Ordinarily Well: The Case for Antidepressants



BECAUSE THE Osheroff case records are extreme—tainted by dogma and disdain—they give an unfair impression of psychotherapy’s brief against medication. For balance, I want to turn to a graceful document of resistance, one that helped shape views of antidepressants for doctors who favored psychological approaches.

In 1975, the British Journal of Medical Psychology published a biting commentary by Doris Y. Mayer, an American-trained, psychoanalytically oriented child psychiatrist practicing in England. Mayer had admirable reach. She wrote an anticapitalist stage play and did anthropology fieldwork in Ghana. As a psychiatrist, Mayer’s best-known piece was “Psychotropic Drugs and the ‘Anti-Depressed’ Personality.” The distinctive adjective conveys the argument’s considerable appeal.

In her essay, Mayer questioned whether antidepressants worked but then dropped the complaint: “Let us assume that drugs have at least moderate success in alleviating some forms of distress.” What did medication offer?

Mayer worried over patients’ losing “emotional experience” and the “protective function of unpleasant feelings.” Pills might interrupt crises, but patients risked emerging “with lessened rather than enhanced ego strength.” Tartly, she countered a narrative that I would later offer: “It is sometimes said that medication makes patients more amenable to psychotherapy. In my experience, it merely makes them more amenable.” She recommended drugs only for unbearable mental states.

Her memorable indictment went:

Not anxious but not at ease; not incapable of working but not capable of working well; not tormented by the children, but not able to enjoy them; willing to be made love to, but not actively loving; neither tense nor relaxed, neither cheerful nor tearful, neither ill nor well, more depressing than depressed, the bland, tranquillized, “anti-depressed” personality of our time.

What a stunning passage! Mayer gave incisive expression to a viewpoint that continues to energize the antidepressant controversy and any number of recent discussions of our culture’s valuation of happiness: prescribing represents a failure to appreciate the signal benefits of discomfort.

Despite her essay’s compelling title, Mayer’s critique was not limited to antidepressants. To support her views, Mayer offered case examples. Only one patient, a grieving widow, took an antidepressant alone, and with her, Mayer described no emotional flattening. (The concern was that medication robbed the woman of the opportunity to mourn.) Another patient was on imipramine along with an anxiolytic, Librium, which would explain the tranquilization. Mayer’s remaining vignettes discussed patients on anxiolytics and antipsychotics, along with Ritalin.

Given the prescribing patterns of the time, the state Mayer complained of may have resulted from drugs we would not consider antidepressants. Discussing patients’ arriving on medication, Mayer referenced a 1971 drug-use survey. It found that in Britain over 14 percent of adults had taken an antianxiety medication in the prior year.

Use in the States was at that level or above. During 1973, the year prescribing peaked, over a quarter of American adults took a psychotherapeutic medication. Changes in survey methods make comparisons imprecise, but that estimate is higher than the numbers that we worry over today. In the early 1970s, most scrips were for anxiolytics. Under 2 percent of adults had taken an antidepressant in a given year, and as many as half of those had also taken a “mother’s little helper,” like Miltown. The odds that Mayer had seen large numbers of patients taking antidepressants alone were slim. The “anti-depressed” label notwithstanding, the bland personality arose from Librium or Valium.

It is interesting to juxtapose Mayer’s description with Ray Osheroff’s report of his response—glad to feel sad. In my own observation, the early antidepressants could be restorative, making patients more available emotionally and then more engaged as parents and workers. These effects might be apparent even in those who experienced an unpleasant awareness of being on medication, often the price of taking tricyclics.

If Mayer’s list of incapacities is evocative, it may be because of its relevance to medications like Prozac. These drugs, the ones that affect serotonin-based brain pathways, interfere with sexual desire. With extended use, they sometimes cause apathy. It seemed that Mayer was looking at Valium, pointing to imipramine, and, with prophetic vision, seeing Prozac.

As for the expression of doubts about efficacy, they arose when antidepressants were among the best-validated treatments in medicine. (In 1974, Jonathan Cole revisited the efficacy literature, now more extensive, with a different young colleague, John Davis, and found much the same level of benefit as appeared in the 1960s data.) Mayer was offering a fallback case. If a reader does not buy the primary argument, that the drugs’ mitigation of depression is counterproductive, a weaker, somewhat contradictory complaint stands at the ready. Over time, my impression has been along these lines: often, the claim that antidepressants do not work is in the service of a prior position, mistrust of medication when it does relieve suffering.

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