Journalists love declaring that psychiatric medications symbolize some slice of the zeitgeist. So I can't say I was entirely surprised when I opened my mailbox the other day and saw New York magazine's cover article proclaiming that "If the 90s were the decade of Prozac, all hollow-eyed and depressed, then this is the era of Xanax, all jumpy and edgy and short of breath."
Translation: Depression is out, anxiety is in, antidepressants are passé (Statistics showing continued robust usage be damned) and anti-anxiety benzodiazepines, around since the 60s, are trendy again, the perfect no-commitment chill pills for a nation of "panicked strivers" contending with a new age of anxiety but without time or inclination to commit to actually changing their lives or going to therapy.
How convenient, I thought. My psychiatric problems -- and corresponding psychopharmaceuticals -- match up with the trends! First I was depressed and angsty and got Prozac, then I got anxious and got benzos! Of course, I happen to be getting depressed again lately, but one can't be completely on-trend all the time.
In fact, if you didn't know me better, you might well mistake me for one of the "functionally anxious" types who dominate journalist Lisa Miller's New York story, rather than the sort of person she quickly shuffles off into another category altogether -- the people with an actual, you know, anxiety disorder.
The people without anxiety disorders who do populate the New York piece are the sort most of us love to hate, but also can't resist reading about in these sorts of articles: Manhattanite professionals who in the Annie Hall era would have been called "neurotic" but who now like to describe themselves as "super stressed," like it's a badge of honor.
According to the article, they're turning more often these days to drugs like Xanax or Ativan when anxiety from their legitimately high-pressure lives gets to be too much. Prescriptions of these drugs, collectively referred to as benzodiazepines, are up 17 percent since 2006. The article does not mention that prescriptions for other psychiatric medications have increased, too -- antidepressant use in adults grew nearly 30 percent between 2001 and 2010 at Medco, one of the nation's largest pharmacy systems, and atypical antipsychotic usage grew a staggering 350 percent. Writing the New York article with a different thesis in mind, one could contend that we're all demoralized over the stalled economic recovery and turning to antidepressants -- or that we're frustrated and adding antipsychotics to our antidepressant regimens to give them a boost.
But back to benzos and anxiety.
The article makes it sound as though it's terribly easy to distinguish between the ordinary, high-functioning people who turn to benzos every so often when the stress of their lives overwhelms them and the people with diagnosed anxiety disorders. In fact, it can be quite complicated -- and that's why psychiatrists are fighting so bitterly over the definitions of the various disorders to be included in the DSM-5, the profession's diagnostic manual, which is under revision and due out in May 2013.
Doctors are curiously absent from the New York piece, though they are, of course, the ones responsible for actually doling out the prescriptions for benzos and all other drugs. They are quite rightly very concerned about how to determine which anxiety is pathological and overwhelming and warrants such a drug, and which kind might be better dealt with through other means.
This is a subject that has been troubling the medical profession for decades, In the 70s and 80s, benzodiazepine misuse became enough of a public health problem to prompt doctors to cut down on prescribing -- and publish a lot of anguished articles on the subject in medical journals. Some of the increase in use the New York article discusses may even reflects a recent return a shift in doctors' attitudes to more comfort prescribing the drugs after years of shying away from them. (Recent articles in trade publications have made a case for their judicious use.)
All this difficulty distinguishing the casual users from the truly stricken lies in the nature of the conditions for which benzos are typically prescribed. Although sometimes given in high doses as sedatives to seriously agitated patients in psychiatric hospital settings, they are more commonly given to people whose anxiety is self-described and not necessarily readily observable to the doctor. This is true even when we are talking about anxiety of the sort that impairs people's day-to-day functioning, as opposed to the kind Miller focuses on in her New York article, which we might call the "just as easily dispatched with a glass of wine variety."
Anxiety is a funny thing, because although it seems the most all-consuming and obvious thing in the world when you are experiencing it, in fact it's actually quite difficult to detect. When I've been at my most anxious, I suspect that I've struck my psychiatrists and therapists as, at most, a bit agitated. Perhaps they've noticed some circles under my eyes, or that I look a little thin. Conceivably, I would talk a little faster than usual, or my eyes would dart around the room. But they have told me that, frankly, I don't seem all that different. I put on a good façade of normality.
In contrast, here is what I do experience: When I arrive at the psychiatrist for a "med check," I won't have slept a solid eight hours in weeks. I will have awoken early every morning with a jolt, my heart racing at some threat I can't place. It will continue that way all day until I go to bed. My stomach will churn and the room will spin and I'll be unable to eat. My thoughts will race from one unarticulated worry to another. I will feel desperate for companionship yet unable to listen or focus on conversation. I will feel constantly on the verge of tears. But I would have to tell my doctor all of this. She is not likely to go offering me a benzodiazepine prescription on the basis of some dark circles and a little hurried speech.
Once procured, such a prescription usually works magic, however. During the three periods of sustained anxiety I've suffered, I have taken a small dose of Klonopin, a long-lasting benzo, every few hours, as a way of keeping a steady level in my system. I've also taken it many other times when I've felt my anxiety flare on isolated occasions.
Despite the drug's effectiveness -- or perhaps because of it -- I never feel good about taking it. When my anxiety is pervasive, I need to constantly watch for a resurgence of panic. This makes me feel dependent, like a drug addict eyeing the clock for my next hit. When my anxiety returns in isolated episodes, I wonder if I'm simply the equivalent of the functionally anxious people in the New York article -- someone who happens to have a Klonopin prescription but who really doesn't need to be taking it and could just as well go to a yoga class. I tend to feel guilty about it until I get the telltale early morning waking -- and then I start to worry that I'm entering another terrible extended anxious phase.
The other reason articles like the one in New York make me cringe is that benzos, being controlled substances, already carry the taint of misuse, and talk of overworked PR execs popping pills to deal with anxiety over a work presentation or helicopter moms doing so to handle separation anxiety from their preschoolers is likely to make doctors, already cagey about prescribing, even more so.
Even for those of us with an anxiety disorder diagnosis and a history of benzo prescriptions, there's already an awkward dance involved in procuring a refill. Since benzos are controlled substances, doctors can't call in prescriptions (and may not have emergency appointments available to hand over the precious slip of paper). Anxiety, however, has a tendency to spiral -- and quickly. Many people find it useful, therefore, to have a bottle around in case of an emergency. But that means requesting a refill when you are not, technically, quaking under the covers in a fetal position.
Some doctors are sensitive enough to realize this, but, wanting to avoid tolerance and misuse, the responsible ones generally don't go around offering up refills out of the blue. For many people, especially young people in their 20s and 30s, who happen to be the group most likely to abuse psychotherapeutic prescription drugs according to federal government statistics, this makes asking for refills a delicate and awkward affair. I'm sure that my requests, for example, are accompanied by far too much justifying. One young woman I interviewed for my book on the topic of growing up on psychiatric medication suffered from debilitating anxiety and was so terrified of being judged an addict (she had a family history of alcohol abuse) that she refused to ask for benzo refills at all. This, even though it was patently obvious from the most casual encounter with her that some benzos would have done her good.
After my last psychiatrist's appointment, during which my doctor upped the dosage of my antidepressant to deal with a creeping recurrence of my depression, she ended the appointment by asking what I was doing for the rest of the day. I told her I was working on a column responding to the apparent news that benzodiazepines were the hot new drugs. She rolled her eyes as though this were the height of ridiculousness. "Benzodiazepines are the hot new drugs? Since when?" She did not ask if I would like a refill on my Klonopin.
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