Listening to Paxil

Seven millions Americans suffering from depression were prescribed antidepressants last year. Yes, they wanted to raise their serotonin levels, but, more important, they wanted to improve their mood.

Here's the story of one man's quest for happiness.

Harry's Bar

I realized it was too early—not in the day but in the century—to go down to Harry's for a serotonin cocktail, ice and a dash of bitters, please, to match my cold and melancholic mood. "Transmission fluids low," I'd explain, meaning that the spaces between nerve cells in parts of my brain weren't sufficiently lubricated with serotonin for certain messages to slide through.

But my imaginary bartender wouldn't require an explanation. He would just need to look and listen to me: my eyes vacant and unrefreshed by a good night's REM sleep; face set in a fierce grimace, like one of those Chinese opera masks; voice strained; and remarks—when I bothered or managed to articulate them—caustic, vituperative, and gloomy.

The gloom? Someone on the radio said there was nothing wrong with middle-age, except the age that follows it. Alleviated by a course of Prozac several years ago, my depression had now wormed its way back. But today I was older. Late middle age, I guess, is my new seniority category, although it, too, is creeping ahead. As a result, I can now number among the usual depression-causing suspects a new one—the approach of old age. It wasn't the fear of dying. It was wondering if I could afford to live to be elderly. What, in short, was the cost/benefit ratio of such prolongation? Harry the Wise would point out that by posing this purportedly economic question, I was really intellectualizing a suicidal impulse.

Harry knew another thing about me, that I'd suffered a heart attack five years ago. That explained why over the last year I drank a couple of glasses of red Bordeaux daily, believing devoutly the findings of French researchers that such a regimen reduces the risk of another attack. Never a quantifier, I paid scant attention to dosage. Two glasses became three, and so on. The more Bordeaux, the better for the heart, no? Wrong, other scientists said, for the heart as well as the liver and brain. But I denied it. In any case, as my "cardiac therapy" addiction grew, the depression recurred, pickled in wine like one of those dead worms in a tequila bottle, but suddenly revivified.

The Screening Process

In reality, Harry's Bar turned out to be a depression outpatient clinic in a prestigious university hospital. Given one of my old/new symptoms, low self-esteem, I doubted I'd get accepted into the program, which I knew was topflight and free of charge.

On the long subway ride to the screening session, I felt as tense as a high school junior hoping to get into a good college but fearing he wouldn't do well on the SATs. So I crammed on the train, trying to recall every symptom that might qualify me as a true depressive—anxiety, insomnia, agoraphobia, careless grooming, apathy, dwelling on the past, the whole kit and caboodle. The only thing that made me feel less isolated was noticing that everyone else on the train seemed depressed as hell. I spotted a few good downcast looks and practiced them as we rode along, hope rising that I would overwhelm my interviewers with the legitimacy of my affliction.

I was right about the SATs, or DATs as I now call them—Depression Aptitude Tests. First I saw a social worker who was also a trained psychotherapist, then a psychiatrist of the pharmacological persuasion. They asked similar questions. Did my moods swing (Not widely), how much did I drink (Too much, probably), had I ever attempted suicide (If so, not successfully), did I experience blackouts (Once, at a hell of a party in Madrid), did I go on wild spending sprees (With what?), do I ever think someone's after me (The IRS, every April), do I wash my hands all the time (Only in the morning and after I've gone to the bathroom), do I often feel blue (Night and day), how's my libido (On vacation), and more of the same. Afterward, the interviewers were noncommittal.

The written test followed the orals, a questionnaire maybe 200 pages long, true and false and yes and no. Many of the questions appeared the same as those on the orals, but others seemed intended to search for applicants with mental problems of a different stripe. Do you ever think you're God? Ever hear voices telling you to do bad things? Do you sometimes think you're invisible? Do you wipe doorknobs all the time because you think they're covered with germs? Have you ever been abducted by aliens from another planet?

The only truly difficult question came around number 600: How often did you lie on the previous questions?

After I surrendered a urine sample and underwent a quickie physical exam (including an EKG), I was ushered back to the psychiatrist's office. Let's call him Dr. Fontana, and the social worker Mr. Whiteside.

"Congratulations," offered Dr. Fontana, "You've been accepted." In lieu of a certificate of admission, I was given a consent form to sign, a copy of which I have since framed and hung in my study. Then Dr. Fontana escorted me to the dispensary where an extremely attractive nurse handed me a vial of Paxil. "One a day," she said radiantly, "with food. See you in a week."

I found myself depressed on the way home. What if I wasn't a "good responder?" Or—though I knew they were rare with Paxil—I suffered some ghastly side effects: nausea, headaches, or even greater sexual dysfunction? I tried to smile at my reflection in the train window, cheer myself up, but I didn't look at all convincing. Why wasn't I even a little happy, now that I was back at Harry's Bar, so to speak?

WEEK ONE

On the first day I found myself on high alert, waiting to catch an early hint of liberation. But nothing happened. I went about my business but accomplished little, except knowing exactly what time it was by glancing at the kitchen clock every few minutes, impatient. I held myself to two glasses of wine. (No one said I couldn't drink.)

By day three, the fog still hadn't lifted so I decided to look again at the book that started the craze for mood-altering antidepressants, Peter Kramer's Listening to Prozac. I wanted to refresh myself on how antidepressants work, which might come in handy in the unlikely event of my going to a party I suspected many of my peers took one or another of these drugs and, if they were open about it, we'd have something to talk about, perhaps even compare how swell we felt. The assumption, of course, was that by the time I went to a party I would feel swell, an assumption I still regarded as shaky.

I knew Paxil and Zoloft were developed after Prozac, and that their manufacturers claimed they kicked in faster than their predecessor, kicked out faster, and produced slightly fewer side effects. Fundamentally, however, they worked alike. They inhibited brain cells along certain neural pathways from reabsorbing or reuptaking serotonin. Hence the acronym SRI—Serotonin Reuptake Inhibitor. After many years of research on animals and people, it was discovered that subjects who were depressed, bulimic, or otherwise mentally hurting or down on the social totem pole showed low levels of serotonin. Conversely, those who were extremely functional and cheerful and enjoyed good social status tended to show high levels. Dominant males in monkey troops, for example, brimmed with the stuff, while peripheral males suffered a dearth of it.

The rule is that you can't just inject serotonin into the brain. It's technically impossible. So much for my serotonin cocktail idea. But certain drugs slow or even halt the rate at which transmitter cells—presumably in the interest of conservation—reclaim the neural lubricant they had formerly released into the gaps, or synapses, between transmitter and receptor cells. The serotonin, as a result, lingers in the synapses longer, producing in most humans dramatic changes—positive ones, not only in neural functions like memory and concentration but in personality as well. The dour become sunny. The shy, gregarious. The timid, more assertive. According to Kramer, these are profound and often permanent transformations.

I put the book down, nostalgically recalling how terrific I felt when, some years ago, I was a highly dominant male in a creative business. Where, oh, where has all my serotonin gone? Now I think I know. Either my transmitter cells aren't making enough of it, possibly because of their age and mine, or they are hoarding it for some strange, selfish reason, perhaps mistrusting what a generous infusion might do for me. I have read somewhere that, in a sense, cells have a mind of their own. Maybe mine are seared because of some traumas I went through. Lord knows I went through enough of them.

Alas, when I went for the first of my regular weekly sessions with Fontana and Whiteside, I did not arrive a-dance like Fred Astaire. Indeed, I felt rather leaden.

I replied tersely to questions about mood, sleep, eating, bowel movements, social and personal activities, weight, and alcohol consumption. And the libido one again. Whiteside wanted to know more about my personal history. Then he asked what my week had been like, overall.

"No Tabasco," I replied with a shrug.

Fontana told me to hang in there, that the drugs kick in at different times in different people.

WEEK TWO

I got up a little earlier the first day, stopped watching the clock so much, and bitched about the cold weather. Spring had been stubbornly slow in coming so I spent some time starting seeds indoors—cosmos, morning glories, sweet alyssum, a few others.

On the second night, Betty and I made love. It wasn't perfect but, hey, it was love. I vowed to try it again sometime soon, and could barely wait for Fontana to ask his libido question on Friday. Betty and I drank a few glasses of red Bordeaux afterward, a small celebration. We had been living together for two years and the last year had been pretty meager in the sex area.

After closely trimming my beard Tuesday morning, I walked to the barber shop for a haircut. Tuesdays seniors get a discount. When I got in the chair, Tony asked the usual question: "How you like me to cut it?" The place was quiet, though all the chairs were full. All you could hear were the snip of scissors, the buzz of electric razors, and a Frank Sinatra tune coming from Tony's little cassette player.

Usually I tell him regular on the sides, short on top, keep the back low. But this time something else came out, not privately, the way one usually confers with one's barber, but in full voice.

"Tony," I announced, "I want you to cut it so that it's perfect on Friday—Not when I walk out of here today, but on Friday."

Everyone hooted, barbers and customers. Maybe it wasn't all that funny, but I'd ventured a joke of a sort, and it worked. I felt good about it. I realized it had been a long time since I'd laughed, even if it was at my own joke.

On entering Whiteside's office on Friday, I asked him how his week had gone and how he was feeling.

"Fine, fine," he replied, almost stammering. Then he got it, my little role-reversal prank.

I reported that my week seemed to pass quickly, that I had stayed away from alcohol three days running and got a kick out of getting my hair cut. No, I didn't feel all that great, but not that bad, either. Kind of neutral.

"Weight?" asked Fontana as he went down the standard checklist, more like an accountant than a psychiatrist.

"Down a couple of pounds."

"During the week, did you ever think you were someplace else or were someone else?"

"Yes," I answered. He looked up, surprised.

"On Wednesday, I spent 10 bucks on the lottery," I explained. "For about a half hour, I had a nice fantasy about winning it and living in Tahiti."

"Oh," he replied, turning back to his list. Then, when the session was over, he told me he was doubling my dose. It didn't matter to me that much.

WEEK THREE

Monday night my mother called from Florida. We chatted a bit about how all the relatives were doing, then she said I sounded different.

"What do you mean, different?"

"Just different." She didn't elaborate.

It came as a shock when, on Tuesday and Wednesday, I made terrific progress on a book I was working on, which had been stalled for weeks. Then, to wind down, I drank too much and got into an argument with Betty because she came home late from work. As a result, I woke up late Thursday morning, feeling miserable. Feeling, in fact, depressed. Had I blown it? Was the stuff not working?

To my great relief, the feeling didn't persist. By noon I was out in the garden transplanting the tiny sprouted morning glory seeds into window boxes.

Later that afternoon, I received from a friend a fax of a Wall Street Journal article. It reported that Prozac was now meeting stiff competition in the antidepressant market from its offspring, Zoloft and Paxil. That didn't surprise me nearly so much as the current size of the U.S. market—$3 billion was spent on these drugs in 1995. Evidently, I have a lot of cohorts out there. Perhaps I'm living on a frontier, after all, albeit a pharmacological one.

Before leaving for my session on Friday, I made a discouraging discovery. A squirrel had pillaged my sprouted morning glory seeds.

The tenor of my interview with Whiteside proved more relaxed than before, a wide-ranging conversation rather than the usual interrogation. He, too, had read the Journal article and we speculated both on the widespread occurrence of different types of depression, or mood disorder, and on the promise the SRI strategy held when applied to other neural pathways. Now researchers are homing in on dopamine, a brain chemical associated with schizophrenia, Parkinson's, motor control, and addiction.

For the first time, Whiteside told me I appeared to be a "good responder." I felt as though he'd given me a gold star.

Once again I surprised Fontana when he asked if I thought anyone was out to get me.

"Yes," I replied, "this goddamned squirrel."

I explained about the morning glory seeds and we continued with business as usual. "What do you expect to get out of this program?" he asked. "What do you really want to happen?"

"I want to smile again," I replied. It seemed to satisfy him.

WEEK FOUR

The first tangible physiological sign of Paxil's impact manifested itself over the weekend and held true the rest of the week. I slept far less but didn't wake up in the middle of the night, almost a lifelong annoyance. Obviously, my days became longer. They also became deeper and more expansive. I could now remember in detail everything that happened, and in the evening sat amazed at how much actually had. It was as though my life had suddenly doubled in volume.

Tuesday night, while straightening out the kitchen, Betty dropped the glass-and-pewter beer mug I had treasured for 40 years. The glass shattered, and Betty winced.

"Those things happen," I shrugged as I went for the broom.

"What?"

"Don't worry about it." I swept the shards into the dustpan.

She was speechless, and I knew why. I hadn't blown my top.

But on Wednesday, I hit a glitch. A panic attack, or so I thought. For some reason, I couldn't remember if I had taken my Paxil. If I hadn't, would I fall off the wagon? If I had and now took more, would I overdose? It took me about 30 seconds to resolve the dilemma by counting the pills in the vial. I had taken it. Tranquility returned. Later I recalled that Paxil is said to be highly effective in people who suffer panic attacks.

The end of my first 30 days on Paxil wasn't an ending at all but a continuation. I told Whiteside that Friday, He looked pleased with himself. I noticed his office no longer seemed as drab.

As for Fontana, I walked into his office and shook his hand. Not that there was anything specific to celebrate. I was just glad to see him. It was the first time I saw him smile.

I had no surprises for him this time, except, he pointed out, my eyes were sharply clear and I looked especially healthy.

He asked me how I felt about my life these days.

I pondered his question for a moment. I was far from a state of ecstacy. On the other hand, I had never before experienced such a sense of steadiness.

"It seems to me," I finally answered, "that I'm in some sweet middle. I mean, the past no longer hounds me, the future appears unfrightening, and my sweet alyssum are thriving. So are the cosmos."

I walked to the dispensary for my weekly pills looking forward to chatting it up with that stunning nurse.