Last summer, near the end of my mother’s life, I woke up in my childhood bedroom in the middle of the night in a fever of panic. My heart was thrumming, my mind racing. In 1819, the English poet John Keats called anxiety a “wakeful anguish,” and so it was with me. Relief seemed impossible.
Then I had an idea. I wandered into the room where my mother lay dying and found the hospice nurse—a gentle, generous soul—sitting quietly beside my mother as she slept. She looked up from her fat paperback.
“Do you want to hold her hand?” she asked.
“No,” I said. “I’m looking for the Ativan.”
The nurse went back to her book, and I went rummaging through the pill bottles. Point-five milligrams and fifteen minutes later, the anti-anxiety medicine prescribed to my mother had bound itself to my GABA receptors, and I was calm enough to sleep. Afterward, I felt the occasional twinge of regret about my priorities at that moment. Then a friend told me she had swiped drugs from her just-dead mother to cope with her own surging anxiety. “I was glad for it,” she said.
In my Brooklyn kitchen last December, not long after a report circulated about veterinarians using Xanax to treat post-traumatic-stress disorder in military dogs, a neighbor mentioned that she had begun to carry Xanax in her purse after her first child entered kindergarten, for relief from the uncontrollable separation anxiety she felt each time she boarded the subway and headed to work. “It was just so obvious that time was passing, and I could never get it back,” she told me. Another friend, the breadwinner in her family, started taking Xanax when she saw that she was about to get laid off, then upped her dose when she did. Around Thanksgiving, I found myself sitting on a plane next to a beautiful young FIT graduate in a rabbit-fur vest. Before takeoff, she neatly placed a pillbox on her knees, plucked out a small tablet, and swallowed it. “Control issues,” she said sweetly, giving me a gorgeous smile. As we became airborne, she reached out and clutched my hand.
If the nineties were the decade of Prozac, all hollow-eyed and depressed, then this is the era of Xanax, all jumpy and edgy and short of breath. In Prozac Nation, published in 1994, Elizabeth Wurtzel describes a New York that today seems as antique as the one rendered by Edith Wharton. In the book, she evokes a time when twentysomethings lived in Soho lofts, dressed for parties in black chiffon frocks, and ended the night crying on the bathroom floor. Twenty years ago, just before Kurt Cobain blew off his head with a shotgun, it was cool for Kate Moss to haunt the city from the sides of buses with a visage like an empty store and for Wurtzel to confess in print that she entertained fantasies of winding up, like Plath or Sexton, a massive talent who died too soon, “young and sad, a corpse with her head in the oven.”
This is not to say that clinical depression is ever a fashion statement—it’s not. In the nineties, just as now, there were people who were genuinely, medically depressed, who felt hopeless and helpless and welcomed the relief that Prozac can provide. But beyond that, the look and feel of that era, its affect, was lank and dissolute. It makes sense in retrospect that Clerks, that cinematic ode to aimlessness, and Eddie Vedder (in his loser T-shirt) came along as the country started its two-decade climb toward unparalleled prosperity. In 1994, all the fever lines that describe economic vitality—gross domestic product, median household income, the Dow—pointed up. Just as teenage rebellion flourishes in environments of safety and plenty, depression as a cultural pose works only in tandem with a private confidence that the grown-ups in charge are reliably succeeding on everyone’s behalf.
Anxiety can also be a serious medical problem, of course. It sometimes precedes depression and often gets tangled up with it (which is why Prozac-type drugs are prescribed for anxiety too). But anxiety has a second life as a more general mind-set and cultural stance, one defined by an obsession with an uncertain future. Anxious people dwell on potential negative outcomes and assume (irrational and disproportionate) responsibility for fixing the disasters they imagine will occur. “What’s going to happen?” or, more accurately, “What’s going to happen to me?” is anxiety’s quiet whisper, its horror-show crescendo the thing Xanax was designed to suppress. Three and a half years of chronic economic wobbliness, the ever-pinging of the new-e-mail alert, the insistent voices of prophet-pundits who cry that nuclear, environmental, political, or terrorist-generated disaster is certain have together turned a depressed nation into a perennially anxious one. The editors at the New York Times are running a weekly column on anxiety in their opinion section with this inarguable rationale: “We worry.”
Panicked strivers have replaced sullen slackers as the caricatures of the moment, and Xanax has eclipsed Prozac as the emblem of the national mood. Jon Stewart has praised the “smooth, calm, pristine, mellow, sleepy feeling” of Xanax, and Bill Maher has wondered whether the president himself is a user. “He’s eloquent and unflappable. He’s so cool and calm.” U2 and Lil Wayne have written songs about Xanax, and in her 2010 book Dirty Sexy Politics, John McCain’s daughter Meghan copped to dosing herself and passing out the day before the 2008 election “still in my clothes and makeup.” When news outlets began reporting that a cocktail of alcohol, Valium, and Xanax might have caused Whitney Houston’s death, it felt oddly inevitable. Coke binges are for fizzier eras; now people overdo it trying to calm down.
Anxiety can be paralyzing and life-destroying for those who suffer it acutely. But functional anxiety, which afflicts nearly everyone I know, is a murkier thing. Not quite a disease, or even a pathology, low-grade anxiety is more like a habit. Its sufferers gather in places like New York, where relentlessness and impatience are the highest values, and in industries built on unrelenting deadlines and tightrope deals. The shrinks say that these people—urban achievers—retain a superstitious belief in the magical powers of their worry. They believe it’s the engine that keeps them going, that gives them an edge, that allows them to work weekends and at five o’clock in the morning, until at last it becomes too much. That’s where the pills come in.
“I use my anxiety to be better at what I do,” says an executive at a boutique PR firm. “A certain amount of anxiety makes me a better employee but a less happy person, and you have to constantly balance that. If I didn’t constantly fear I was about to be fired or outed as a loser, I’m afraid I might be lazy.” She takes a melt-in-your mouth .25-milligram tab of Klonopin once a week, she estimates: at bedtime, if work stress has her too revved up, or on the subway in the morning if her schedule for the day is making her sweat. Anti-anxiety drugs are the salvation of those for whom opting out of the to-do list isn’t an option.
Xanax and its siblings—Valium, Ativan, Klonopin, and other members of the family of drugs called benzodiazepines—suppress the output of neurotransmitters that interpret fear. They differ from one another in potency and duration; those that enter your brain most quickly (Valium and Xanax) can make you the most high. But all quell the racing heart, spinning thoughts, prickly scalp, and hyperventilation associated with fear’s neurotic cousin, anxiety, and all do it more or less instantly. Prescriptions for benzodiazepines have risen 17 percent since 2006 to nearly 94 million a year; generic Xanax, called alprazolam, has increased 23 percent over the same period, making it the most prescribed psycho-pharmaceutical drug and the eleventh- most prescribed overall, with 46 million prescriptions written in 2010. In their generic forms, Xanax is prescribed more than the sleeping pill Ambien, more than the antidepressant Zoloft. Only drugs for chronic conditions like high blood pressure and high cholesterol do better.
“Benzos,” says Stephen Stahl, chairman of the Neuroscience Education Institute in Carlsbad, California, and a psychiatrist who consults to drug companies, “are the greatest things since Post Toasties. They work well. They’re very cheap. Their effectiveness on anxiety is profound.”
Benzos can also be extremely addictive, and their popularity can be gauged by their illegitimate uses as well. According to the federal Substance Abuse and Mental Health Services Administration, rehab visits involving benzodiazepine use tripled between 1998 and 2008. Though benzos have come to signify the frantic overwhelmed-ness of the professional elites (they were discovered in the autopsies of both Michael Jackson and Heath Ledger), SAMHSA says the person likeliest to abuse the drugs is a white man between the ages of 18 and 34 who is addicted to another substance—alcohol, heroin, painkillers—and is unemployed. Last year, a 27-year-old man named Dominick Glowacki demanded that a Westchester CVS hand over all its Xanax while he held up the store with a BB gun. Jeffrey Chartier, the Bronx lawyer who represented Glowacki, says he’s seeing more and more cases of benzo abuse among young men who aren’t working. “Two pills and two beers make them as high as drinking the whole six-pack.”
In these anxious times, Xanax offers a lot. It dissolves your worries, whatever they are, like a special kiss from Mommy. “Often referred to as God’s gift,” reads the fifth definition of Xanax on Urban Dictionary. “You could come home with your house on fire and not even care,” reads another. “You don’t give a fuck about nothing.” So reliably relaxing are the effects of benzodiazepines that SAMHSA’s director of substance-abuse treatment, H. Westley Clark, says they’ve gained a reputation as “alcohol in a pill.” And their consumption can be equally informal. Just as friends pour wine for friends in times of crisis, so too do doctors, moved by the angst of their patients, “have sympathy and prescribe more,” says Clark. There are a lot more benzos circulating these days, and a lot more sharing.
In my social circle, benzodiazepines are traded with generosity and goodwill. My first Klonopin was given to me three years ago by a friend, during the third of seemingly endless rounds of layoffs. “You’ll know it’s working when you stop spinning,” she told me as she dug for the foil packet in her purse. Another friend admitted she has recently found herself playing fairy godmother with her Xanax. To friends worried about enduring a family holiday, she doles out a pill; to colleagues fearful of flying, she’ll commiserate before offering a cure. “I can’t fly without half a Xanax,” she’ll say. “Want some?” (Such casual bigheartedness is perhaps abetted by how cheap alprazolam can be. “How’s this for something nutty,” the same friend wrote to me in an e-mail. “Just refilled alprazolam. It was $2.56 for 30 tabs. Less than pretty much anything in the drugstore except maybe gum or Blistex.”)
The beauty of a benzo is its simplicity. SSRIs like Prozac or Celexa can work on anxiety as well as depression, but take two to three weeks to kick in. A benzo is, plain and pure, a chill pill: You can take it when you need to without committing to months or years of talk therapy. A real-estate executive I spoke to packs anti-anxiety drugs whenever he travels to guard against the circumstance he most dreads: being stuck in a hotel room (or, as he was recently, on a family camping trip), unable to sleep and worrying about not sleeping. “It’s just one of my little neuroses,” he says. He finds that as long as he has the pills on hand, he rarely has to use them. “Just knowing they’re there makes me feel better.”
I understand what he means. The Ativan I snagged from my mother is mostly untouched since she died six months ago. Benzos are great when you are freaking out—and they’re great because you know that something will make you freak out, eventually.
The last anti-anxiety drug Americans loved as much as Xanax was called Miltown. Discovered by accident in 1955 by a researcher looking for a new muscle relaxant, it caught on almost overnight. In Hollywood and New York, where busy, glamorous people worked all hours to feed the masses’ appetite for information and entertainment, hostesses served martinis with a Miltown garnish. Tiffany & Co. produced a line of tiny jeweled cases in which a woman might carry her pills. Lucille Ball, Lauren Bacall, Tennessee Williams, and Norman Mailer all took Miltown. Not only did they take it, but they boasted about the relief they felt from the miracle drug the press dubbed “Executive Excedrin.” On his show, Bob Hope called Miltown the “I don’t care” pill.
Against a backdrop of the real and present threat of nuclear attack, it would not be an exaggeration to say that during the Cold War it was patriotic to take an anti-anxiety drug. The medicine kept ambitious working people (mostly men) on an even keel while their children were ducking and covering at school. Miltown allowed Americans to manage the stresses of modernity while “doing one’s job and earning a good salary, but also playing a social role: making decisions and completing tasks while maintaining confidence and control,” writes Andrea Tone in her excellent book The Age of Anxiety: A History of America’s Turbulent Affair With Tranquilizers. It wasn’t just that anxiety was normal. It wasn’t normal if you weren’t anxious.
Valium came along in 1963, developed by Roche to knock Miltown off its perch. Unlike Miltown, which was a word-of-mouth phenomenon, Valium was aggressively marketed as a consumer convenience. The target audience was women, whose grouchiness, stress, romantic woes, and mood swings the drug would cure. One 1970 ad showed “Mrs. Raymond,” a schoolteacher, facing a relatable female crisis. “Valium has helped free her of the excessive psychic tension and associated depressive symptoms accompanying her menopause,” it read. “Now she’s poised and cheerful again.”
Valium’s success was unprecedented. It was the first drug, according to Tone, to reach $100 million in sales. It was also the first drug to trigger in Americans the suspicion that they were being sold a panacea for a condition they didn’t have or that might otherwise be cured by fulfilling work, a good laugh, or a more empathetic husband.
Xanax, approved in 1981, was a massive technological improvement. Valium can linger in the system for as many as 100 hours and had gained a reputation for leaving its users hung over and zombified—“unable to feel warmth, unable to love, unable to cry, to taste, to smell,” as Barbara Gordon put it in her 1989 memoir I’m Dancing As Fast As I Can. Xanax has a similar chemical composition but a much shorter half-life, vanishing hours after it takes effect. It gained a foothold in the anti-anxiety market as a spot treatment; it was indicated for “panic disorder,” which had just been established as a legitimate pathology. But a growing number of Americans found that it worked on quotidian panic as well, the kind that comes with a child’s disappointing, future-ruining report card or an intimate dinner party at the home of the person who signs your paychecks.
Benzodiazepines also got a boost from the Prozac era. Though new research has raised questions about their efficacy, SSRIs revolutionized the way people sought and received treatment for minor mental illnesses. Before Prozac, a person with low-grade depression or anxiety would turn to talk therapy, which was expensive, time consuming, and not necessarily effective; another treatment was a family of drugs called tricyclics, which could have nasty side effects. After Prozac, that same person could take a much safer pill, and that pill could be procured with a simple visit to the family doctor. So even though doctors and drugmakers continue to recommend drug therapy together with talk therapy, people with minor mental illness have over the past ten years increasingly sought help from drugs alone. A study published in the journal Psychiatry in 2008 showed that 55 percent of all prescriptions for benzodiazepines were written by general practitioners, and according to the National Institutes of Mental Health, people in treatment for psychological problems now spend half their budgeted dollars on drugs and less than a third on therapy. In 1997, those ratios were reversed.
It may be that this moment in history justifies an increased use of benzos. Ronald Kessler, an epidemiologist at Harvard University, does sweeping, long-term studies for the National Institutes of Health. He has found that a quarter of Americans will have a diagnosed episode of anxiety—generalized anxiety disorder, panic, phobias, post-traumatic stress disorder, obsessive compulsive disorder—in their lifetimes. That number, he says, hasn’t changed in decades. But Kessler’s research doesn’t account for the blips he calls “situational anxiety,” which come with tough times: an underwater mortgage, a diminished retirement account, or a child deployed in a foreign war. A benzodiazepine, says Kessler, could be a reasonable answer to “a terrible situation.” Just as the exhausted new mother of a colicky 3-month-old might drink two cups of coffee in the morning instead of one, so might a banker facing the wrong end of a “strategic restructuring” pop a Xanax before an encounter with the boss. “This goes beyond the science,” says Kessler, “but it could be that a pharmacological solution is the smart thing to do.”
The question, then, is one of degree. The crises people face in these early months of 2012 are individual and circumstantial, yes, but they’re global and abstract as well, stemming largely from the haunting awareness (it’s certainly haunting me) that the fates of everyone in the world are intertwined and the job of protecting civilization from assorted inevitable disasters seems to have fallen to no one. “Situational anxiety” today stems from threats that are both everywhere and nowhere at once. How will the debtor nations in the eurozone ever manage to pay back what they owe? How can Israel disarm Iran’s nuclear program without inciting the messiest international conflict since World War II? How can you be absolutely, 100 percent sure the cantaloupe you had for lunch wasn’t contaminated with listeria that will make you or your kids or one of your guests deathly sick?
To the point: Do modern realities merit an increased dependence on Xanax? Steven Hayes, a clinical psychologist at the University of Nevada, believes that benzos stop a gap that evolution has yet to fill. As humans try to control an exponentially growing number of inputs with which they are confronted, “our attention becomes less flexible, our minds become more chattering, and the next thing we know, we’re frantic.” Humans are ill-equipped to process or accommodate all these new signals. “Our task now is to create modern minds for the modern world, and that modern mind has to be psychologically flexible.” In the absence of that flexibility, Hayes says, people need a bridge—a pill—between what life doles out and what people can realistically handle.
In 1972, a psychiatrist named Gerald Klerman coined the phrase “pharmacological Calvinism” to describe Americans’ tortured love affair with psychopharmaceutical drugs. Klerman was writing at the height of the Valium era, when its huge popularity lived alongside the perception, fed and perpetuated by the nascent feminist movement, that the pills were creating a generation of robot wives—numb, unfulfilled suburbanites forced into domestic servitude by the men who ran things, including the pharmaceutical companies. “You wake up in the morning,” wrote Betty Friedan in The Feminine Mystique, “and you feel as if there’s no point in going on another day like this. So you take a tranquilizer because it makes you not care so much that it’s pointless.” As fashionable as it was to take the pills, it was also fashionable to blame them.
On the one hand, Americans love convenience and scientific progress and thus herald drugs like Miltown and Xanax as miracle cures (like the washing machine or canned spaghetti) for the travails of modern life. On the other, Americans value self-reliance and authentic experience and regard dependency on chemicals as weak. Especially in this era, when entire sectors of the population have devoted themselves to eating organic and giving birth without painkillers, when otherwise sane parents decline to vaccinate their children against fatal diseases, chemical purity is held up as a sacred shield against future environmental cataclysm and failures of personal health.
Benzos sit at the locus of all this ambivalence, the love and the loathing often bumping awkwardly together within the same person. The same people who rely on Xanax, joke openly about it, and share it with friends refuse to identify themselves on the record for fear of reprisal from colleagues and bosses (who, they tell me, are using it and joking about it as well). The same kinds of people who shop at the Park Slope Food Co-op, that high temple of food purity, also take the occasional Xanax to chill out. “Coming to the co-op and doing something that is easy and meeting people actually helps me relax (no Xanax needed!),” one member opined about her work shift on Yelp. The inconsistency dwells even in my own self: As I write this story, I keep wanting to insist upon my physical and mental health and the lightness of my benzo habit. I spin, I do yoga, I eat lean meats and vegetables. I take half a tablet of Ativan every three weeks. At most. Honest.
A friend of mine had dental surgery recently, a procedure she both hates and fears. So proud was she that she’d sworn off Klonopin that she decided to forgo the medication ahead of her dental appointment. “I thought, Don’t be a baby. That’s just weak. You should be able to handle things.” She had a panic attack in the chair and was “a total bitch,” she says, to the dentist. “Oh, wait a second,” she reminded herself as the drill whined and the tooth dust spattered, “there’s a medical reason for these things.”
Psychologists wish people wouldn’t take so many benzos and, especially, so much Xanax. “Surely it can’t be right that this level of pharmaceuticals makes sense,” says Hayes. Partly they say this out of professional obligation. Tone’s book refers to Xanax as “the crack [cocaine] of the benzodiazepines.” Its short half-life can mean disaster for people who use it daily: They crash as the drug is wearing off and immediately yearn for more. “The withdrawals are the worst (put me in the hospital),” reads a posting on a drug-rehab website. “Find something else to do like pot or beer.” Dr. Peter Breggin, who crusades against benzodiazepines, pointed out in an editorial in the Huffington Post after Whitney Houston died that even short-term use of Xanax can make people more anxious than they were before and that sporadic use can cause what he calls “medication spellbinding”: impaired judgment, loss of memory and self-control. “I have all these mixed feelings about psychopharmaceuticals,” says the friend who, like me, stole drugs from her deceased mother. “Messing with your brain chemistry isn’t something to be taken lightly.”
But the anti-benzo psychologists are also making a value judgment. They believe Americans would be better, and healthier, if they learned to manage their anxiety without pills. They believe people should feel their feelings. A pill can be a crutch, says Doug Mennin, an anxiety specialist at Hunter College who does private therapy for the functionally anxious. The more you use it, the less able you are to navigate life’s tough spots on your own. “I’m a New Yorker,” says Mennin. “I see dependency on pills all the time. What I say to clients is, ‘You’re selling yourself short a little bit.’ If you’re going through a stressful time, and you say, ‘I’m going to get some of these,’ then the next time you get to that kind of problem, you start seeking out that pill. If you didn’t have the pill, you’d probably be okay.” The mind is a muscle, Mennin adds. With practice, you can teach it to handle anxiety: “It’s the same kind of skill as learning a better backhand in tennis.”
Mennin, Hayes, and other anxiety researchers are excited about a new kind of treatment that seems to work even on therapy-resistant worriers. It’s called “acceptance therapy” or “mindfulness therapy.” Instead of trying to show a worrier how his anxiety is irrational, ill-founded, overblown, or corrosive to his physical health, intimate relationships, and personal happiness (the protocol in conventional therapies), the therapist instead endeavors to teach him to regard his anxiety with the cool dispassion of a Buddhist monk. Thus the patient doesn’t get “entangled,” as the shrinks say, with his anxiety. He doesn’t try to flee from it. Nor does he try to evade or suppress it. He sees that it’s there but resists the urge to respond to its call: to pick up the phone, turn on the computer, check the e-mail, eat that bag of cheese puffs, pour another drink, take that pill.
“If you can train people to be more in the present moment, they may be less worried about what could happen in the future. The idea is to be accepting of what your experience may be, whether it’s anxiety or sadness or boredom,” says Susan Evans, a professor of psychology and clinical psychiatry at Weill Cornell Medical College. “It may feel this way now, but it won’t feel this way an hour from now, a day from now, a month from now.” Evans teaches “mindfulness-based stress reduction” to groups on the Upper East Side. The cost of the training is $600 for eight two-hour sessions.
It turns out that I am afflicted not just with pharmacological Calvinism but with mindfulness skepticism as well. For while I believe, in theory, that learning to coolly regard my anxiety as a purple, hairy monster I could stash in my tote bag, as Mennin suggests, might steady my pulse on sleepless nights, I am suspicious of any cure that requires more effort and expense on my part and more hours away from my work and my family. In this skepticism, I am like my anxious peers. “We go through rough patches, and we do things that make us feel better,” says Lisa Colpe, an epidemiologist at the NIMH, with the vocal equivalent of a shrug. A lot of people with anxiety would simply prefer to live with it; they know that when it becomes unbearable, the drugs will be there.
A cure isn’t what the PR executive with the occasional Klonopin habit wants. “My own personal experience is that there’s a healthy level of anxiety, and I don’t believe ‘healthy’ is the absence of anxiety,” she says. “I live in a world that puts unreasonable demands on me, and sometimes I need help. I wish I could do it without the pills, but I can’t.”
The real love affair, then, is not with the pills but with the anxiety itself. Anxiety is like the spouse you’re stuck with for better and worse, who makes you nuts but has permeated your cells and without whom you cannot imagine your own heart beating. Anxiety lives with you day and night, holding your hand and nudging you to act, urging you to get up, do more, fix something, make something. Never satisfied, always pressing, it wants you to win, to outlast the others, to impress, excite, excel, astonish. And, as in a marriage, you comply, mostly agreeably, for your anxiety traces the rhythm of your life. Then one morning, it has you by the throat and you find yourself weepy and overwrought, unable to respond to its call. Like a reliable friend, Xanax is there, offering an intermission, the gift of quietude, a break. Because the truth is, and I’ll speak for myself here, I want tranquillity once in a while. But I don’t want a tranquil life.
Chill-Pill Matchmaking Chill-Pill Matchmaking Four anxious archetypes and the drugs that might suit them.*
An architect is heading into a presentation she knows will make her freak out. A gray divorcé who likes the occasional Scotch is kept awake by money worries. → She pops a XANAX. → He reaches for the ATIVAN. Xanax takes effect very quickly but leaves the mind clear, which can make it an effective preemptive balm for predictable stresses. Since it can be highly addictive, the drug isn’t recommended for people with substance-abuse problems. Ativan is less addictive than Xanax but still has a relatively short half-life. It’s good for older people with nocturnal anxiety—it helps them nod off, but won’t have them too zonked to get up to use the bathroom. Ativan has a fall risk and is not a viable option for the frail.
A young working mother juggling her job, kids, and assorted domestic duties feels constantly stressed about her to-do list. A bicoastal entrepreneur deeply afraid of flying boards a cross-country flight; he has no plans to drive upon arrival. → She relies on KLONOPIN. → He takes a VALIUM. Klonopin is a longer-acting benzodiazepine with less withdrawal risk than other drugs in the category, providing relief without producing a high. “It is not a ‘fun’ drug,” says Columbia clinical-psychiatry professor Philip Muskin. Valium kicks in fast, but its effects can linger for a day or so. It is not recommended for substance abusers (our theoretical entrepreneur is a teetotaler) or people who need to operate heavy machinery. *All examples here assume low dosages. Case histories of real people are of course far more detailed and nuanced than these hypotheticals; those vagaries, along with physicians’ preferences, mean that actual prescriptions will definitely vary. Illustrations by Mark Nerys
Chill-Pill Matchmaking: Four Anxious Archetypes and the Drugs That Might Suit Them