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Note: This article originally appeared in Speakeasy Magazine
May June, 2003
By Carl Elliott
In DeLillo’s 1985 novel White Noise, a pharmaceutical company has developed a secret experimental drug called Dylar. Dylar is a medical treatment for the fear of death. Some people are not simply apprehensive of death in the ordinary, abstract way. They seize up, break out in killer sweats, lapse into reveries on the prospect of dying. But Dylar can help. As a character in the novel explains, “They isolated the fear-of-death part of the brain. Dylar speeds relief to that sector.”
I started to think about Dylar again recently after a conversation with a friend of mine, Rick Kodish, who is an oncologist. Rick told me that a colleague of his had begun prescribing antidepressants such as Prozac and Paxil to all of his dying patients. His rationale was that dying patients are almost universally depressed by the prospect of imminent death, and their psychological condition would improve with antidepressants. Clinical studies back him up. Dying patients who are given Prozac show significant improvements on the Hamilton Depression Rating Scale, the Hamilton Anxiety Rating Scale, the Memorial Pain Assessment Card, and the SF-36 Health Survey. Who could argue with that? Imminent death is “psychologically distressing,” as the palliative care specialists put it; and “psychological distress impairs the patient’s capacity for pleasure, meaning and connection.” For a meaningful death, try Prozac.
In America we take happiness seriously, and nowhere do we take the grim business of happiness more seriously than in American medicine. The pharmaceutical industry is now the most profitable industry in America, with 18 percent annual profit margins, and its most profitable class of product is the antidepressant drugs. A list of the fifty best-selling drugs of 2001 compiled by the National Institute for Health Care Management includes Prozac, Paxil, Zoloft, Effexor, Celexa, and Wellbutrin. Our enthusiasm for psychoactive drugs is not new, of course. Before Prozac there was Valium, which consistently ranked among America’s best-selling prescription drugs until the 1980s, and before Valium there was Miltown, a “tranquilizer” developed in the 1950s specifically for the anxiety of ordinary life. At the height of its popularity, Miltown was being taken by one American in twenty.
Not that we ever felt especially proud of that statistic. The Miltown boom was widely criticized as yet another symptom of American moral decline. Like Prozac in the 1990s, Miltown was called a “crutch,” a “mental laxative,” “emotional aspirin,” a “prescription for happiness.” Beyond these clichés, however, it is not all that easy to say just what is wrong with medicating away our anxiety, our shame, or our fear of death. Crutches, aspirin, and laxatives are very useful if you happen to have a broken leg, a headache, or a stubborn case of constipation. Anxiety about death is deeply unpleasant. Why not medicate it?
When Prozac and the other selective serotonin reuptake inhibitors (SSRIs) were introduced in the late 1980s and early 1990s, it was natural for critics to compare them to anti-anxiety drugs like Valium. Yet it quickly became clear that the SSRIs were different. Valium tranquilized, whereas Prozac energized. Valium took effect immediately; Prozac took weeks. Patients took Valium and said they felt weird; they took Prozac and said they felt like themselves. The effects of Prozac and the other SSRIs were not limited to patients with clinical depression. Clinicians soon started to use SSRIs to treat social phobia, obsessive-compulsive disorder, premenstrual dysphoric disorder, eating disorders, paraphilias, sexual compulsions, body dysmorphic disorder, and generalized anxiety disorder. With each new disorder came a new market of potential antidepressant users-uptight Americans, melancholy Americans, weight-obsessed Americans, shy and lonely Americans sitting at home on the couch, watching cable TV. Soon the antidepressant makers began funding anxiety support groups, obsessive-compulsive disorder Web sites, and depression awareness campaigns.
When the FDA relaxed its restrictions on direct-to-consumer advertising in 1997, the drug industry started running ads on television and in glossy magazines. The Eli Lilly Corporation began to distribute cutout ProzacWeekly coupons. By September 11, 2001, when terrorists crashed airplanes into the World Trade towers and the Pentagon, GlaxoSmithKline was ready with another flurry of advertising: Paxil for the effects of post-traumatic stress disorder. In the 1960s, the U.S. government was very worried about our preoccupation with psychoactive drugs. Richard Nixon proclaimed that Americans were looking for “happiness in a tablet.” When Senator Gaylord Nelson opened a Senate inquiry into the pharmaceutical industry, he began the session on psychoactive drugs by invoking Brave New World: “When Aldous Huxley wrote his fantasy concept of the world of the future in the now classic Brave New World, he created an uncomfortable, emotionless culture of escapism dependent on tiny tablets of tranquility called soma.” These days, it is hard to tell the difference between the pharmaceutical industry and the government. The Bush administration’s budget director, Mitch Daniels, is a former vice president of Eli Lilly, and Secretary of Defense Donald Rumsfeld is a former president and CEO of Searle (now a subsidiary of Pharmacia, the maker of Xanax).
Back then, too, we knew what dissent looked like. We learned about it from The Invasion of the Body Snatchers, The Stepford Wives, and One Flew over the Cuckoo’s Nest. Dissent was about resisting authority, fighting conformity, staying true to who you really are. It was about asserting yourself as an individual against the government, the organization, the Establishment, the Man. Dissent was Peter Fonda and Dennis Hopper in Easy Rider, Muhammad Ali resisting the draft, Tommy Smith and John Carlos raising their fists in Mexico City. Dissent was about speaking truth to power, and we knew what truth and power looked like. Truth wore blue jeans. Power wore uniforms and suits. Truth looked like Randall McMurphy. Power looked like Nurse Ratched. These days dissent has gotten a lot more confusing. These days the ultra-rich wear jeans and ride motorcycles to their jobs at Microsoft and Celera. Ali is celebrated as a hero by the U.S. government and lights the torch at the Atlanta Olympics. Counter-cultural icons like William S. Burroughs are familiar mainly for their appearances in television ads. Now we dissent through what we buy. In the words of the writer and Baffler editor Thomas Frank, dissent is now the official slogan of corporate America. On the eve of war with Iraq we have no antiwar anthems, and why should we? These days, antiwar anthems are used to sell Wranglers.
It took awhile for the pharmaceutical industry to catch on. Back in the 1960s, the pharmaceutical company Sandoz placed ads in medical journals for its new tranquilizer, Serentil. The ads featured the slogan, “For the anxiety that comes from not fitting in.” Sandoz suggested that doctors could prescribe Serentil for the “the newcomer in town who can’t make friends,” or “the organization man who can’t adjust to his altered status within his company.” Medicating dissent, however, was not a successful advertising strategy. Sandoz might as well have used the slogan “How to make a Stepford Wife.” Nobody wants to see him- or herself as a docile, medicated misfit. We want to see ourselves as hip, outrageous misfits, fists in the air, striking a blow against the system. At a time when everybody wanted to be a rebel, Sandoz evoked Randall McMurphy after his lobotomy.
Drug advertising looks a lot different now. In the imagery of today’s advertising, taking antidepressants is all about becoming yourself, refashioning yourself, fighting back against the oppressive social forces that make you feel small, shy, or anxious. The SSRIs are not drugs for Stepford Wives. They are tools of resistance. With SSRIs you can strike back against the oppressive social forces that make you feel ashamed of your body. You can withstand the glares of the company bureaucrats gathered around the table as you stumble though a business presentation. The SSRIs can even be seen, as Peter Kramer puts it in Listening to Prozac, as “feminist” drugs-instruments to aid women in their struggle to break free of their alienating domestic routines. With an SSRI, an unhappy woman can leave a bad marriage, ask for a raise at work, go back to school, or apply for a new job. “I feel like myself again,” says the woman in the Paxil ad, a genuine smile on her face.
The novelist and physician Walker Percy understood this back in 1970. The hero of Percy’s satire Love in the Ruins, Thomas More, is an alcoholic psychiatrist in Louisiana who has invented a medical instrument that can diagnose and treat existential ailments. The Ontological Lapsometer, More calls it-a “caliper of the human soul.” With the Ontological Lapsometer in hand, Dr. More can treat alienated housewives, bored suburbanites, sexually impotent liberals, and conservatives with large-bowel complaints. The Ontological Lapsometer is not a sedative. It does not act as a tranquilizer. When More’s patients are treated with the Laposometer, they become healthy, happy, and fulfilled. A quick pineal massage with the Lapsometer and a senior citizen exiled to the Senior Center will actually start to enjoy his daily routine of shuffleboard, ceramics, and Papa Putt-Putt. The villain in Love in the Ruins is not a government bureaucrat, not a Brave New World functionary; in fact, he’s not even much of a villain. He is a cheerful Mephistopholean character named Art Immelman, who looks a little like a drug rep (a “detail man”) and a little like the kind of fellow who might have serviced condom dispensers in the 1950s. When Immelman appears in More’s office, accompanied by the smell of sulphur and the overture from Don Giovanni, it is to license and develop the Ontological Lapsometer. Immelman is no mere drug company representative. He is a “liaison between the private and the public sectors.” He wants More to sign over the patent rights to the Lapsometer. And why not? “What is the purpose of life in a democratic society?” Immelman asks More. “Isn’t it for each man to develop his potential to the fullest?” Like Prozac twenty years later, the Ontological Lapsometer is an instrument for self-fulfillment. It was made for consumer capitalism.
For Percy, consumer capitalism is at least part of the reason we have become so alienated from the world around us. We have begun to see ourselves not as wayfarers on a pilgrimage but as consumers-passive receivers of information and goods packaged by experts: planned communities, televised entertainment, shopping malls, sea cruises and package vacation tours. We are consumers of managed happiness, and psychiatry takes its management yet another step further. The psychiatrists define mental health, and we see our own situation as a specimen of what they define. They define proper sexual responses, and we see our own behavior as an example. They define social anxiety disorder, and we compare our own anxiety. They define psychic well-being, and we measure our own well-being by their yardstick. Instead of seeing the world fresh, we see a world packaged by experts. With each step, each additional plan and theory and yardstick, we surrender a little sovereignty over the self.
At the beginning of his essay “The Delta Factor,” Percy asks the following question:
Given two men living in Short Hills, New Jersey, each having satisfied his needs, working at rewarding jobs, participating in meaningful relationships with other people, etc., etc.: one feels good, the other feels bad; one feels at home, the other homeless. Which one is sick? Which one is better off?
From the medical point of view, the answer is clear. It is better to feel good than to feel bad. It is better to feel at home than to feel homeless. If you feel bad and homeless, you probably have “dysthymia” or “generalized anxiety disorder.” You are probably a candidate for antidepressants. Yet for Percy (and, I suspect, for many others) the answer is a lot more complicated. Most of us would rather feel good, it is true, yet some situations call for feeling bad. Who is better off: the contented slave, or the angry one? The man who sins happily, or the one who feels guilt and shame? Psychiatric diagnoses make all unpleasant psychic states seem like medical conditions, the treatment of which means fixing the unpleasant psychic state. Yet psychic states are also reactions against the world outside our own heads. Part of what is worrying about medicating all dying patients with antidepressants is the prospect of blunting what might be seen as the proper reaction to death. “Psychological distress”? Of course dying patients feel psychological distress. Is it really pathological to approach death with fear and trembling? Yet from the medical point of view, anxiety, grief, sadness, shame, and alienation all become transformed into unhealthy mental states to be measured on a psychological rating scale, given a billing code, and treated with psychoactive medication. If Dylar were a real drug, it would not be a secret. It would be FDA approved for “mortality dysphoria” and advertised on television.
Percy is by no means the only writer to point out the appealing creepiness of engineering our emotional responses to the world. Philip K. Dick’s science fiction novel Do Androids Dream of Electric Sheep? features a device called the Penfield mood organ, with which you can dial up and even schedule precise emotional states-a “businesslike professional attitude,” “ecstatic sexual bliss,” “a desire to watch television no matter what is on” or “pleased acknowledgement of husband’s superior knowledge in all things.” It is an eerie idea, not because there is anything wrong with controlling your emotions-in many situations this is entirely admirable-or even because we are unfamiliar with the idea of controlling our emotions through chemical means. (As Willie Nelson sings it, “I’m gonna get drunk and I sure do dread it, because I know just what I’m gonna do.”) It is eerie because emotional states are almost by definition states that we do not completely control. (Would engineered love really be love?) So alienating does one of the characters in Dick’s book find the Penfield mood organ that she begins scheduling regular intervals of “self-accusatory depression.”
The moral theologian Gilbert Meilander imagines a thought experiment that gets at precisely what is troubling about the use of antidepressants to treat what were previously regarded as natural (or at least expected) human reactions. He is concerned about the use of antidepressants to treat grief. Imagine, says Meilander, that you have died. Imagine further that your wife (or husband), with whom you have shared a long and happy marriage, feels no grief at your death. In fact, she is positively buoyant about your departure. Would you feel that you had been truly loved? Meilander’s point, I believe, is not that grief is part of what makes us human, though that may well be true. It is that a person who does not feel grief at the loss of what he has loved has not really experienced love. He has experienced something else, something different from what we call love, because grief at this kind of loss is essential to what we mean when we talk about love. To medicate away the reactions that have always been a part of the way we live-grief, anxiety, shame, righteous anger-means also getting ridding of the forms of life that have sustained them. Maybe some people will welcome this, but we should at least be clear-eyed about what we are changing.
CARL ELLIOTT teaches at the University of Minnesota and is the author of Better than Well: American Medicine Meets the American Dream.