PillsThere's your college friend, years on an antidepressant to fend off funks, who finally persuaded her jittery, stock-junkie husband to start popping the same pill; no longer reading investment reports through the night, he's up early now to make the kids breakfast and let her sleep in for a change. And there's your neighbor who confides that Prozac saved his marriage: His wife told him she'd file for divorce if he didn't get on an antidepressant-she'd had it with his self-obsessed grumpiness (apparently not relieved by three years of therapy). So far-knock wood-so good. The guy, eyes wide with wonder, says he's definitely mellower and more engaged with his wife and kids: "Just wish I'd done it sooner."
Then there are those seemingly sane, high-functioning women who mention casually-driving to meet clients, packing up after spin class-that they're taking Paxil, Zoloft, Viibryd, or another popular SSRI (selective serotonin reuptake inhibitor). On these triumphantly named meds, they say, they're better equipped to handle full-to-bursting days: They sleep more soundly, stew less, and-big boon to those around them-just don't get overwhelmed, blow up, go global with the negativity like they used to.
Depression's Direct Affect on Relationships
Writer Cathi Hanauer was racing a few years back to finish her first big book, The Bitch in the House, an essay collection about (how apropos) the hazards of navigating a dual-career life with children. She worried incessantly, suffered from insomnia, and yelled a lot: "I was the bitch in the house." But "the most direct effect of feeling like shit," she says, was to start "looking at my life, thinking, I have to change things. I obviously couldn't leave my kids, so I looked at my husband, who was easy to blame." She went on Celexa, off it for a time, and then-after realizing that her tendency toward mild anxious depression is chronic-got back on it. "My husband and I are very compatible; I know he's the right guy for me," she says. "But when the world felt gray and hopeless, it carried over to how I viewed my marriage. I'd think, Oh, I shouldn't be in this life! I need to get my own apartment!" On Celexa, she says, she feels calmer, more confident-and less trapped. Hanauer is so convinced that depression can distort husbands' and wives' perceptions of each other that it's a major theme of her new novel, Gone, out next month. "Like every marriage, mine goes up and down. But on medication, the downs feel like normal downs." Hanauer says she and her spouse are "natural" types who typically look askance at drug fixes, "but we're both pretty happy that I'm on this: It's good for me, so it's good for us."
Can Antidepressants Actually Help Couples?
To women attempting to keep careers well groomed, kids well loved, and partners intimately allied, the idea that a pill could somehow make the whole enterprise hum is definitely provocative. If one or both of us went on antidepressants, would we give the finger to each other's backs less-and have each other's backs more? Would we cut down on the bickering, making our houses happier, healthier places for everyone? Might we just-to bastardize that old Romeo Void song-like each other better if we medicated together? Or is even posing questions like these-when the Centers for Disease Control estimates that one in 10 Americans over 12 now takes an antidepressant (with women 40 to 59 being the drugs' biggest consumers), when Bloomberg Rankings tells us antidepressant use has increased apace with the unemployment rate-proof that the pharmaceutical-industrial complex has already succeeded in pathologizing normal life challenges?
The answers, like most debates about antidepressants' benefits, risks, and limitations, are complicated and controversial. One key finding is that, while antidepressants can significantly reduce symptoms of major depression-including prolonged and pronounced hopelessness, self-doubt, unexplained pain-up to 40 percent of people don't benefit from the drugs at all (and those who do may have to cycle through several prescriptions before finding the right one). Another eyebrow-raiser? A large 2010 study funded by the National Institute of Mental Health culled data from multiple randomized, placebo-controlled drug trials and concluded that antidepressants are basically no better than placebos for the treatment of mild to moderate depression. This is particularly startling because surveys (formal and informal) suggest the majority of people seeking treatment for depression may not meet the formal criteria for the condition but are still enduring everything from agitation and excessive rumination to feeling unusually down or disconnected. So if antidepressants may barely help individuals, according to the data, is it crazy to think they might help couples?
Not necessarily, according to Peter D. Kramer, Brown University professor of psychiatry and author of the 1993 best-seller Listening to Prozac. As much cultural lightning rod as academic doc, Kramer has drawn heat for holding what many regard as an overly rosy view of the benefits of antidepressants for the down-but-not-totally-out. (Google him, and you'll find the jabs about his being drugmakers' dream pitchman.) Still, Kramer and his critics agree about this: The toll depression takes on couples is real and dangerous. Studies show that if your partner is depressed, your chances of developing the condition increase. And depression, which afflicts 17.5 million Americans, doesn't just migrate from spouse to spouse. It spills down generations. Children whose parents are withdrawn, remote, or short-tempered are at higher risk of developing anxiety and depression, several decades-long studies have shown. But whereas skeptics say antidepressants' potential to relieve middling mood problems is largely an illusion-as Marcia Angell, former editor of The New England Journal of Medicine, argued in a much-discussed essay last year in The New York Review of Books-Kramer contends that, among those who are mildly depressed, familiar medications like Prozac can treat a variety of "personal glitches" that cause relationship friction.
Take the woman whose husband turns to check the football game when she's trying to tell him something. Not a precipitous moment for many couples. But if the woman is acutely sensitive to rejection, the gameward glance may not be just annoying but "send her into a mini depression or anxiety, where it takes her a couple days to recover," Kramer says. Simply recognizing that she's the reactive type might inspire a wife to, say, save the important conversations for occasions when her husband isn't distracted, or the couple could negotiate talk versus TV time in couples therapy. Or, says Kramer, whose mantra is "depression causes divorce as often as divorce causes depression," the woman might suffer from diagnosable depression and get help from a pill. "When you take the medicine, there's a little floor under you," he says. "You're still hurt if you don't have someone's full attention. But the price paid is much smaller, making it possible to work it out, or live with it, or"-he pauses to chuckle-"take it back out on him in some way that makes it look much more like a workable relationship."
The Couples Who Are Good Candidates for Medication
Leslie Greenspan, a psychiatrist in Madison, Wisconsin, says couples sometimes come to her when one has urged the other to get help after circumstances (trouble at work, struggles with a child, a major marital disagreement) pushed him or her to a new low. If that person meets the criteria for depression and chooses medication, Greenspan generally waits about a month-the time it typically takes antidepressants to kick in-to see the couple again. By then, the unmedicated spouse often (gratefully) reports "a huge difference" in his or her partner's level of irritability, while the one taking a pill every day has yet to notice a thing.
Many standard measures of depression focus on mood-based symptoms such as sadness, withdrawal, and loss of appetite rather than on how respondents are getting along with spouses, coworkers, and kids, which Greenspan thinks may be a mistake. As she and other therapists I spoke to assured me, anger, often simply the unpleasant by-product of stress, is common in depression-and spouses tend to bear the brunt of it. Indeed, scientists' failure to appreciate this could be one reason studies suggest antidepressants don't work terribly well-the data doesn't capture their ability to reduce volatility because researchers don't ask about it in the first place. "It's the kind of thing where something like 'He left the top off the toothpaste tube' just grates," Greenspan says. But for the person on meds, the toothpaste cap becomes a mere bother rather than a roadblock that prevents her from hearing about her spouse's day.
Being able to calmly download their days together over a glass of wine-as opposed to driving straight into each other's buzz saws of angst and fear-is a boon of parallel medicating cited by East Coast couple Will and Susan Gore*. They both spent years (on and off, together and apart) in therapy, but it wasn't until one of their children was diagnosed with a developmental disability that they heeded their respective therapists' suggestions to try antidepressants. The biggest change for Susan-"a very intense person with a depressive side," by her own account-is that she's stopped taking everything personally. "Instead of ruminating, I can catch my breath and say, 'That didn't work out,' and move on," she says. "If I were Madonna and could get to the gym every day, I might be able to create this kind of consistency another way. But I don't think we're actually made to go through what we have to in contemporary society-the high-activity, pressure-filled lifestyle. I'm okay with getting it this way."
Will is too: "I like to joke, 'The couple who stays on Lexapro together stays together.' " But, as with many jokes, this one hints at a darker possibility. Before they got on antidepressants, Susan's tendency to rail at length (about whatever happened to be irking her) exacerbated Will's "extremely self-critical" tendencies: "Whereas in her depression she'd tend to lash out, in mine I'd tend to sink inward," he says. "When she'd come in the door in a bad mood, I'd just be crushed. I'd be running around meekly suggesting this or that. Just this obsequious wimp, fetching a spoon or whatever. It was pretty rough." When I ask if medicating saved his marriage, he takes a moment. "Let's put it this way: I probably wouldn't have had the balls to get divorced." But, he adds, "We were heading down a bad path." Now, though, they agree their marriage is much better balanced. Susan's rough edges have "softened," as Will puts it, and with this-plus the boost medication has given his own confidence-he's become more forthcoming: They're able to work together to solve problems. "We really are each other's best partners," Will says. "To call us soul mates I think would be accurate."
The "New" Depression-and How Antidepressants Relieve It
Will and Susan, like many of us, believe that SSRIs work by correcting a simple serotonin deficiency in the brain, but scientists who study depression now mostly consider that to be "last-century thinking," as one Harvard neuroscientist put it. The new view of how depression develops, and how antidepressants work to relieve it, revolves around stress-wear and tear, that is, in parts of the brain that regulate emotions. "What we and others have found is that chronic stress can decrease the levels of neurotrophic, or growth, factors in the brain," says Ronald S. Duman, a professor of psychiatry and pharmacology at Yale University and a leading scientist in the field. Mental illness occurs, the theory goes, when stress mechanisms are on overdrive, causing the atrophy of neurons in such areas as the hippocampus (the region controlling mood and emotion) and the prefrontal cortex (the seat of executive thinking). "It's very clear," Duman says, "that antidepressants increase neurogenesis, helping the brain recover."
Interestingly, Will mentioned that in his twenties he'd tried cognitive behavioral therapy, a program designed to challenge and change dysfunctional thoughts. He got some relief from CBT, the most empirically validated form of psychotherapy, but soon disputing his own negative thinking became too difficult: "It took a lot of discipline, and, honestly, it was frustrating to have to keep doing it and doing it." After he got on an antidepressant, though, some skills he learned in CBT-such as pausing to rationally analyze and disarm destructive thoughts-became simpler.
No one knows exactly why the combination of antidepressants plus therapy-specifically CBT but also some types of couples therapy-helps many people recover from depression and prevents relapse better than either treatment alone, as studies have consistently shown. Psychologist Zindel Segal's supposition is that antidepressants allow therapy's messages to sink in "by regulating emotions, creating a buffer between you and what you're feeling." When your brain "is hijacked by strong emotional reactions, the cognitive learning centers shut down," says Segal, a professor at the University of Toronto. And evidence is building that long-lasting recovery from depression requires actually learning to behave in some new way, with brain and body fully engaged, so that harmful, ingrained thoughts are overridden by healthier ones.
Mental health experts do worry about possible overprescription of antidepressants by primary care doctors, from whom millions of Americans get their meds. "Most primary care doctors aren't reading the psychiatric literature," says New York University School of Medicine psychiatry professor Norman Sussman. "They're not going to meetings that go into details about these drugs. And, quite frankly, a lot of information they have comes from drug company representatives."
But Sussman and his colleagues generally worry more about too little treatment of depression rather than too much. "Once your brain is working again, you have to retrain it, as you would a knee after orthopedic surgery. You have to rehabilitate," says Emory University psychiatrist and neurologist Helen Mayberg, who specializes in treatment-resistant depression. "Unless you reach remission-which means having virtually all your symptoms go away-you're at risk to relapse." Many people stop taking antidepressants because the drugs make them drowsy or interfere with sexual response-both common reactions. But skilled psychiatrists can often adjust dosages or find new drugs that can ameliorate a particular set of symptoms with fewer side effects.
Experts also stress that antidepressants are not the only, or even the best, way to make marriage sunnier for people with mild depression. Exercise has been well established to lift mood. Increasing dietary intake of high-purity Omega 3 fatty acid to 1-2 grams per day reduces depressive symptoms, studies have found. A program known as Mindfulness-Based Cognitive Therapy (MBCT), which combines elements of CBT with mindfulness meditation, curtails anxiety and prevents relapse of major depression on par with antidepressants, Segal's research has shown. And, yes, good couples therapy can also help people understand better the contours-weak but possibly stronger than they think-of their relationships.
For those who do opt for antidepressants, Stephanie Coontz, the director of research at the Council on Contemporary Families, has a warning: "They can be tremendously helpful to tamp down emotional static that surrounds the disagreements men and women have always had in intimate relationships," or turn into "a long-term hindrance" if they're being used to mask serious conflicts. Women often become depressed after the birth of a child, Coontz points out, and it's not all hormones-another factor is that many expect to share more of the housekeeping and child care with their husbands but instead find themselves backsliding into more traditional roles, losing social contacts, and assuming the lion's share of child-rearing. "Those are objective reasons for depression. They're also ones you don't necessarily want to medicate away, because you want to deal with the problem."
Wendy Schmidt's* husband calls her low-dose antidepressant "Dumbo's feather," because, as she explains, "Dumbo just needed that feather to fly." A mother of three and her family's primary breadwinner, Schmidt, 47, a paralegal at a midwestern law firm, says the drugs help curb her generalized anxiety and occasional frustration with her husband-a civil engineer who can fix a toilet in the clutch but is clueless about their kids' day-to-day activities. "When you get married, you effectively carve off half your life and give it to your mate, saying, 'Here, do with this what you will.' Combine this with working in a bloodthirsty field; being the one who quarterbacks all the homework; and reads Tom Friedman and makes sure the kids understand the world is flat, that they'll have fewer opportunities, and, yeah," she says, pausing to snort, "women are in a tough spot today."
Antidepressants are just part of Schmidt's formula for keeping herself-and her marriage-on track. Meditation grounds her, she says, while couples therapy gave her and her husband a better grasp on "each other's baggage." And after treating her marriage for a long time as if it were the sole driver of her happiness, she recently started reconnecting with female friends. "The lady who cuts my hair said something wise: 'Maybe we're just not set up to have long-term partners. Don't forget, you have many friends.' " And bearing out the wisdom of smart hairdressers, as well as psychologists who say marital distress often results from relying too much on our partners to buoy us up (although they should do some of that), Schmidt says plugging into her social network has dramatically improved her outlook-which, in turn, has made it easier to stop dwelling on her husband's faults and see him as "the wonderful guy" he is. "I really do love him," she says, as if suddenly struck by the miracle of this.