Coming of Age on Zoloft (24 page)

Nathan bounced around the country for a while, in and out of schools and relationships—still, by his own admission, abusing drugs and alcohol. Around the holidays in 2006, he ended a serious relationship with a woman who had been scared away by his mental problems. He was twenty-five, and he decided it was time for a big change.

Around Christmastime 2006, I moved back home, and around the end of February, I found a therapist. I told him I wasn’t going to go on any medication, that I wasn’t drinking, I’d quit smoking cigarettes, I was training to run a marathon in three months, and I just wanted to talk to the guy. He was a young man. I really liked him. He was a great listener. He listened enough that I felt comfortable with him enough that I basically just started saying out loud things that I could then puzzle through myself. I talked to him for about three months, and at the end of the three months I felt, honestly, like the whole ordeal was done.

I asked Nathan what he thought therapy had done for him. He told me it had helped him to process a lot of what had been bothering him in his earlier twenties, and to deal with the problem of his own expectations for himself. He had wanted to be an academic, but his mania and his drug use had forced him to lay those dreams aside. Therapy helped him adjust to the loss of the life he’d imagined and focus on his daily reality. “I think we spend a lot of time up until somebody says ‘Okay, this is your life, do what you want with it,’ creating illusions about what that’s going to be like, and what you can do,” he explained. “Other people had expectations for me, but really most of them were expectations I’d built for myself. And to start to see those unravel is a painful thing.”

He continued:

Here’s the difference between me now and me then. Me now realizes that grief and pain are not endless, you know? And they’re not useless. I’m not afraid of pain so much that I need to go tell somebody, “I think I’m about to hurt, and I’m really scared; is there any way you can make me not hurt?” I do feel much more confident in myself for having—my therapist basically gave me the courage to sit with that pain for as long as it takes before you can understand it and it goes away.

For a while I even wanted to be a therapist, because I felt so strongly about talk and the power of talking. I still feel very strongly about it.

8
| Quitting

T
he autumn after I moved back to New York, I stopped taking my Zoloft. I didn’t make any grand pronouncements to myself or anyone else about going it alone. I just decided, quietly, to take a little bit less, and a little bit less, and then less still. A hundred milligrams a day became 75, then 50, then 25—one buttermilk-yellow capsule, to a half, to a quarter, to the point where tiny slivers of pill turned to dust between my fingertips, and I couldn’t swallow a smaller dose. Tapering down took months, but it was privately thrilling: the feeling of wading one, two, three steps farther out from shore, feeling the lake bottom bounce away underfoot, and finally, floating free.

In hindsight, it surprises me that stopping should have felt so dramatic. But it did. By that point, in 2006, I had been taking antidepressants for nine years, punctuated by only a few short breaks. And like a lot of people who use antidepressants for a long time, I had developed a side effect not printed on the label: a fear of living without them.

Partly, the sense of adventure was an indication of how mysterious and even off-limits the topic of quitting antidepressants can be. For a long time it had seemed remarkable to me how little people talked about it; in a culture that couldn’t shut up about antidepressants—whether you should go on them, how you would know—discussion of the corollary question seemed strangely absent. There were no helpful magazine articles about judging whether it was time to chuck your Prozac, or how to do it the smart way. More surprisingly, no doctor I had seen had ever broached the issue, either to warn me that I should never stop, or to tell me when I might expect to or how to approach the decision. The few times when I tried to bring it up, the line of questioning didn’t feel especially welcome, and the present-focused replies—
This seems to be working now; why don’t you just stay on it?
—felt as though they concealed the lack of a larger answer.

In fact, most of the advice I’d ever heard about getting off of medication was practical, not “whether” but “how.” I had read that weaning oneself off slowly was preferable to quitting cold turkey. Tapering was supposed to prevent “discontinuation syndrome,” stories of which had begun to surface in the news media and the urban-legend network by the mid-2000s. It seemed that some people, getting off some antidepressants—notably the SNRI Effexor, but also the SSRI Paxil, among others—experienced a host of unpleasant side effects that could last for weeks or months, including the frighteningly-named “brain zaps,” which were often likened to the feeling of a sharp electrical shock inside one’s head. I had even heard it whispered in a few places that discontinuation syndrome could involve emotional symptoms as well as physical ones, making it possible that some number of people who went off their medication and then had a relapse quickly weren’t actually experiencing “true” depression, but a form of drug withdrawal instead. I had no way of judging these claims, which felt a bit like early-1970s hippie paranoia to me, but they provide an example of how fraught the whole topic of quitting had come to feel. That the stories existed suggested that some people were doing it. But the tales often had the same vigilante tone, a sense of confused people feeling the need to take matters into their own hands.

In a way, the lack of free-floating official guidance made sense. Depression can be dangerous, and perhaps for that reason, doctors and other experts are loath to put forth one-size-fits-all proclamations about quitting. Many doctors, and some lay-people too, seem to believe that once started, antidepressant therapy should go on more or less forever—and in some cases that may be absolutely right. There is still a little touchiness around the fact that depression was and is a stigmatized illness; some may feel that to talk about quitting medication is to question the seriousness of the disease, or to confront suffering people with the damning and probably incorrect idea that they
could
be okay on their own, if only they would
try harder
. That reasoning is understandable. But given that millions and millions of people start using antidepressants, for a great variety of reasons, it seems equally outrageous to assume that everyone ought to stay on their medications indefinitely, or that collectively skirting the issue is the approach likely to lead to the best and safest outcome for all.

As it turns out, there are some guidelines regarding how long people should stay on antidepressants, but I had to do a little journalistic sleuthing to find them. One psychiatrist I talked to told me that as a rule of thumb, an adolescent with a first episode of depression should be maintained on an antidepressant for about six months following a full remission of symptoms; after that, the dosage could be brought down slowly and the patient monitored for signs of a recurrence. Subsequent episodes, he said, should be dealt with more aggressively, with antidepressant therapy maintained for longer; after a third episode, continuous maintenance on an antidepressant was advisable.

But in practice, those guidelines are far from universally applied. My own experience was more like that of Alexa, who in talking about antidepressants spoke offhandedly of “the way they’re prescribed to sort of never end,” or Dana, who said that one of her motivations for quitting antidepressants was the fact that “nobody was having a conversation with me about ever going off them, and that seemed odd.” It seems safe to say that many doctors feel more comfortable getting people started on antidepressants than coaching them off. If the patient seems to be doing fine on medication, the feeling seems to be that it’s fine to keep them there. And in a world where patients who take psychiatric drugs are often seen in fifteen-minute increments that may fall months apart from one another, it’s easy to grasp why physicians might feel reluctant to rock the boat.

In the absence of clear advice about how long a course of antidepressant treatment should last, many people adopt a self-guided version of the pattern that the psychiatrist described to me. They take medication, stabilize on it, feel better for a certain period of time, and then experiment with taking themselves off.

That’s certainly what I was doing. To date, I had quit antidepressants three times—the summer after my freshman year in college, at nineteen; the summer before graduate school, at twenty-two; and finally at twenty-six, not six months before returning to New York. I had been living temporarily in California, first doing a magazine internship and then looking for work. While I hadn’t actually stopped taking Zoloft when I was living in Ithaca, I had gotten newly curious about it. I wondered whether the things I’d learned in therapy might make a difference. Was it possible that I’d become better at knowing, and meeting, my own needs in a way that could shift my relationship with medication? I didn’t mean to quit just when I did, but with that question in the back of my mind, I let two events in California make the decision for me: I fell in love. And I ran out of prescription refills.

It was not a success. As with the other times I’d stopped, I felt fine for a few months, but toward the end of my time in the Bay Area, as the structures that had been giving my life shape fell away one by one, I drifted into a state of near-constant anxiety that left me exhausted and, eventually, practically galloping toward the office of a San Francisco psychiatrist. By the time I arrived in New York a few months later, I felt calmer but still bruised, like a vase that’s been glued back together, ser-viceable but still shiny along the seams.

Some people would have called me foolhardy for trying again, or masochistic, or even ungrateful. At moments I wondered whether I was one or all of these. Still, I couldn’t seem to resist trying again. I had my general reasons—I’d never wanted to stay on antidepressants forever—and my particular ones: coming to New York and starting a new job meant starting over again, and I wanted to be sure I knew how this new life was making me feel. It felt as though, after some delay, I was beginning to build the foundations of my adult life, and if something about that life was making me uncomfortable, I wanted to know it. Finally, I wanted to quit antidepressants simply because I believed that I’d feel a sense of achievement if I was able to live without them. That belief had been with me for a long time. It felt problematic and un-P.C., but it was also stubborn. I knew that you weren’t supposed to care if you used medications or not, that you weren’t supposed to
root
. That you were meant to take them if you needed them and be okay with it.

But I couldn’t help it. I wanted to stop if I could. And I had beliefs about why this time might be different. For the first time in years, I had moved to a city that I didn’t have any immediate plans to leave. (I added it up and realized that I’d changed addresses twelve times since the end of college.) I had a full-time job, a regular schedule, and a roommate who was also a good friend. There were no big changes looming. All the previous times I’d quit, I realized, I’d done it before a major transition, and I wanted to test my theory that timing might have accounted for some or all of the failure. Finally, I had my new attitude. I was taking it slowly, almost comically slowly. I told myself that this was just an experiment. If I started to feel bad, I would go back up on the dosage—and it wouldn’t be an all-time thing, just a hint that now wasn’t the right moment. It didn’t have to succeed. But I was also hoping, quietly hoping, that it would.

WITH GUIDANCE OR
without, rashly or at a snail’s pace, people do discontinue antidepressants, of course. During interviews for this book, I talked to ten people who described stopping antidepressants after spending a significant amount of time on them. They named a few major reasons for their decisions. Some felt that medication never worked well for them; they belonged to the 30 percent or more of people who either don’t obtain significant relief from antidepressants, or develop side effects so intolerable that they can’t continue. Some people, like Dana, cited the fear of unforeseen physical consequences of using antidepressants long-term as a major factor. At twenty-nine, Dana had been on Wellbutrin for about eight years continuously, and on other antidepressants on and off for another seven years before that. “I was having some concerns about long-term effects,” she said, “like a little bit of anxiety about what are these pills maybe doing to my brain in a long-term way.” Also, she added,

I was growing increasingly dubious about my need to be medicated in such a consistent manner. I didn’t want to take them if I didn’t need them. And I knew that I wouldn’t ever know if I needed them if I didn’t try to kind of set myself up for success by being thoughtful about it, and come off them, and see.

—Dana, age thirty-one

Dana wasn’t the only person who mentioned the fear of possible physical or psychological effects of staying on antidepressants for years. Are these worries founded? It’s an interesting question. The SSRIs have been around for a quarter century now, and reports of serious cognitive or physical effects from extended use have yet to emerge. At the same time, no truly long-term studies have examined either the effectiveness of antidepressants beyond a few years, or systematically tested for long-term side effects. This lack of research largely reflects the fact that most studies of pharmaceuticals are driven by the FDA approval process, which requires that new drugs be shown to be clinically effective and not acutely toxic for a finite period of time, often in the range of weeks or months; there’s no regulation that would require drug makers to test for side effects emerging years later. “Most of the data suggest that the adverse effects that happen with antidepressants happen relatively soon,” said David Kupfer, a research psychiatrist at the University of Pittsburgh, who added that there is no evidence of harm from lengthy use of SSRIs. Still, questions like “Does this medication change my brain in a permanent way?” are questions that we don’t yet have the definitive knowledge to answer.