The Noonday Demon (43 page)

Reading the clinical pharmacology of ecstasy makes my stomach turn. The idea that I ever allowed such a substance to enter my body appalls me. At the doses used for recreational purposes (between a hundred and a hundred fifty milligrams), ecstasy damages brain serotonin axons—the part of the nerve cell that reaches out to other cells—in monkeys and other mammals. The evidence strongly suggests that it does the same thing in humans. The drug essentially causes an explosion of serotonin and dopamine, releasing big stores of these substances and then damaging the cells where they were stored. Furthermore, it prevents the synthesis of more serotonin. Regular users of ecstasy have lower serotonin levels than other people, sometimes as much as 35 percent lower. Researchers have reported a number of episodes of a single dose of ecstasy triggering permanent psychiatric illness—sometimes immediately, and sometimes years later. Depressed people are in no position to be lowering their serotonin levels and should therefore give this drug the widest possible berth. “If you take a lot of it over an extended time, you may destroy your capacity to feel happiness; it can cause in the long term the adverse effects that cocaine causes in the short term,” David McDowell of Columbia says of the drug. “Freshmen love it; sophomores like it; juniors worry about it; and seniors are afraid of it. Alcohol can become your best friend, but ecstasy can’t. My real fear is that a lot of people who have used a lot of ecstasy in the past two decades are going to think they’re fine, and then when they turn fifty, they’re going to plummet.
Depressed patients who use the drug? I say to them, ‘In twenty years, do you want to be on three medications or on ten?’ ”

The benzodiazepines (or benzos)—Valium, Xanax, Klonopin—and their cousins (Ambien and Sonata) are perhaps the most confusing drugs of all: they are addictive and they are useful for psychiatric complaints. They are very effective against anxiety, but because there is a lot of cross-tolerance between them and barbiturates or alcohol, they should not usually be prescribed for people likely to abuse those substances. The benzos are a valid short-term way of dealing with something that needs both an immediate and a long-term solution. The idea is to get on other medications that will allow you to taper off the benzos and then to use them only for regulatory purposes, to help on days when one particularly requires help. To take the benzos daily long-term is ill-advised and dangerous. The benzos that are most often sold on the street are short-acting ones, roofies, called the “date-rape drug” because they induce a temporary miasma in which someone cannot necessarily assert or defend herself. In general, however, the benzos are abused by people for whom they have been prescribed. You should always think twice before you take a benzo, and if you find yourself needing escalating doses, you should figure out why. Covering up symptoms with benzos is like taking antacids for stomach cancer.

I am a huge fan of the benzos because I believe that Xanax saved my life when it alleviated my insane anxiety. I have used Xanax and Valium for sleep when I am in agitated periods. I have gone through miniature benzo withdrawal a good dozen times. It is important to use the benzos only for their primary purpose, which is to allay anxiety; this they will do fairly consistently at fairly consistent levels. When my anxiety is high, I need more of the benzos; when it is moderate, I need less. Nonetheless, I am aware of the dangers of these drugs. I have made little forays into substance abuse, but I had never been addicted to anything until Xanax was prescribed for me. I stopped taking drugs abruptly at the end of my first go-around with depression. It was not a good strategy. The withdrawal symptoms from Xanax—which I had been taking on doctor’s advice for several months at a rate of, on average, two milligrams a day—were horrible. For at least three weeks after I stopped taking Xanax, I could not sleep properly, and I felt anxious and strangely tentative. I also felt the whole time as though I’d had several gallons of cheap cognac the night before. My eyes hurt and I had an upset stomach. At night, when I was not really asleep, I had unrelenting, terrifying half-waking nightmares, and I kept sitting up with my heart pounding.

I went off Zyprexa, the drug that saved me from my mini-breakdown,
a few weeks after I finished a draft of this book, and I had another round of acute withdrawal. I put myself through it because Zyprexa had caused me to gain seventeen pounds in eight months, but while I was getting off the drug, I felt unspeakably awful. My dopamine system was dysregulated, and I was anxious, withdrawn, and overwhelmed. There was a knot in the pit of my abdomen that seemed to tighten like an internal noose around my stomach. If I had not had hopes for improvement, I would have contemplated suicide. The horrendous strung-out feeling was worse than I could have remembered. I kept poking at my little potbelly and asking myself why I was so vain. I wondered whether I could control my weight while on Zyprexa by doing a thousand sit-ups every day, but I knew that when I was on Zyprexa, I didn’t have the wherewithal to do a hundred sit-ups every day. Going off Zyprexa just turned up all my energies—it grated in the same way that a perfectly nice piece of music will suddenly turn painful and distorted if you shoot the volume way up to the top of your stereo’s range. It was hell. I put up with this for three long weeks; and though I did not have a breakdown, I felt so low by the end of the third week that I lost interest in seeing whether my body could bring my dopamine system back into line. I chose fat and functional over slender and miserable. I forced myself to give up the sweets I always loved and to do ninety minutes of exercise every morning, and I stabilized at a weight that didn’t please me. I gradually cut my dose in half. I soon lost ten pounds. To get my energy up and going while on the Zyprexa, my psychopharmacologist added in Dexedrine.
Another
pill? What the hell—I take it only when I’m at my worst.

I no longer take Xanax regularly, but am I addicted to the little cocktail of antidepressants—Effexor, Wellbutrin, BuSpar, and Zyprexa—that allowed me to write this book? Am I dependent on them? The most acute version of this question is whether the drugs I have been taking will all remain legal. Heroin was originally developed by the Bayer aspirin people as a cough medicine, and ecstasy was patented by pharmacologists in Germany before the First World War. Drugs regularly move from the world of medicine to the world of abuse and back. We seem currently to endorse any drug that does not essentially impair functioning. I think about the effect that Zyprexa had in my most recent round of battles with depression. What is Zyprexa really doing inside my brain? If going off Zyprexa gave me all those fidgety, anxious symptoms of withdrawal, then was it a drug on which I was reliant? How would I react if someone told me that in the wake of recent discoveries, Zyprexa had been positioned among the enemies in the war against drugs?

Michael Pollan has argued in the
New York Times Magazine
that there is in fact no truly consistent basis for declaring substances legal or illegal
and writes, “The media are filled with gauzy pharmaceutical ads promising not just relief from pain but also pleasure and even fulfillment; at the same time, Madison Avenue is working equally hard to demonize other substances on behalf of a ‘drug-free America.’ The more we spend on our worship of the good drugs (twenty billion dollars on psychoactive prescription drugs last year), the more we spend warring the evil ones (seventeen billion dollars the same year). We hate drugs. We love drugs. Or could it be that we hate the fact that we love drugs?” In principle, addictive, illicit drug taking crowds out all other activities, while antidepressant drugs make you function better than you would without them and do not cause long-term harm. William Potter, who formerly ran the psychopharmacological division of the NIMH, comments, “We’ve made a judgment that drugs that prevent you from experiencing appropriate emotional response are not acceptable. That’s why cocaine is illegal. There are too many problems when you cease to detect warning signs and threats. You pay a price for an excessive high. That’s not moralizing; that’s just my observation.” In contrast, “No one gets an intense Zoloft craving,” says Steven Hyman. “No one would ever kill to get a Zoloft.” They also do not produce either euphoria or supersize relaxation. One does not speak of a diabetic as being addicted to insulin. Perhaps our society’s emphasis on deferred gratification is so intense that we simply prefer those drugs that make you feel bad (side effects) and then good (mood effects) to drugs that make you feel good (high) and then bad (hungover)? Still, are new-generation antidepressants anabolic steroids for the brain? The psychiatrist Peter Kramer, in his famous book
Listening to Prozac,
wondered whether people who take these drugs have an unfair advantage, thus creating pressure for others to take them. Will they reproduce the effect of modernization, which has been not to give people free time but to raise expectations and speed up life? Are we at the brink of making a breed of Supermans?

It is certainly true that antidepressant drugs are hard to give up; I have in two years tried three times to get off Zyprexa and failed every time. Getting people off the SSRIs can be very difficult. The drugs are not intoxicants, but they make you feel better and they do have a lot of adverse side effects—mostly adverse for the individual rather than for the society, but distinctly adverse nonetheless. I feel some concern for my overall state of mental health, and I exercise considerable care around readjusting my brain chemistry: I am terrified of plummeting back into the abyss, and no high could be worth that. I’m too mistrustful of recreational drugs to get much pleasure out of them these days. But on the rare occasions when I have taken them and had a high, I have had to contrast that heady feeling with the effect of the prescribed medications on which
I am now reliant. I wonder whether the permanent repitching of my personality just a notch higher is not somewhat akin to the heady high. I actually write pretty well in altered states: I have come up with good prose at the end of a night of drinking, and I have spun out some ideas when I was flying on cocaine. I certainly wouldn’t want to be in either state all the time, but I wonder just where I would pitch my personality if anything were possible. I’d definitely bring it up a few levels from where it is now. I’d like to have the boundless energy, the quick precision, and the apparent resilience of, say, Wayne Gretzky. If I found a drug that would give me those properties, would it necessarily be an illicit one? Much is made of the fact that antidepressant medications do not provide immediate relief, while substances of abuse mostly give you a desired high really fast. Is it simply that speed of effect that so disturbs us, that eerie bewitched-before-your-very-eyes phenomenon? If someone made up a powder that didn’t deplete neurotransmitters and that didn’t bring about a crash and that instead allowed me to function like Wayne Gretzky so long as I inhaled it every five hours, would that necessarily have to be illegal?

To my mind, I am no longer independent. The medications are expensive, though they are at least regularly and conveniently supplied. I don’t mind the idea that I am reliant on them, nor the idea that reliance is a cousin of addiction. So long as they work, I’m pleased to take them. I carry pills around in my pocket all the time every day, so that I will have them in case I can’t for some reason get home one night. I take bottles of pills on airplanes because I have always thought that if I were hijacked and held prisoner, I’d try to keep the medication secreted about my person. Janet Benshoof recalls being put in prison in Guam and calling her psychiatrist from jail. “He was frantic about my having a depression in prison, not to mention withdrawal, and he was vigorously trying to get antidepressants through the security system for me. It was hysterical; I was hysterical too.”

I pop about twelve pills a day to keep myself from getting too down. Frankly, if I could accomplish the same effect with two good drinks (and I know people who can), that would be a perfectly satisfactory alternative, so long as it didn’t turn into three drinks or four drinks or eight drinks—which, if you are fighting depression, it usually does. A dependence on alcohol may be fully socially acceptable even if it interferes with REM sleep. I was charmed by someone I used to know who would at six o’clock sharp cry out, as he decanted his whiskey, “Every fiber of my being cries out for alcohol.” He had built a life that accommodated his evening vagaries, and I think it was a happy life, though when he once visited a Mormon household in which alcohol was unavailable, he hardly made it through the evening. It would be stupid to put such a man on
Prozac instead. For other substances, the law often creates trouble instead of controlling it—or as Keith Richards put it, “I don’t have a drug problem; I have a police problem.” I have known people who used marijuana and even cocaine in truly controlled and disciplined ways that improved their states of mind and being. Ann Marlowe’s book
how to stop time: heroin from A to Z
convincingly describes reasonable controlled manipulation of mood with heroin. She took heroin on and off for many years without ever becoming addicted to it.

The big problem with self-medication, far worse than the selection of inappropriate substances, is that it is so often inept and ill-informed. “I deal with bad cocaine abusers,” says David McDowell of Columbia. “People who are using a hundred fifty dollars’ worth of cocaine a day at least twenty-two days a month. And they don’t like the idea of medication and think it sounds unnatural. Unlike what they get from Billy the dealer! These substances are unregulated, and utterly unreliable.”

Many of the people quoted in this book have had substantial problems with substance abuse, and many of them have blamed substances for their depression. Tina Sonego is unusually frank about the interaction of the two kinds of trouble. She is a woman with unusual vitality, a rich sense of humor, and staying power. Over a span of three years, fifty letters, and dozens of E-mails, she created an intimacy with me purely by supposing it. She took to “freebasing my dark moods on paper,” as she described it, and the result was a remarkable set of documents of rising and falling moods. Her struggles with self-destructiveness and addiction and depression are so tightly bound together that it is nearly impossible to see where one breaks off and another begins.