Can antidepressants help or hinder waking up?
One wintry day in the late sixties, when I should have been studying for finals at college, I took a bus 150 miles to a dowdy New York City hotel room to get my very own mantra from a pale young man with a vaguely Scandinavian accent. I remember how, in those heady days, it seemed not only possible but highly probable that the right mantra, koan, or guru could allow one to leapfrog easily over one’s neuroses and “hangups” (as they were then called) into nirvana—or something like it. After all, the Beatles had gone to India and we had seen Dr. Richard Alpert metamorphose into Ram Dass. Of course, spiritual practice turned out be a lot of long, hard work, and my neuroses are still pretty much intact.
These days, my ideas about how to improve myself might incline more toward medication than meditation. Might I be a better person on Prozac, the wish-fulfilling gem of the nineties? In a description that sounds a lot like New Age pitches for Eastern mysticism, psychiatrist Peter Kramer, the author of Listening to Prozac, writes, “Prozac has the power to transform the whole person—illness and temperament. When you take it, you risk widespread change.”
Of the fifty-million-odd Americans on Prozac or one of its cousins, a few thousand, let’s say, must be practicing Buddhists. That’s just a guess, but anyone in denial about Buddhists on Prozac would have been brought up short at the 1998 conference of the Institute for Meditation and Psychotherapy in Boston. There, a respected Zen teacher stood up and described his struggles with clinical depression, his unsuccessful attempts to dispel it with practice, and his eventual relief with a Prozac-type antidepressant. “When a Zen master says this at a conference, it’s a big shift,” says therapist Boston psychotherapist Philip Aranow, president of the Institute for Meditation and Psychotherapy. There are other dharma teachers who, like many practitioners, still relate to Prozac as a taboo and resist any public disclosure.
Ten years ago, or even five, a Buddhist student struggling with the symptoms of depression would most likely be prescribed more dharma. “You’d be told, 'You’re not practicing enough,’” recalls Curtis Steele, a psychiatrist in Halifax, Nova Scotia, who is a member of the Shambhala community. “I think that’s changing, although there are still born-again Buddhists who think meditation is the answer to everything.” Yet a drug such as Prozac poses a special problem for Buddhists. If one’s object of inquiry is the mind, then the question becomes: Does altering this landscape affect the nature or efficacy of practice? Can Prozac help or hinder this process? Also, the question is tinged with a moral quandary: If I decide in favor of Prozac, am I somehow “cheating” in my practice? Or, if I need such a drug, have I failed in my practice?
The compass for practice is set by the Buddhist concept of original enlightenment: Enlightenment is not a matter of adding anything but rather of peeling away the false, fabricated sense of self to allow the innate Buddha being to emerge. In contrast to the self-centered, separated small mind, big Mind is unfettered and boundless, purified of greed, anger, ignorance, and all defilements, as clear and stainless as an empty mirror. For some Buddhists, Prozac—or any deliberate alteration of the mental landscape—automatically adds another layer to the mind’s “obscurations,” pushing clear Mind further from reach. And despite the new general acceptance of Prozac by Buddhist teachers and therapists, among students there still exists a widespread belief that the mind on Prozac, however “realized,” cannot be “pure.” An alternative view is that whatever state the mind is in—greedy mind, angry mind, in-love mind, or Prozac mind—that is the mind that one must work with, and it is the concept of “purity” that creates further obstacles.
One Buddhist teacher tells a story in which, several years ago, a dharma friend confided to being on Prozac. The teacher, believing that Prozac hindered a “pure” mind and added to delusional realties that made facing life’s big ordeals even more difficult, asked, “And what are you going to do in the bardo?” Now, the teacher, laughing at her own folly, says that she would never say that.
Susan Morgan, of Boston, who is both a Buddhist and a clinical nurse specialist who prescribes antidepressants, tells me, “When I work with meditators, they ask questions like, 'What is the self that I am medicating?' I don’t have an answer to that, but it’s very interesting sitting with the question.” The question is remarkably similar to, "Who is the self that is meditating?
From the point of view of “who is the self,” each of the major schools of Buddhism prevalent in the West contains orthodox elements inimical to antidepressants. In the Theravada tradition of southeast Asia, for example, a narrow interpretation of the Fifth Precept lends itself to rejecting antidepressants as mind-altering intoxicants. In traditional Asian Zen, the psychological self is not an appropriate subject for study. In contrast, the Vajrayana practices of Tibet include examining one’s own anger, greed, and fears and making them grist for the mill. When Tibetan Buddhism first took hold in the United States, during a therapy boom, there was a widespread sense among Vajrayana students that their practices precluded a need for therapeutic help—verbal or pharmacological.
Fluoxetine hydrochloride, or Prozac, was unleashed on the market in 1987, quickly becoming a extraordinary cash-cow for its maker, Eli Lilly. A stream of Prozac “wannabes” followed, their very names (Zoloft, Paxil, Luvox) suggesting sublime lassitude, or levitation above the turmoil of samsara. Every day there are more antidepressants in the family known as Selective Serotonin Reuptake Inhibitors (or SSRIs), a term coined by SmithKline Beecham, maker of Paxil. SSRIs are designed around serotonin (chemical name, 5HT), a natural chemical found in large concentrations in the gut walls, the walls of blood vessels, and in blood platelets, as well as throughout the brain. Neurons (brain cells) communicate by means of chemical messengers, such as serotonin, which are released into the small gap, or synapse, between neurons. After being released into the synapse, the serotonin must connect with specially designed receptor molecules on the postsynaptic cell to transmit its message. SSRIs are supposed to enhance the amount of available serotonin for a longer duration by inhibiting the reuptake of the chemical by the presynaptic neuron. The hype about SSRIs is that they “target” serotonin neurons cleanly and efficiently, without scattershot effects on other neurotransmitter systems such as norepinephrine or dopamine. Whether this is actually true is another matter.
There is an old science writer’s axiom that any new medical treatment can be guaranteed to generate two headlines. The first is “Treatment X is a miracle cure”; the second, a year or so later, is “Dangers of X Revealed.” So it is with Prozac and its cousins. With the enormous success of Listening to Prozac, Dr. Kramer became the Pied Piper of the newly minted SSRI, hailing it as “a designed drug, sleek and high-tech,” that “comes from a world even most doctors do not understand.” Because patients do not normally feel “drugged” on SSRIs, he asserted, these nouveau antidepressants could be prescribed for “less ill patients”— patients who do not meet the criteria for major depression but suffer from a kind of chronic melancholia known as dysthymia. It was primarily among such patients—with dysthymia, anhedonia, social maladroitness, and, especially, “extreme rejection sensitivity”—that Kramer observed a phenomenon of fairytale proportions. On 20 milligrams a day of Prozac, some of these people didn’t just emerge from depression but underwent profound metamorphoses. Before Prozac they were self-effacing, timid, inhibited wallflowers and milquetoasts; after Prozac they were the life of the party, the head salesman, the belle of the ball.