Carl Elliott - Medicate Your Dissent

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http://www.tc.umn.edu/~ellio023/medicate.htm

Note: This article originally appeared in Speakeasy Magazine.

Medicate Your Dissent

By Carl Elliott

In Don 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 antianxiety 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, GlaxoKline 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. Nixon proclaimed that Americans

were looking for " happiness in a tablet. " When Senator Gaylord 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 s, is a former vice president of

Eli Lilly, and Secretary of Defense 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 Fonda and Dennis Hopper in Easy Rider, Muhammad Ali resisting

the draft, Tommy and 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 Mc. 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 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 , 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 Mc 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 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 Percy understood this back in 1970. The hero

of Percy's satire Love in the Ruins, 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 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.

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