“I’ll never go on antidepressants. Once you start, how do you stop?” —a friend
A couple of weeks ago I paid my biannual visit to the Manhattan office of the woman who prescribes me my medication. For many years I have been on two classes of medication: a selective serotonin re-uptake inhibitor (first Effexor, now Lexapro), and a benzodiazepine, typically Ativan, which I take only at times of acute distress. The woman who prescribes my medication is a psychiatric nurse. She does not provide therapeutic services and she does not have a medical degree. From what I have gathered, she spent much of her career working on an impatient psychiatric ward. She charges $140 an hour, which, given the relief she provides, is a very reasonable expense. For years she was a heavy smoker; the habit has done lovely things to her voice.
Like a lot of anxious people, particularly, I suspect, those of the bookish, cerebral type, I have an actively conflicted relationship with my medications (or, I should probably say, with the fact of my being medicated). On the one hand, as I say, the pills provide relief — although in this claim, I see, already lies the seed of the conflict, for I can not be certain that the pills provide relief. The Ativan is exempt from the dilemma: it has a quick and discernible sedative effect. A benzodiazepine, the best known brands of which are Ativan and Xanax, acts like a martini, but without the inebriation. The problem pill is the SSRI, the efficacy of which can be very hard to gauge. How can you be sure it’s working? Anxiety, like all psychiatric complaints, is subjective. Despite the best efforts of the clinical establishment, the only extant measures of anxiety are purely linguistic: answers to the old eye-roller, “How are you feeling?” There is no blood test, no objective factor like blood sugar or cancer markers. There is only the blooming, buzzing, oceanic flux of experience: description.
At first, if my experience is any guide, the matter of medication efficacy isn’t terribly fraught. When an anxious person first goes on an SSRI, she typically does so because she is in crisis, and the medication either works or it doesn’t. Let six weeks pass. Is there still a crisis? Then the medication isn’t working. Has the crisis abated? Then the medication is working. There remains some doubt clouding the picture, because usually the patient is simultaneously in talk therapy, which could conceivably be the dominant clinical factor. But we are talking here of crises — pronounced and atrocious spikes in mood. Therapy works more slowly than pills. A person can simply tell.
As time goes on, however, and the spike does not recur, and one keeps ingesting the pills and, with a dutiful self-preservation, keeps talking to one’s shrink and making responsible adjustments in one’s habits — in diet, in exercise, in romance, in work —a more serious and insidious confusion creeps in. Changes have been made, real changes. The anxiety is there — it will always be there; you admit this to yourself — but it is now, as the clinicians say, “manageable.” To what do you one owe this protracted, if incomplete, relief: medication or will? Once you needed the pills — urgently you needed the pills. But do you still need the pills? How can you be sure they’re even still working? If the pills were discontinued would the panic come raging and roaring back? Or would life continue along as it is now? Doesn’t it make sense — wouldn’t it make perfect sense — to wean yourself from the medication, to see if it is no longer essential to your continued contented existence?
It does make sense. This is how the medication was sold to you, after all — as a temporary measure, something to get you over the hump. It is troubling, then when you resolve to thank this natural step and you are assailed, quickly, by two vexing and countervailing questions. The first question regards timing. Wisely, you want to be sure that you are not going off your medication during a period of transition or flux in your life. You do not want to be reckless. And yet you know well (because like many anxious people you have looked into Buddhism and absorbed its precepts) that life is nothing but transition and flux — transition and flux to which, you also know well, you are prone by virtue of your anxious temperament to respond with painfully exquisite sensitivity. Now is not the right time. This is the boldness-killing thought. Just now I have an assignment to finish. Just now my child is entering school. Just not my wife and I are quarreling. Just now we are about to move. Just now. Just now I want to be sure of my sanity.
The second question to enter your mind is: Why bother? For me, at least, SSRIs have never caused a significant side effect. I don’t experience constipation, diarrhea, dizziness, drowsiness, dry mouth, headaches, light-headedness, loss of appetite, or nausea. I can still easily summon an erection and I can still reach orgasm. The only annoyance is the very mild one of being handcuffed to the pills themselves: it’s one more thing to before bed, along with brushing my teeth and removing my contact lenses; it’s one more item to remember to pack in my carry-on luggage. There is still, it’s true, the nagging stigma of being among the medicated — but at a time when twenty percent of Americans are on some kind of psychiatric drug, whatever shame one feels is very arguably self-imposed and anachronistic. You’re on a pill. So what? What’s the big deal? May as well continue along as before…..
And so it is that every six months or so I take the subway to the West Side, ascend to the seventh floor of a tall, beige-stone building, and sit thumbing through a Vanity Fair with a check in my pocket, waiting for a fresh prescription. It has been — I don’t know exactly how long it has been. Six years? Eight? Ten? A long time. Periodically I ask the woman who prescribes me my pills how I might go about getting off them. I defer to her expertise — nervously, I defer. Is it a good idea? Is now a good time? She is a person who prescribes medication for a living. She is, in other words, a true believer. But she is ethical and understanding as well, and she tells me that “we” can try. Here is how we might go about it. Here is a schedule, a method, whereby we can lower the dosage — slowly, slowly, until the pills are no more.
I carefully write these instructions down. I always write these instructions down. But I have yet to use them, or even to start the process.
Starting is, of course, the vital step.