Dopamine Nation

dysphoria.
Beyond the problem of addiction and the question of whether or not these
drugs help, I’ve been plagued by a deeper question: What if taking
psychotropic drugs is causing us to lose some essential aspect of our
humanity?
In 1993, the psychiatrist Dr. Peter Kramer published his groundbreaking
book Listening to Prozac, in which he argued that antidepressants make
people “better than well.” But what if Kramer got it wrong? What if instead
of making us better than well, psychotropic drugs make us other than well?
I’ve had many patients over the years who have told me that their
psychiatric medications, while offering short-term relief from painful
emotions, also limit their ability to experience the full range of emotions,
especially powerful emotions like grief and awe.
One patient who seemed to be doing well on antidepressants told me she
no longer cried at Olympics commercials. She laughed when she talked about
it, happily forfeiting the sentimental side of her personality for relief from
depression and anxiety. But when she couldn’t even cry at her own mother’s
funeral, the balance for her had tipped. She went off antidepressants and a
short time later experienced a wider emotional amplitude, including more
depression and anxiety. She decided the lows were worth it to feel human.
Another patient of mine who tapered off high-dose OxyContin, which she’d
taken for over a decade for chronic pain, came back to see me months later
with her husband. It was my first time meeting him. He’d tired of so many
doctors over so many years. “My wife on Oxy,” he said, “stopped listening to
music. Now off of that stuff she enjoys music again. For me it feels like I got
back the person I married.”
I’ve had my own experiences with psychotropic medication.

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Restless and irritable from childhood, I was, for my mother, a difficult
child to raise. She struggled to help me temper my moods and in the process
felt bad about herself as a parent, or at least that’s my interpretation of the
past. She admits she preferred my brother, docile and biddable. I preferred
him too, and he effectively raised me when my mother threw up her hands in
frustration.
In my twenties, I started on Prozac for chronic low-grade irritability and
anxiety diagnosed as “atypical depression.” I felt better right away. Mostly, I
stopped asking the big questions: What is our purpose? Do we have free
will? Why do we suffer? Is there a God? Instead, I just sort of got on with it.
Also, for the first time in my life, my mother and I got along. She found me
pleasant to be around, and I enjoyed being more pleasing. I fit her better.
When I went off Prozac some years later in anticipation of trying to get
pregnant, I reverted to my old self: cranky, questioning, restless. Almost
immediately, my mother and I were at odds again. The very air in the room
seemed to crackle when we were both in it.
Our relationship decades later is marginally better. We do best when we
interact least. This makes me sad because I love my mom and I know she
loves me.
But I don’t regret going off Prozac. My non-Prozac personality, although
not a good fit for my mom, has allowed me to do things I never would have
done otherwise.
Today, I’m finally okay with being a somewhat anxious, slightly depressed
skeptic. I’m a person who needs friction, a challenge, something to work for
or fight against. I won’t whittle myself down to fit the world. Should any of
us?
In medicating ourselves to adapt to the world, what kind of world are we
settling for? Under the guise of treating pain and mental illness, are we
rendering large segments of the population biochemically indifferent to
intolerable circumstance? Worse yet, have psychotropic medications become
a means of social control, especially of the poor, unemployed, and
disenfranchised?

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Psychiatric drugs are prescribed more often and in larger amounts to poor
people, especially poor children.
According to the 2011 data from the National Health Interview Survey of
the CDC’s National Center for Health Statistics, 7.5 percent of American
children between the ages of six and seventeen took a prescribed medication
for “emotional and behavioral difficulties.” Poor children were more likely
to take psychiatric medications than those not living in poverty (9.2 percent
versus 6.6 percent). Boys were more likely than girls to be medicated. Non-
Hispanic whites were more likely than people of color to be medicated.
Based on the extrapolation of Georgia Medicaid data to the rest of the
nation, as many as ten thousand toddlers may be receiving psychostimulant
medications like Ritalin.
As psychiatrist Ed Levin wrote regarding the problem of overdiagnosing
and overmedicating American youth, especially among the poor: “While a
tendency to rage must, as does all behavior, involve some biology, it may
more significantly reflect a patient’s reaction to adverse and inhumane
treatment.”
This phenomenon is not limited to the United States.
A nationwide study in Sweden analyzed rates of prescribing for different
psychiatric drugs, based on indices of what they called “neighborhood
deprivation” (index of education, income, unemployment, and welfare
assistance). For each class of psychiatric medication, they found prescribing
of psychiatric medications increased as the socioeconomic status of the
neighborhood fell. Their conclusion: “These findings suggest that
neighborhood deprivation is associated with psychiatric medication
prescription.”
Opioids too are disproportionately prescribed to the poor.
According to the US Department of Health and Human Services, “Poverty,
unemployment rates, and the employment-to-population ratio are highly
correlated with the prevalence of prescription opioids and with substance
use measures. On average, counties with worse economic prospects are more
likely to have higher rates of opioid prescriptions, opioid-related
hospitalizations, and drug overdose deaths.”

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Americans on Medicaid, federally funded health insurance for the poorest
and most vulnerable people, are prescribed opioid painkillers at twice the
rate of non-Medicaid patients. Medicaid patients die from opioids at three to
six times the rate of non-Medicaid patients.
Even medications like buprenorphine maintenance treatment (BMT), which
is what I was prescribing to Chris to treat opioid addiction, may constitute a
type of “clinical abandonment” when psychosocial determinants of health are
not likewise addressed. As Alexandrea Hatcher and her colleagues wrote in
the journal Substance Use and Misuse: “Without attention to the basic needs
of patients without race and class privilege, BMT, as medication alone,
rather than being liberatory, can turn into a form of institutional neglect and
even structural violence to the extent that it is considered adequate for their
recovery.”
—
The sci-fi movie Serenity (2005), directed by Joss Whedon, imagines a
future world in which national leaders conduct a grand experiment: They
inoculate an entire planet’s population against greed, sadness, anxiety, anger,
despair in hopes of achieving a civilization of peace and harmony.
Mal, a rogue pilot, the movie’s hero, and the captain of the spaceship
Serenity, travels with his crew to the planet to explore. Instead of finding
Shangri-La, he finds corpses without a ready explanation for their death. An
entire planet is dead in repose, lying in their beds, kicking back on their
couches, slumped at their desks. Mal and his crew eventually puzzle it out:
The genetic mutation deprived them of hunger for anything.
Like real-life dopamine-depleted rats who starve to death rather than
shuffle a few centimeters for food, these humans died for lack of desire.
—
Please don’t misunderstand me. These medications can be lifesaving tools
and I’m grateful to have them in clinical practice. But there is a cost to
medicating away every type of human suffering, and as we shall see, there is
an alternative path that might work better: embracing pain.

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