Moody Bitches: The Truth about the Drugs You’re Taking, the Sleep You’re Missing, the Sex You’re Not Having and What’s Really Making You Crazy.... Julie Holland
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are overwhelmingly marketed to women, stigmatizing depression as a feminine illness, making men less likely to seek treatment, and giving women the go-ahead to take their daily dose so they can cook for their families and dote on their children. Ads for antidepressants (and antipsychotics used to treat depression) are commonplace in women’s magazines like Good Housekeeping and Better Homes and Gardens, and on daytime talk shows. They typically feature pictures of women with sad faces, staring out the window, unable to play with their neglected, frowning children or text their friends. (I wish I were kidding about this last one. The “after” picture for one antidepressant shows a woman now on meds, happily texting someone on her phone.) Many ads now encourage a woman to ask her doctor to consider adding an antipsychotic into the mix after a mere six-week trial of her antidepressant has “failed.”
While the number of Americans on antidepressants has skyrocketed year after year, two big bumps are seen historically. The first was when direct-to-consumer advertising broadened in 1997, completely orchestrated by the Big Pharma lobbies. The other jump in sales came after 9/11, when pharmaceutical marketing homed in on women even more. That September, the women I saw in my office were acutely anxious, fearful for the safety of their Wall Street husbands or their children who were in downtown elementary schools near the attack. They were tense, twitchy, and unable to sleep. Coincidentally, the makers of Paxil (paroxetine) came out with a print ad of a woman on a crowded city street, clutching her bag, jaw clenched, surrounded by words like “sleep problems” and “worry,” with the tagline “Millions could be helped by Paxil.” Drug makers appeared to have found 9/11 to be a marketing opportunity. Glaxo doubled its advertising to $16 million in October 2011, compared with the previous October’s $8 million. That’s just one month of advertising dollars to hook all the women who had a natural, fearful response to a terrorist act. And it paid off big. They got on their meds and stayed on them.
All of this direct-to-consumer advertising has given many of us, especially people who came of age in the 1990s, an inflated sense that we are lay psychopharmacologists. We’ve seen enough ads to know which medicines have lower incidences of sexual side effects (bupropion, an antidepressant that does not raise serotonin levels) and which ones report an increased risk of sudden death (aripiprazole, an antipsychotic prescribed for depression, when used in elderly dementia patients). My mother often said, “A little bit of knowledge is a dangerous thing.” Gen Xers are quick to stock up on pharmaceuticals garnered from friends, the Internet, and physicians, and dole them out to friends and family. As the New York Times explained, “they choose to rely on their own research and each other’s experience in treating problems like depression . . . a medical degree, in their view, is useful but not essential.”
At this point, everybody and their cat are on antidepressants. Seriously—one of my patients has an underweight cat that was recently prescribed mirtazapine, an antidepressant that can cause increased appetite. In today’s insurance-driven health-care system, handing over a prescription is the easiest, quickest way for doctors to get someone out of their office so they can see their next patient. It also keeps the patients coming back for easy, efficient refills. Unfortunately, shorter doctors’ visits, now the norm, mean more time spent alleviating symptoms with pills and less spent digging down to really fix the problem. There is simply no talking about the harder but healthier ways to treat the symptoms. Cholesterol-lowering medicines called statins are a good example. A doctor can spend twenty minutes trying to educate a patient about dietary changes and exercise that could lower cholesterol levels, or can hand over a prescription for a pill being pushed by every drug rep who comes to the office bearing a tray of cheese Danish.
Women are particularly vulnerable to overprescribing. Numerous medical chart reviews consistently show that doctors are more likely to give women psychiatric medications than men, especially women between the ages of thirty-five and sixty-four, who often present with complaints of nervousness, difficulty sleeping, sexual dysfunction, or low energy. A patient recently asked me if he should take Risperdal, an antipsychotic, for his nervousness, because his female colleague told him it had been helping her with anxious thoughts. Risperdal was originally formulated for use in schizophrenia, but people with schizophrenia make up only 1 percent of the world’s population. It’s obviously better business to target 50 percent of the population: women.
I’m not suggesting that all use of psychiatric medicines is counterproductive. People who don’t really need these meds are taking them, while people who are genuinely psychiatrically ill remain undiagnosed and untreated, often due to socioeconomic factors. Clearly there are times when we need to pull out the big guns. Vegetative depressions that last for weeks, when you can’t get out of bed, bathe, or feed yourself, are not going to resolve themselves through soul-searching. Manic episodes where there is no sleep to be had for many days in a row will require mood stabilizers. But we’ve gotten ourselves into a situation in America now where more women are taking antidepressants and antianxiety medications for years on end, and it’s lowering the bar for all of us, creating a new normal in terms of invulnerable posturing and emotional blunting, and, more important, it is changing the tipping point for when other women will seek chemical assistance.
Cosmetic psychopharmacology is not unlike cosmetic surgery. As more women get breast implants, the rest of us feel flat chested. And so it is with more women taking antidepressants and antianxiety medications. Suddenly, you’re the odd one out if you aren’t like your friends, taking something to “take the edge off ” or give you a little lift to withstand the slings and arrows on your journey. More women are feeling lousy and finding themselves on psychiatric medications, and staying on them far longer than they were ever meant to be used. And we’re not necessarily getting any better.
Made to Be Moody
As women, our interior lives are complex and ever changing. Our neurotransmitters and our hormones—estrogen in particular—are intricately linked. When estrogen levels drop, as in PMS, postpartum, or perimenopause, it’s common for moods to plummet as well. Waxing and waning levels of estrogen help us to be more emotional, allow us to cry more easily and even to break down when we’re overwhelmed. There are estrogen receptors throughout the brain that affect our mood and behavior, and there are complex back-and-forth interactions in the brain between estrogen and serotonin, the main neurotransmitter implicated in anxiety and depression. Although it’s more complicated than I’m making it out to be, it’s helpful to think of serotonin and estrogen as yoked. When one is up, the other is likely to be as well. So it is not your imagination. Where you are in your reproductive cycle, monthly and over your lifetime, is an enormous factor in determining what you are feeling.
Think of serotonin as the “it’s all good” brain chemical. Too high and you don’t care much about anything; too low and everything seems like a problem to be fixed. When serotonin levels are lower, as is seen in PMS, emotional sensitivity is heightened. We’re less insulated and end up more cranky, irritable, and dissatisfied. The most common antidepressants, also used to treat anxiety, are serotonin reuptake inhibitors (SSRIs). These are medicines (such as fluoxetine, sertraline, paroxetine, citalopram, and escitalopram) that block the brain’s natural recycling of the serotonin back into the nerve cell, so more can get across to the next neuron. If your serotonin levels are constantly, artificially high, you’re at risk of losing the emotional sensitivity that makes you you. You may be less likely to cry in the office or bite your nails to the quick, but you’re also going to have a harder time reacting emotionally and connecting fully with others, especially sexually.
SSRIs not only affect behavior, they alter perception of the environment. If the “it’s all good” chemical is bathing your brain, will you really try very hard to fix anything? At higher doses, SSRIs sometimes promote apathy and indifference. Patients report having less motivation overall. When one of my patients becomes blasé about things, making the big W sign for “whatever” about life, it’s a sign to