Bringing Up Girls
A few months ago, a 17-year-old girl I know went to her family doctor in Eugene for a routine physical exam. Her anxious feelings about leaving home were compounded by the recent death of a family member, so in filling out the questionnaire at the doctor's office -- where everything from constipation to cancer is a yes or no question -- Nina marked "yes" next to chronic anxiety. After the examination, the nurse practitioner, who did not know Nina's medical or mental health history, asked if she wanted a prescription "for the anxiety." Nina was shocked by the practitioner's casual suggestion and refused the drugs. Telling me about it later, she added that most of her girlfriends were taking some kind of anti-depressants, and that during her first week at college she'd met several girls who were taking Prozac.Nina's experience is commonplace. In 1996, 600,000 children and adolescents in the U.S. were prescribed Prozac, Zoloft or Paxil, trade names for the current generation of anti-depressants. While this number of prescriptions represents, for Prozac alone, a 46 percent increase over 1995 prescriptions written for 13-to 18-year-old adolescents, it is a soaring 298 percent increase in prescriptions written for children ages 8 to 12.Yet, neither Prozac nor the other drugs have been approved by the FDA for adolescents and children, whose minds and bodies are still in the process of developing. Though Eli Lilly & Co., the makers of Prozac, have recently submitted data to the FDA on trial studies done on youth, Eli Lilly spokesperson Steven M. Paul says the drug will not be approved for children or adolescents any time soon. Eli Lilly's webpage for Prozac says in bold print, "Prozac is a treatment for depression in adults. The safety and effectiveness of Prozac in children have not been established."The vast increase in the use of anti-depressants for young women raises troubling questions. Why are so many being prescribed a drug that hasn't been deemed safe for them? Has this society let anti-depressants become a widespread solution not only to emotional difficulties, but to any emotional response to life?When I was a teenager, around 1970, two women involved in the women's liberation movement spoke at my school about sex role stereotyping. I couldn't relate to what they said. At 15, I already knew I wasn't going to be relegated to the kitchen and laundry like my mother, but this awareness didn't have anything to do with feminism. In my mind, I was a free person to do whatever I wanted. I didn't need a movement.But not long after this I read an article in a feminist journal that changed my attitude. The story was critical of prescribing the tranquilizers Valium and Librium, often referred to as "mother's little helpers," to a burgeoning number of housewives to cope with the anxiety and depression in their lives.This criticism struck home. My mother, seeking help with long-term unhappiness, had recently gone to a psychiatrist. He had listened to her cry, asked her a few questions, then prescribed an anti-depressant, Elavil. The doctor didn't even set up another appointment. To me, this "solution" to my mother's unhappiness communicated despair and hopelessness. By not investigating her situation, the doctor was essentially telling my mother that her life was not worth examining and that there was no hope of making any changes.I didn't accept that message then, and I don't now. When our society sanctions doctors prescribing mind-altering drugs in large numbers to depressed women, whether they are adults or teenagers, we are giving the message that personal and social conditions cannot change, that the best women can do is cope.Preferred treatments by mental health professionals have shifted over the years, spurred by social and political conditions as well as changing hypotheses about how the mind and body work. Currently, the majority of mental health professionals are focused on brain chemistry as the source of emotional and mental troubles -- and they've focused on one chemical in particular: serotonin. For more than 50 years, researchers have been investigating the complex physical and emotional role of serotonin, one of many neurotransmitters -- chemical messengers -- in our brain that seem to affect our moods.The hallucinogens LSD, mescaline, psilocybin, ecstasy and Elavil (my mother's anti-depressant) are all serotonin-related drugs. So is the recently recalled (because 30 percent or more of its users could develop abnormalities in their heart valves) diet drug Redux (fenfluramine, or fen fen). Prozac, Zoloft and Paxil are called "selective serotonin re-uptake inhibitors" (SSRIs) because they act to keep more of the already present serotonin active in the brain synapses for a longer period of time. Using SSRIs as anti-depressants is based on the theory that sluggish or low levels of serotonin in the brain is a cause of impulsive behavior, depression, violence and suicide.Many people who take anti-depressants are pleased with the results. Some would swear the drugs saved their lives. This does not, however, negate the fact that researchers have yet to comprehend fully the body's complex system of neurotransmitters.Currently, Prozac and the other SSRIs are prescribed for, among other conditions, anorexia, bulimia, anxiety and panic disorders, obsessive-compulsive disorder, child and adolescent emotional and behavioral problems, depression, pms, chronic fatigue syndrome, phobias and seasonal affective disorder.Curiously, most of these conditions are diagnosed most often in women and girls. The makers of Prozac have emphasized Prozac is for "clinical depression," and not, as their advertising seems to imply, to improve personalities or relieve the everyday stresses of living.But a report in the April 1996 issue of Professional Psychology, Research and Practice (PPRP) summarizing all research on SSRIs up to that date, indicates the drugs have failed to "demonstrate greater efficacy than placebo in alleviating depressive symptoms in children and adolescents, despite the use of research strategies designed to give anti-depressants an advantage over placebo."And yet, the number of prescriptions for adolescents and children is steadily rising. Prescriptions for girls make up the large majority, and with recent studies on the use of SSRIs for pms and eating disorders, more girls will be given prescriptions.To help me understand this trend from a more personal point of view, I spoke to a number of young women in Eugene who were prescribed the new anti-depressants. Sasha, a 17-year-old girl who has been depressed on and off since she was 13, tells me that during her first session with a new therapist she was told that a healthy brain makes and circulates good chemicals, but a depressed brain means that circuit is interrupted. "What the Prozac does," she was told, "is bridge that gap."Essentially, after just one session, Sasha heard there was something wrong with the way her brain works. Still, she says she's relieved to be diagnosed with clinical depression because it gives her hope she can get better. She likes taking Prozac, she says, because it gives her more energy. Her complaint is that she doesn't feel comfortable expressing her feelings to her therapist."When I start to get a little bit more depressed, she ups the dosage," Sasha says. "I'm not dealing with anything in therapy, but I'm talking to my friends more. I think taking Prozac has been the right thing for me, but I still have a lot of work to do."In fact, none of the 10 girls I interviewed were actually in a productive therapeutic relationship while they were taking anti-depressants. Most of the prescriptions had been written by a family doctor or by psychiatrists to whom their parent(s) took them with one purpose: to get them on anti-depressants. What is even more striking is that most of the girls did not initially want to take anti-depressants.One young woman, "Teresa," was prescribed Prozac after being hospitalized because she had overdosed on Tylenol and sleeping pills. "They insisted I was anorexic or bulimic and I wasn't either," Teresa says. "Their 'treatment' consisted of not letting me into the bathroom and prescribing Prozac. I was really depressed, but I don't think Prozac was the answer. I needed more than just something that was going to change my brain."Eighteen-year-old Sandra had abused drugs and alcohol in her early teens, but had been clean and sober for more than two years when she went to see a therapist to help her through what she thought was seasonal depression. After one session, the therapist suggested she see a doctor about anti-depressants, but Sandra felt uncomfortable about putting drugs back into her body. Instead, she found another therapist who helped her stay on a program of meditation, exercise and good food. She is now doing well -- taking a full load in school while continuing to see her therapist.In some cases, ambivalence about taking anti-depressants led to irregular use and wild experimentation. Carey, who I spoke to at a drug and alcohol recovery program, says she was prescribed Paxil by her family doctor, but wasn't sure she wanted to take it. Sometimes she just wouldn't. Once she swallowed 10 pills at one time "just to see what it would be like."Another girl said she felt sick if she took Zoloft and then consumed alcohol, so if she wanted to go out drinking she'd just throw the pills under the bed. I also heard reports of girls snorting Prozac, "sharing" pills with friends and selling the pills on the street.Even though Lucy Zammarelli, program manager for Project START, a local drug and alcohol recovery program for teenage girls, knows her clients abuse drugs -- whether those drugs are legal or illegal -- she favors using SSRIs in the recovery process because they help make her clients feel better, she says."Even outside the brain chemistry, there is an emotional sadness in the girls we see in recovery," she says. "Many of the girls have been sexually or physically abused, but even for the ones who haven't, most don't have fathers or any caring man in their lives. Relationships with their mothers are strained. They have a yearning for the wonderful TV family. They've lived in poverty and we know that poverty is one of the premier precedents for depression."These girls start by drinking and/or smoking marijuana or using meth to make themselves feel good. "Then we say your life is a mess, you've got to stop using. So they go into the deep depression that goes with withdrawal and detoxing," says Zammarelli. Most of the girls start to feel better after a few weeks of being off drugs and alcohol, she says, adding that only 10-15 percent of the girls are recommended for anti-depressants. Those clients, she says, "tend to do better than the ones not on anti-depressants" in terms of staying in recovery and getting on with their lives."Even after they are clean, the sadness is still there, the craving, and the desire to drink is still there," says Zammarelli. "They still don't have resources in their family, their moms still really aren't there for them. So we tell them, 'Well here's something that you can take. It's going to help your brain feel better.' They try it and they can smile, they can laugh, they can have fun. It's so sad when the girls are depressed. I mean, it breaks your heart."Other mental health professionals also see the new generation of anti-depressants as beneficial. Betty Merten, a Eugene therapist who specializes in depression, estimates that one-third of the girls who come to her are already using anti-depressants. After getting a full picture of her clients' lives and making diagnoses, Merten says, she recommends to another third that they should start taking the drugs."Depression can happen when a series of things finally deplete a person's resources," Marten says. Most people can get well without anti-depressants, she admits, "but adolescence is such a critical time, I'm for using all the tools that are available."Merten and Zammerelli's views assume that these anti-depressants are essentially innocuous; that if they don't help the girls, at least they don't hurt them. However, there is much evidence to cast doubt on that belief.Several of the girls I talked to experienced unwanted effects from the anti-depressants. Many felt anxious and had trouble sleeping, and were then prescribed something to help them sleep. Some had a loss of appetite.Teresa describes the most seriously negative effects from Prozac: "It really heightened my emotions and my biggest emotion right then was anger. So it made my anger so much worse. I'd run around the house screaming. I couldn't control my emotions. I would yell at people for no reason. Finally, I tried to kill myself again by taking all the Prozac and whatever else I could find."According to research, Teresa's reactions to Prozac are not unusual. One published study specifically designed to investigate side effects of Prozac in youth 8-16 years old showed that 50 percent of the participants exhibited two or more of the behavioral side effects described as "motor restlessness," "sleep disturbance," social disinhibition" and "subjective sensation of excitation." In a study of children diagnosed with obsessive-compulsive disorder, 14 percent developed self-destructive phenomena associated with being treated with Prozac. Serotonin's action in the body is not limited to the brain, but affects the entire central nervous system and blood vessels in the lungs and heart. Though there are significant differences between the weight-loss drug Redux, which was recalled just 18 months after it received FDA approval, and SSRI anti-depressants, the Redux experience ought to add at least a note of caution to the assumption of harmlessness.Nor should we forget women's experience with another of Eli Lilly's infamous "wonder drugs," DES. Between 1947 and 1971, five million women in the U.S. were prescribed the synthetic hormone diethylstilbestrol to prevent miscarriage and to ensure healthy pregnancies. However, research as early as the '50s showed DES not only ineffective in preventing miscarriage, but shown to cause cancer and deformed reproductive organs in rats and mice. Though the FDA issued a warning in 1971 against pregnant women taking DES, and thousands of daughters born to women who took DES developed an often fatal vaginal cancer, Eli Lilly has never publicly admitted any problem with the drug. They have, however, settled many lawsuits out of court.Clearly, neither Eli Lilly nor the FDA can be trusted to ensure Prozac's safety. According to a January 1996 interview with Peter Breggin, medical doctor and author of Talking Back to Prozac, "there are about 160 suits out against Eli Lilly, for people who either committed murder or suicide or mutilated themselves or done something horribly violent on Prozac."Another danger is that the prescription will be seen as a quick fix, or as an end in itself. Although every professional I talked to stressed the vital nature of continuing therapy whenever an anti-depressant in prescribed, there were vast differences among therapists in their use of the drugs with their patients.For instance, Eugene psychologist Mitch Schwartz says that in his years of practice, he's never referred an adolescent client for medication. If a client's depression hasn't lifted after several months of therapy, he says, he would consider an anti-depressant. But only as a last resort. "If someone is depressed, I try to find out why they are not enjoying life," he says. "Then we work cognitively. What are the person's assumptions and beliefs about the world? What are her self-talk tapes? The idea is to take perspective on one's own thinking."Therapist Jon Garlinghouse, whose specialty is suicide prevention, also isn't satisfied with the medical approach to relieving depression, but he's glad it's there. "I use it as a backup all the time. I'm absolutely certain it saves lives," he says. "But as a singular approach or solution to depression without any analysis of what is driving the depression in a person's history, it's nuts. You need an integrated approach where somebody asks certain questions, and knows how to ask the questions."Whatever people say about psychiatric medication as an intervention," Garlinghouse emphasizes, "it is a profound thing to do to your body. There are times when that is exactly what is needed to keep a person alive." Still, Garlinghouse says, he would only recommend anti-depressants if he felt it was dangerous not to. If it's possible though, he would "rather take the time to do the education, put the connections together to see what a person can do on their own."Schwartz and Garlinghouse's approaches are supported in the April 1996 PPRP article. The authors of the study, University of Montana psychologists John and Rita Sommers-Flanagan, recommend that psychologists seeing adolescents should find all the following criteria before referring youth for medical consultation: the absence of clear environmental determinants (e.g., family conflict, divorce, etc.); severe depressive symptoms with strong physiological components (e.g., sleep disturbance, somatic complaints, appetite changes and associated weight loss or gain); treatment response is lacking after 10 to 15 therapy sessions; and the patient expresses a clear preference for medication over psychological interventions.But a huge difficulty for girls and their families in this era of managed care is the time this kind of therapeutic approach takes. Managed care health insurance simply will not pay for the "long haul" therapy needed to get to the bottom of serious depression. Schwartz and Garlinghouse's approaches, far from quick fixes, would probably not be covered by most medical plans or HMOs. In fact, HMOs may be heading in the opposite direction by recommending that customers start taking anti-depressants in order to cut health care costs.According to a recent story in Fortune magazine, at least one HMO recently decided to cut costs by identifying customers they think might benefit from mood-elevating drugs. Lovelace Health Systems, based in Albuquerque, New Mexico, speculated that heavy users of medical services may suffer more from mental distress than physical. If a person has been admitted to a hospital or used an emergency room three times in a year, or is taking seven or more medications, or has run up over $25,000 in medical bills in one year, Lovelace sends out a psychological survey of 20 questions. Based on the individual's answers, Lovelace may refer that person to a doctor, who generally prescribes a combination of counseling and Prozac.According to Lovelace's own report, the program has already yielded results: The medical expenses of 2,079 patients who started taking SSRIs at the suggestion of Lovelace were $2.1 million lower than in the previous year. The story concludes that "Prozac and its sibling drugs could be an important remedy for rising health care costs."Though most of the girls I talked to were prescribed anti-depressants after one or two sessions with a therapist, every therapist I talked to, including some who regularly recommend anti-depressants to clients, said they thought that psychotherapy alone was "equally effective" in the vast majority of clients, and more effective for the long term.Zammarelli of Project START said she thought that eating healthy food, getting exercise, a weekly massage and acupuncture treatments would be as effective in improving girls' depression as the pills. "But none of these are paid for by available health plans," she says.My mother's situation had two important elements in common with many other women of her time, and unfortunately of ours: When she turned to the mental health system for help, she was given the message that her individual thoughts and feelings were of no interest or importance, and the only "aid" available was to alter her body chemistry so that she could cope.Now, in the 1990s, pharmaceutical solutions, rather than looking at real issues, are still the way women are encouraged to cope with our lives. We're told that the new generation of anti-depressants are "feminist" drugs because, according to Peter Kramer in his best-selling book, Listening to Prozac, they get women out of the house and into the workplace. But being drugged into being "happy" cannot be an answer. Are adolescent girls who are anxious, sad or angry being prescribed the new drugs because adults want a shortcut to making these young women happy, satisfied and calm?A generation ago, the over-prescribing of Valium and Librium helped spark radical thinking about the extent society was willing to go to keep from listening to, much less doing anything about, women's concerns. It is time for a similar analysis to be done in response to the massive increase in the prescribing of anti-depressants to adolescent girls.Letting girls speak their hearts and minds, and listening to them, is certainly one place adults can start. Teresa told me, "I'm not on Prozac or anything right now. I started going to a therapist and I really love her. She was different because she listened to me, she was understanding and a really thoughtful person."Of course, it's not just therapists who need to be listening. We as a society have been resistant to hearing girls when they try to tell us, or show us through their desperate actions, how they feel about the world they are growing into. Is it because if we did we would feel compelled to do something about the conditions that contribute to their depression? Beyond listening, what are we willing to do to honor the lives of girls?