaceutical marketers, that SSRIs increased the risk of suicide, and that the long-term risks of the drugs were unknown. I’d gone on a low dose of Celexa, 10milligrams, six years earlier for anxiety and insomnia and had been completely cured of both. As I wrote, “The white noise in my head vanished—poof!—and a feeling of calm came over me, the likes of which I hadn’t felt since childhood summer vacations, if ever. My anger at my husband, my annoyance about the mess of our house, my stress about public appearances, all quietly abated…. For the first time in a decade, I began to sleep deeply through the night.” I quit therapy, which no longer felt necessary; I cheerfully did a book tour I’d been fearing; I wrote a novel for the first time in years.
And then, after five years of taking Celexa, I stopped. My doctor had suggested it; with my life in a less taxing place, she said, I might not need it anymore. I respected my doctor, and I was secretly relieved to no longer “need” a drug for my head.
The withdrawal, however, was harrowing. “SSRI discontinuation syndrome” had been unheard-of when I’d started Celexa, which was initially marketed as dependence- and withdrawal-free, but by the time I went off, it was well known. A week after halving my dose to five milligrams, I woke up with what I thought was the flu: headache, dizziness, achiness, exhaustion. That lasted six weeks. I spent the next nine months tapering from five milligrams to zero.
I also adopted some classically “good” habits, practices recommended to people struggling with virtually any affliction: eating better, doing hot yoga a few times a week, returning to therapy. When I wrote the ELLE story, I’d been drugless for three months. Out of what I called “Pharma Nirvana,” I was “getting used to no longer hovering above myself watching myself live, but instead was actually living. Living and yelling and stressing, yes, and often anxious and angry and sad—but with the sadness came an awareness that I had not really experienced on the drug….Time was passing. My kids will be gone soon, I’d think, and tears would run down my face.”
If that sounds like a bit much, I can now tell you: It was. As the months passed, the old feelings and behaviors reemerged—all of them, like before, annoying and debilitating but not life-threatening—until one day, sitting in my therapist’s office alternately whining about my wonderful, chosen life and weeping because everything seemed just so sad, I begged her to affirm what I felt sure of: I was a tad, um, depressed, wasn’t I? When she agreed, I hightailed it back onto Celexa, felt worlds better soon after, and have been on it for the last seven years with no plans to ever abandon it again.
Since then, I’ve noticed that we read a lot of stories like mine, about people getting “free” of these drugs, but we rarely know what happens later. This makes sense; there’s a certain euphoria and nobility that comes with kicking a drug for the mind, something that, if you’re a writer, makes you want to, well, write about it. Two years ago, in a series of riveting essays for the New York Times called “Going Off,” Diana Spechler chronicled her decision to wean herself from a trio of psychiatric drugs because of their “grim, unbearable” side effects. The 11 columns spanned five months; by the final installment,she was “20 days med-free, eating only whole foods, stepping back into the world, a yoga mat strapped to my shoulder.”
Twenty days isn’t a long time to be off an antidepressant; some of these drugs don’t completely exit your system for weeks. I wondered: How was Spechler coping now? And then there was Patricia Pearson, the author of the gorgeous and philosophical 2008 book A Brief History of Anxiety: Yours and Mine—which I’d referenced in my earlier piece. Her book, too, was written right after she’d stopped taking first Effexor and then Lexapro, which she’d used to help her cope with quitting Effexor. It ended as she hit her six-week drug-free anniversary. But again, what happened after the six weeks…or six years?
I got my answers. But first, I want to address some of the controversy and doubt about SSRIs—a shadow that hasn’t lifted appreciably since I last wrote about this.
First, it’s true that even though it’s been 30 years since Prozac hit the market, no one knows exactly how SSRIs and their cousins work, although that’s the case with medications for everything from penicillin for infections to acetaminophen for pain relief. One long-standing theory is that SSRIs recalibrate levels of neurotransmitters—dopamine, serotonin, norepinephrine—which brings relief to people with a supposed deficiency of them.
But depression is a complicated illness, with multiple causes—some mix of genetic, environmental, and psychological components—and different symptoms for different people (anxiety, sadness, apathy, hopelessness, irritability, fatigue, change in appetite, suicidal tendencies), not to mention different side effects from its medications. Treating it is as much art as science. “Even as I faithfully took my pills,” writes Daphne Merkin in her new memoir, This Close to Happy: A Reckoning With Depression, “I couldn’t help wondering: Was I medicating a bad childhood or a chemical irregularity?”
That said, we do know that SSRIs help a lot of people, whether alleviating chronic mild depression (dysthymia) or preventing attacks of the major, paralyzing variety. Here’s Merkin again, who’s taken psychiatric drugs for more than three decades: “It’s only when I begin to sink that I remember why I am on antidepressants to begin with, which is they seem to keep me from hitting rock bottom.”
Second, it’s also true that no one is sure of the long-term impact of these drugs. Some—among them Katherine Sharpe, who wrote Coming of Age on Zoloft: How Antidepressants Cheered Us Up, Let Us Down, and Changed Who We Are—believe that “the brain habituates to SSRIs,” so that when they’re withdrawn, depressive symptoms come sneaking back. The corollary to that, of course, is that once you start, you can never stop. I asked psychiatrist Peter Kramer—who wrote the landmark Listening to Prozac in 1993 and last year returned with Ordinarily Well, which is in large measure a defense of antidepressants—what he thought of Sharpe’s assertion. “If she means that there’s a higher likelihood of depression when you come off medicine than you would’ve had if you’d never been on medicine…it’s just very hard to research that question,” he said. In Ordinarily Well, he calls a theory like Sharpe’s the “nightmare scenario” and, ultimately, deems it implausible—partly because he’s seen patients give up SSRIs and do fine, and partly because there are shortcomings in the research that supposedly proves they’re doing harm.
Even Sharpe admitted, in a piece in the Atlantic, that “SSRIs have been around for 25 years, and anecdotal reports of catastrophic ill effects have yet to emerge.” (There is something called “Prozac poop-out,” a sudden return of depressive symptoms after sustained usage. Though he hasn’t encountered this in his own practice, Kramer, a professor emeritus at Brown University, doesn’t dismiss it outright, comparing antidepressants to insulin for diabetics. “It’s not that insulin fails at its job, it’s that it doesn’t do everything,” he writes. “Something comparable may occur with antidepressants in depression; they help whatever brain system they are helping, but the underlying illness will break through, so that more or different help is needed.”)
In contrast, the risks of not treating depression are considerable. Once the illness sets in, it’s harder and harder to interrupt—and the longer someone remains depressed, the more likely the illness will continue or recur, and with more virulence. Plus, persistent depression may, among other things, cause memory loss and increase the chance of Alzheimer’s, Kramer says.
Perhaps what has stoked the biggest suspicion about the value of SSRIs are studies that suggest they work no better than placebos. To be clear, few experts make this argument with regard to treating major depression—the drugs are widely judged effective for that. The controversy focuses on the milder manifestations of the disease. In his new book, Kramer documents myriad flaws in data collection and interpretation that undercut this conclusion; for just one persuasive example, he offers evidence that a significant swath of the subjects participating in SSRI trials aren’t actually depressed, so of course they improve on “dummy pills,” as he puts it.
For my part, I’m not sure I care whether or not it’s the placebo effect that’s responsible for the transformation SSRIs have wrought in my life. I don’t believe it for a minute, but then placebos have been shown to mitigate the symptoms of all kinds of physical illnesses,after all. Mind-body dualism is dead.
It came down to this: The amount of time,energy, and money I was spending in an effort to feel half as well off Celexa as on it seemed ridiculous—notwithstanding how much I vibed with high-flown thinking about the virtues of feeling one’s feelings. “It is necessary to go / through dark and deeper dark / and not to turn,” the poet StanleyKunitz wrote. Rumi: “You are the cure for your own sorrow.” And the chronically anxious philosopher Kierkegaard theorized extensively about the condition as a source of creativity and personal growth: “Who ever has learned to be anxious the right way has learned the ultimate.” (Today, anxiety disorders are the most diagnosed mental illnesses in the U.S., though anxiety and depression often overlap and are now considered essentially flip sides of the same coin.)
I get all this—and I’m also disquieted that a record number of young people take SSRIs, for longer and longer periods. Will this interfere with their ability to fully experience,and thus learn from, the glories and rigors of growing up: finding love, discovering what you want and don’t want? Curbing negative emotions isn’t always ideal for artists, either. A writer I know told me she’d tried an SSRI and felt her lifelong anxiety dissipate, but with that, she had a sudden lack of need to do the thing that had quelled it—writing—which was also how she made a living. So she gave up the drug, and the writing came back.
To be sure, there are many “cures” to try before going the medication route, as long as you’re not suffering from major depression or anxiety: therapy (psycho- or cognitive behavioral), regular exercise, even various diets. I know someone who eliminated her depression by going gluten-free. ABC anchor Dan Harris, the author of 10% Happier: How I Tamed the Voice in My Head, Reduced Stress Without Losing My Edge, and Found Self-HelpThat Actually Works—A True Story, trained himself to meditate after having a panic attack on air. And some people decide they need their dreary emotional state, at least for a while. I begged a friend who couldn’t get out of bed after the 9/11 attacks to try an SSRI, but she refused. Later, she told me she’d had “a strong visceral feeling that my depression was caused by something I could change. I suspected that taking Prozac or Celexa would allow me to manage my feelings better—lift me out of them, even—but I wanted to grapple with them and fix what needed fixing.” And she did. She left her frustrating marriage, which was painful, but is now married to a man with whom she’s much more compatible. When she feels depressed, she quits drinking for a while, which so far has worked to set her straight again.
But I have another good friend—another talented woman—who never could settle into a career. She was always insecure or dissatisfied or just plain miserable. For years, I urged her to try an SSRI, but she worried that a drug would “change” her. I try to respect this; every person’s life is her own banana peel to slip on and all that. Still, I can’t help but think that she missed the opportunity to reach her potential and live a better, brighter life. “There are people who want to be the way they are,” Kramer told me. “But there are other people who suffer emotional pain every day who think they have to live with the way they are. And they sometimes need a friend to say, you know, you think this is your fate because you’re in this state right now, but there are ways for you to feel relief, to gain perspective.”
Celexa never made me feel like I was a different person, just a more contented version of me. And it didn’t make me feel drugged or high, just less dissatisfied, easier to be around…a more patient person, mother, and wife. With the mild filter the drug put between events and my emotions, I could step back beforeI reacted—which I deeply appreciated.
I’m lucky, and this is key, that a low dose is enough to give me benefits without many side effects. The few I do have are minor. I’m woozy in the morning. I can’t drink, because more than a few sips of alcohol bring an instant headache. I am “lazier” medicated—but for me, “lazy” just means not shooting around like the Road Runner, making everyone in my orbit want to stab themselves in the face. I exercise daily, but I have no interest in the intense workouts I used to do. Maybe this is bad for my bones; I’m a tiny, thin person,and perhaps at 70, I’ll suffer some consequences from having chosen a drug and a walk (or reading a novel) over lifting weights or training for a marathon or suffering through a hot yoga class. I used to feel great after those classes, like I’d sweated out all the stress, but I remember thinking, Is spending 8 or 10 hours a week in this wildly overheated room just to be able to be at peace…is that really much better than popping a cheap, legal pill for the same or better result?
Which brings me back to Diana Spechler and Patricia Pearson, my fellow “going off” authors. How are they now?
Spechler is writing a book that stemmed from her column, so she wouldn’t say too much, but she shared this: “I didn’t go back on meds in any official capacity, though I did have a brief reunion/romance with benzos around election time.” She made other big changes, though—including moving from the East Coast to somewhere much warmer and sunnier. In other words, she made the sort of dramatic change that alters your life and can alter your depression.
Pearson was more forthcoming. At the end of her book, at six weeks without meds, she was a regular at both the gym and cognitive behavioral therapy, savoring her children and even going to church. Healthy stuff, for sure—but not, she admitted, enough to keep her med-free forever; she resumed Lexapro before the book even came out. First, it was because of anxiety over her hypothyroidism. Then, on the day of the book’s release, her father died suddenly of a heart attack. In short, her life got more stressful, as lives do, and she needed more than exercise and church to get by. The Lexapro eventually made her gain weight, however, so after another year, with her life back on track, she jettisoned it. But, she told me, “I hopped on and off a couple of times between 2008 and 2014.”
I reminded her that her convincing and sophisticated book was largely about how we’re using pills to vanquish anxiety that we might be better off living through. “I was mad at that time,” she admitted. “Mad at Effexor and mad at the pharmaceutical companies. Since then, I’ve become more moderate: When something’s of use to me, great, and when I don’t need it, fine.” She’s not taking anything now, but “if I got anxious again, to the point where I’m almost paralyzed with anxiety, then I’d have no trouble…getting a prescription for 20 milligrams of Lexapro.” She still believes that doctors and especially drug companies should be more honest about the side effects of SSRIs and the difficulty of getting off them. Other than probably Big Pharma itself, who could disagree with that?
My own biggest worry with Celexa is not what eventual damage it might cause—I’ll cross that bridge if I ever come to it—but that someday I won’t be able to get it and I’ll have to go off it cold turkey. The worry is irrational. I do still wonder on occasion, If I’d never found my wonder drug, would I somehow be more “interesting,” the person I was “meant to be”? What might I have written without Celexa? And what about the great artists who were famously depressed? If Van Gogh had been able to pop an SSRI with his morning OJ, would we have all his paintings?
Then I remember: I wrote three books taking Celexa and three not taking it, and of the latter, only two got published—because the third was so depressing no one would buy it. And while it’s true that we might not have all of Van Gogh’s paintings if he’d taken an antidepressant, I have a feeling we’d still have some—and he might not have taken his own life.
As for my young relative who left college because of anxiety, she went into therapy, started on an SSRI, and picked herself up off the floor. She returned to school the next fall and is now thriving. She’d like to eliminate the drugs—she’s had some side effects and chafes at the idea of being on them indefinitely—so she sometimes lowers her dosage (with a doctor’s help) and is learning to meditate. But in the meantime, thanks in large part to antidepressants, she’s making her way in the world, taking advantage of her rights: life, liberty, and the pursuit of happiness.
Cathi Hanauer is the New York Times bestselling author of three acclaimed novels—“Gone,” “Sweet Ruin,” and “My Sister’s Bones”—and two essay anthologies, The Bitch in the House and The Bitch is Back, which was an NPR Best Book of 2016. She’s contributed articles, essays, and criticism to The New York Times, Elle, O, Real Simple, and many other publications, and is a co-founder of the New York Times “Modern Love” column. Find her at her site or watch her Ted Talk.
The original piece that Cathi refers to here was published in 2007 in Elle Magazine, and this piece appeared originally in Elle Magazine in 2017.