Rebuttal to NY Times Article “Medicating Women’s Feelings”

Note from Maggie, Dr. Smith’s daughter and proud editor of eshrinkblog.com

The minister (pastor, reverend, preacher…I never know the correct title) sent my dad an op-ed piece from the New York Times and asked him what he thought of it. To me, it sounds like they are both very well-read people and enjoy intellectual conversations about issues. Below is my dad’s response. For my part, I see why my dad is so baffled by Dr. Holland’s article. I think what she is saying is that the system is set up to reward male-dominated traits, and there is value in many of the traits females have as a part of their biology. But she doesn’t explain it very well. Instead, she seems to be saying, “Suck it up and appreciate your depressive state. These anti-depressants are just making you like a zombie.” As a person who suffered from post-partum depression after my second child, Prozac was a lifesaver…for me and my husband and children.

Here is the article:

Medicating Women’s Feelings

WOMEN are moody. By evolutionary design, we are hard-wired to be sensitive to our environments, empathic to our children’s needs and intuitive of our partners’ intentions. This is basic to our survival and that of our offspring. Some research suggests that women are often better at articulating their feelings than men because as the female brain develops, more capacity is reserved for language, memory, hearing and observing emotions in others.

These are observations rooted in biology, not intended to mesh with any kind of pro- or anti-feminist ideology. But they do have social implications. Women’s emotionality is a sign of health, not disease; it is a source of power. But we are under constant pressure to restrain our emotional lives. We have been taught to apologize for our tears, to suppress our anger and to fear being called hysterical.

The pharmaceutical industry plays on that fear, targeting women in a barrage of advertising on daytime talk shows and in magazines. More Americans are on psychiatric medications than ever before, and in my experience they are staying on them far longer than was ever intended. Sales of antidepressants and antianxiety meds have been booming in the past two decades, and they’ve recently been outpaced by an antipsychotic, Abilify, that is the No. 1 seller among all drugs in the United States, not just psychiatric ones.

As a psychiatrist practicing for 20 years, I must tell you, this is insane.

At least one in four women in America now takes a psychiatric medication, compared with one in seven men. Women are nearly twice as likely to receive a diagnosis of depression or anxiety disorder than men are. For many women, these drugs greatly improve their lives. But for others they aren’t necessary. The increase in prescriptions for psychiatric medications, often by doctors in other specialties, is creating a new normal, encouraging more women to seek chemical assistance. Whether a woman needs these drugs should be a medical decision, not a response to peer pressure and consumerism.

The new, medicated normal is at odds with women’s dynamic biology; brain and body chemicals are meant to be in flux. To simplify things, think of serotonin as the “it’s all good” brain chemical. Too high and you don’t care much about anything; too low and everything seems like a problem to be fixed.

In the days leading up to menstruation, when emotional sensitivity is heightened, women may feel less insulated, more irritable or dissatisfied. I tell my patients that the thoughts and feelings that come up during this phase are genuine, and perhaps it’s best to re-evaluate what they put up with the rest of the month, when their hormone and neurotransmitter levels are more likely programmed to prompt them to be accommodating to others’ demands and needs.

The most common antidepressants, which are also used to treat anxiety, are selective serotonin reuptake inhibitors (S.S.R.I.s) that enhance serotonin transmission. S.S.R.I.s keep things “all good.” But too good is no good. More serotonin might lengthen your short fuse and quell your fears, but it also helps to numb you, physically and emotionally. These medicines frequently leave women less interested in sex. S.S.R.I.s tend to blunt negative feelings more than they boost positive ones. On S.S.R.I.s, you probably won’t be skipping around with a grin; it’s just that you stay more rational and less emotional. Some people on S.S.R.I.s have also reported less of many other human traits: empathy, irritation, sadness, erotic dreaming, creativity, anger, expression of their feelings, mourning and worry.

Obviously, there are situations where psychiatric medications are called for. The problem is too many genuinely ill people remain untreated, mostly because of socioeconomic factors. People who don’t really need these drugs are trying to medicate a normal reaction to an unnatural set of stressors: lives without nearly enough sleep, sunshine, nutrients, movement and eye contact, which is crucial to us as social primates.

If the serotonin levels of women are constantly, artificially high, they are at risk of losing their emotional sensitivity with its natural fluctuations, and modeling a more masculine, static hormonal balance. This emotional blunting encourages women to take on behaviors that are typically approved by men: appearing to be invulnerable, for instance, a stance that might help women move up in male-dominated businesses. Primate studies show that giving an S.S.R.I. can augment social dominance behaviors, elevating an animal’s status in the hierarchy.

But at what cost? I had a patient who called me from her office in tears, saying she needed to increase her antidepressant dosage because she couldn’t be seen crying at work. After dissecting why she was upset — her boss had betrayed and humiliated her in front of her staff — we decided that what was needed was calm confrontation, not more medication.

Medical chart reviews consistently show that doctors are more likely to give women psychiatric medications than men, especially women between the ages of 35 and 64. For some women in that age group the symptoms of perimenopause can sound a lot like depression, and tears are common. Crying isn’t just about sadness. When we are scared, or frustrated, when we see injustice, when we are deeply touched by the poignancy of humanity, we cry. And some women cry more easily than others. It doesn’t mean we’re weak or out of control. At higher doses, S.S.R.I.s make it difficult to cry. They can also promote apathy and indifference. Change comes from the discomfort and awareness that something is wrong; we know what’s right only when we feel it. If medicated means complacent, it helps no one.

When we are overmedicated, our emotions become synthetic. For personal growth, for a satisfying marriage and for a more peaceful world, what we need is more empathy, compassion, receptivity, emotionality and vulnerability, not less.

We need to stop labeling our sadness and anxiety as uncomfortable symptoms, and to appreciate them as a healthy, adaptive part of our biology.


My dad’s response to the article above

Dear Dennis,                                                                                                                                               March 9, 2015

Thank you for sharing the New York Times Op Ed.  Although there are many points in which I agree, I do fear that the opinions expressed may have the power to cause as much harm as the side effects of the psychotropic medications which Dr. Holland feels are overused.   My concern is that her essay may contribute to the stigma already attached to the treatment of mental illness or emotional problems in general.  Although Dr. Holland does make some valid points, I believe that some of her analyses are inaccurate.   She bases her expertise on having practiced psychiatry for 20 years.  Lest you think it audacious of me to challenge her, I trumpet the fact that I had more than twice that many years as a psychiatrist and prior to that another 10 years practicing general medicine.   In the latter capacity, I found myself frustrated by my helplessness to deal with the emotional suffering of many of my patients.   With this in mind I returned for a residency in psychiatry.

The first paragraph of Dr. Hollands’s piece lists qualities which she presents as gender specific, with which I do agree in general.  She then describes these qualities as a “source of power” and continues by asserting that women are  “under constant pressure to restrain our emotional lives” while denying a pro-feminist ideology.   I fancy myself as a firm advocate of equal rights for women having been well indoctrinated by three assertive daughters, and a wife who has extricated herself from the helpless, dependent role which she had been taught.   As I have stated in a previous blog post, I believe that women will eventually achieve equality or even superiority.  In general, I feel this would be a good thing, although I must confess I do occasionally have some nightmares of that Stepford  Wives  thing, for I realize that paybacks are hell.

In the next paragraph she bashes the drug companies for “playing on fear.” Those of you who have read my previous blogs would agree that I am no big fan of the pharmaceutical industry, and I believe that promotion of prescription drugs to the lay public is not helpful, but then neither is the endless promotion of alcohol on TV.  I have long felt the cost of new medications outlandish, but that is another story.   In their defense I must admit that the tools available for treating mental illness although not nearly perfect are amazing considering what was available to us 60 years ago—even 30 years ago.  She uses the example of Abilify as the inappropriate use of a medication.  She does not seem to consider that it may be used so much because it is effective.  Although it was originally developed as an antipsychotic, it has been found to be efficacious when given in small doses to augment the effect of antidepressants.

She presents further evidence of a stoned female population by noting that 1 in 4 women are taking a psychiatric drug compared to 1 in 7 men.  This would seem to indicate that men are under medicated and women are about right for the INH study shows a prevalence of mental illness of 26.3% of the adult population. The disparity may also have something to do with the fact that women are not burdened by the macho thing and the qualities in women, which the doctor extolled in her opening paragraph, allow them to be more likely to seek help.  Could these same disparities in diagnoses between men and women also have to do with the sensitivity and other valued traits in women?  It does not seem illogical that they might have an increased susceptibility to depression and anxiety disorders as is the case in many  types of illness.  After all “men are from Mars and women from Venus.”

Dr. Holland insists that women are designed to “be in flux” and such things as premenstrual syndrome with its despondency, irritability, and anger are simply part of the normal female physiology and apparently is something that shouldn’t be tampered with.

She should be reminded that biologically premenstrual syndrome (PMS) was not a problem for primitive women, because they avoided the problem by being constantly pregnant.  Modern women have rejected that option, and menopausal symptoms likewise were rarely a problem since few lived to be as old as 40.   When these facts are considered one could safely conclude that treatment of these problems is not in violation of natural law.  On the contrary I have seen many women through the years who have been severely impaired and spend sometimes half of each month miserable.  Then there is the guilt that follows when they later realize the effect their behavior has had on their family, friends and coworkers.   I would dispute her statement that menopausal symptoms can ” sound a lot like depression”, and say it not only sounds like but is depression.   If it quacks like a duck, etc.

Perhaps it is with her discussion about SSRI’s that I wonder if I really am on a different planet.  I vividly recall the first time I prescribed Prozac, which was the first SSRI.  The patient was a very unhappy young man who had suffered  a social anxiety disorder with depression since the 6th grade.  He had lived in almost total isolation, had never dated,  and worked in a warehouse on the night shift in order to have minimal contact with other people.  After a few visits he appeared to be a bit more comfortable with me, but shuddered at the idea of branching out socially.  After a couple of weeks there was a remarkable change.  He had started out by making conversation with the check out girl at the grocery, and reported he was no longer avoiding acquaintances as he had in the past, but more importantly  he arrived with a broad smile.  He denied any depressive symptoms, and the changes in his persona were so remarkable that I wondered if he had been into something illicit.  I was skeptical this might be a  placebo effect, but the changes persisted and the last time I saw him he had quit his night job, and enrolled in a university to pursue an engineering degree.

At this point I was sold on Prozac, but my joy was short lived when I found that it did not always work as advertised.  It did however offer many advantages over other antidepressants which were available at the time including fewer side effects , less sedation, and non lethality at even huge doses, an important feature when dealing with depression.   There is a significant group who will experience some sexual dysfunction, but most of my patients say that is a price they are willing to pay.  I do not recall noting the zombie like effects that she describes with SSRI’s.  As a matter of fact, my patients usually are more animated and expressive.  Dr. Holland notes that SSRI’s may dampen what she calls ”human traits” among which are irritation, sadness, anger,  mourning and worry.  I don’t know about her patients, but mine would not mind giving up those human traits.

She also lists as side effects that SSRI’s are apt to result in one becoming “more rational and less emotional.”  It is difficult for me to understand how these traits could be labeled as negative effects; therefore undesirable. We are led to believe that emotional stability will make women more masculine with the capacity for leadership, which again we are to assume is a negative.  Her response to patients who complain about the emotional instability associated with the  premenstrual period could be likened  to such macho statements as  “suck it up, play through the pain, stop whining  etc.” consequently I am confused as to exactly what behaviors she thinks are appropriate.

The most puzzling of all to me is the last statement in the article wherein she states “we need to stop labeling our sadness and anxiety as uncomfortable symptoms and to appreciate them as a healthy , adaptive part of our biology.”  I see nothing healthy about depression and anxiety, but only pain.  Nor do I see any virtue in needless suffering.  As a physician, I have always seen as my goal the alleviation of suffering, and nowhere in life is the suffering more extreme than in those afflicted with mental disorders despite the cause.

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