I was pleased to hear last year that Katherine Sharpe* was writing a book on Coming of Age on Zoloft,  and when I got my review copy a few weeks go, even the first half-hour’s reading showed me the book answered my hopes: The book explores not just the vital, running debate about whether we’re overmedicating depression and melancholy, but what it means to come of age, and of identity, while one is taking these meds, and it does so with smarts, sensitivity, and a sense for nuance. This is quite an absorbing read, in the tradition of Kay Redfield Jamison — a personal but heavily reported look at a dilemma that is both highly personal, for those who face depression, and important for how our culture views mood, mental illness, medicine, and character.  I think it an important book and recommend it highly. You can grab a copy here.

It was a pleasure to discuss with Sharpe some of the questions she explores in the book; our conversation is below. Please feel free to continue it in the comments section.

PS: If you’re in NY today (June 18), you can catch Katherine (and the book) at a reading and Q&A tonight at Bookcourt in Brooklyn, 7 p.m.

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David Dobbs: What led you to write this book?

Katherine Sharpe: Taking antidepressants myself as a college student in the late 1990s. Feeling alone in this experience, and totally freaked out by the idea of “needing” a medication to get by, the idea of being “crazy,” the idea of taking a drug that was going to change my experience of myself and the world. How would I know what was real? How would I know how I truly felt about anything? If I couldn’t know those things, how could I make the choices I’d need to make to grow up?!

Keeping my medication use basically a secret for about a year, until one afternoon I was hanging out with a handful of fellow students, and we discovered that we were all on or had been on various psychiatric medications. Realizing that this thing that had been so personal and so problematic for me was, in fact, a rite of passage typical of my generation. That there must be thousands of other people dealing with similar questions and fears. Right then and there, ‘growing up on medication’ started to seem like a topic worth writing about.

Dobbs: Your book included stories of people who were helped by medication, as well as people who felt they weren’t — which in a rough sense matches the scientific literature.  Yet some have suggested your book is anti-antidepressant, and I don’t see it that way. Did I read you wrong, or did they?

Sharpe: Well, in a sense the book is more interested in being descriptive than it is in making some kind of all-out case for the goodness or badness of antidepressants. There’s so much polemical argument already, both for and against medication.

What’s harder to find is a thoughtful discussion, from people who’ve been through it, about the experience of actually being on these drugs. The fact is that thousands of adolescents and young adults are growing up on antidepressants and other psychiatric medications; I wanted to create a rich description of what that’s like.

I think antidepressants are a useful technology that has helped a lot of people. I’m glad we have them. But I’m definitely sympathetic to the view that they are overprescribed. For a number of reasons, we as a society have come to see certain feelings and states as psychiatric problems that wouldn’t have been seen as psychiatric problems, or psychiatric problems requiring medication, a generation ago. Some people think that’s great. They argue that the stigma around mental illness has lessened, and that people who need care are more likely to get it. To a certain extent, that’s right. But we’ve gone too far. As medication has proliferated — right now, 11 percent of Americans aged 12 and over use an antidepressant — people have become less likely to get other kinds of help, particularly psychotherapy, that don’t have the risk of side effects and have been proven effective for mild to moderate depression.

The mainstreaming of medication has bred confusion about what’s normal. In some sectors, we’ve grown so vigilant about the possibility of having a mental disorder that this vigilance becomes counterproductive, a source of anxiety in itself. Every negative emotion becomes a potential sign or symptom. I think people, particularly adults, should use medication if they wish, but I am concerned about the changing goalposts of what’s considered pathological. It’s nice to know that medication is available, but it’s also important not to lose sight of the comfort that can come from talking openly with each other, realizing that not every instance of feeling sad, or overwhelmed, or disappointed, or anxious, is a sign of something medically wrong.

With youth, I feel that a conservative approach to medication is best.

Partly that’s because of the way that getting a mental-health diagnosis can intersect with the adolescent search for self. Being diagnosed and using medication confers an identity, that of someone with a mental disorder. To an adolescent who is preoccupied with constructing an identity anyway, and looking for clues to who she is, that can be a big deal. Some adolescents feel that having a diagnostic label is clarifying and that it helps them. But others wrestle with it. They ruminate about what it means to be sick. They take that identity deep inside, and sometimes magnify it way out of proportion. A diagnosis event can have lasting, rippling consequences, and I think adults should be very cautious and careful before they impose a diagnostic label, or let a young person self-impose such a label, on what may be ordinary developmental struggles.

Dobbs: What parts were the most fun to write? Which the most challenging?

Sharpe: The first chapter, which is completely personal, was a lot of fun to write. The chapter about antidepressant drug advertisements and the cultural presentation of antidepressants in the 1990s and 2000s was fun to do too. It took on a more bouncy, humorous tone than certain other parts of the book. In individual lives, antidepressants can be serious stuff — when you zoom out to the level of society, it’s easier to see what’s funny and absurd about them.

The most challenging chapter was the one about quitting antidepressants. I had this personal story about going off medication after a long time on it that I wanted to tell. (I’ve been off for about six years now.) But it felt like a delicate topic. I wanted to be true to my experience and acknowledge that I did want to quit antidepressants, and that I did find satisfaction in realizing that I was able to get by without them. After all those years, it was empowering — and I wanted to say so, even though that seems like the kind of thing you’re not supposed to say.

On the other hand, I didn’t want to seem to be saying that people should quit, or that not taking antidepressants is somehow better than taking them. I’m not interested in telling people what to do. I can’t offer medical advice. And I would never, ever hold up a nonmedicated life and say ‘This is more valid or more real.’ A lot of people who take medication feel guilty about it anyway.

Culturally, I think it’s vital that we find a way to have a conversation about quitting medication. It’s just a practical necessity, given how many people start taking them. The challenge was to walk a line where I could start to talk about this under-addressed topic without adding to that pool of guilt.

Dobbs: I especially liked your passages on your own talk therapy. They brought out nicely both the internal and dyadic conversations, assessments, maneuvers and movement that psychotherapy can generate — something increasingly lost as treatment moves to chemicals and psychiatrist appointments are med checks rather than talk therapy. For you, what most distinguishes talk therapy, and what does it seem to offer that meds do not? And for you, did it leverage the meds or seem to work on a parallel track?

Sharpe: Thank you! I became a big fan of therapy, through doing it, but it wasn’t something I felt I understood well before I started, so it was a fun challenge to try to describe what it’s like and how it works.

I think one main thing therapy offers that drugs do not is a chance to develop skills that make you feel more able to handle your own emotions. Doing therapy creates self-awareness, and then almost inevitably, you use that self-awareness to help manage your emotional landscape — avoiding situations that trigger you, coping better when you are triggered because you recognize what’s happening, knowing what’s going to get you out of a given mood or situation and what’s going to make it worse. Acquiring and using these skills can help to create a sense of control and agency, where medication tends to diminish a sense of agency for some people. And of course the skills are portable and long-lasting. Sometimes I think of the difference in terms of that old “Give a man a fish/teach a man to fish…” parable. With medication, you are given a fish; in therapy, you learn how to fish.

It is really fashionable to talk about narrative and story right now, but maybe another way to think about what therapy does that medication doesn’t is to say that therapy is about crafting, with the help of another person, a narrative that both accounts for the facts of your life and gives those facts meaning. It creates a sense of direction, and that somehow helps you to interpret and deal with the situations that life throws in your way.

It’s hard for me to pick apart the relative contributions of medication and therapy. In my own case, I guess I think of it in terms of timescales. Medication, if you hit on the right one, works fast, and its effects can be very marked in the short term. Therapy doesn’t give you that day-and-night, instantly transformative feeling. But the effects and benefits of medication became much less clear for me over time. After the crisis faded, was it really helping me to take antidepressants month in and month out? I couldn’t tell. But by that time, that therapy was making a difference was totally obvious — including with things that medication had never touched. So I’m thinking about rocket boosters that fall off in stages. Medication can get you up there, if you need that; therapy can stabilize you and keep you going.

Dobbs: You talk a lot about antidepressants and identity. Do mind-altering medications really change who we are?

Sharpe: There’s a study that came out of Northwestern University a few years ago that found that antidepressants actually can change people’s personalities, causing them to score higher on measures of extraversion and lower on tests that measure neuroticism.

But when we talk about “who we are,” we’re often talking about something even deeper and harder to define than how outgoing or how irritable we are. Culturally we have this idea of the ‘real self,’ which we think of as something very inward and precious, almost spiritual.

I don’t know whether antidepressants change who we are in the sense that they change — or reveal — the real self. But I do think it’s fascinating that this notion of the real or authentic self has become a key idea in our debate about antidepressants. In my interviews, for example, I found that the people who are happiest using antidepressants tend to be the people who believe that the medications make them more like themselves, and the people who are the least happy are the people who believe that medication alienates them from themselves. We may never know whether antidepressants actually change who we are inside. For me, the significant and interesting thing right now is that we believe they can, and that these beliefs about how the drugs affect our selves are a key piece of how we experience them.

Dobbs: If there were one point about antidepressants and depression you could drive home to everybody, what would it be?

Sharpe: I would let people know what statements like “depression is a chemical imbalance” or “depression is a disease like diabetes,” although they sound scientific and you hear them a lot, don’t actually represent great science. The fact is that researchers don’t know yet what depression is, biologically speaking. We presume that chemicals are involved, but so much is still unclear, including whether, for example, a disturbance in brain chemicals is the cause of a depression or the effect of it.

At best, these claims that depression is a disease like other diseases are well-meaning abstractions. They’re grounded in the idea that if mental disorders can be understood as physical diseases, people will attach less stigma to them. At worst, they’re sales pitches. The more depression can be packaged as a physical disease, the more it makes sense to treat it with drugs. Either way, I think that the biomedical model of mental disorder is too reductive, particularly as applied to the millions and millions of Americans who get diagnoses.

There’s this word that refers to what I think is a much more accurate and helpful way of understanding depression and other common disorders, and that word is “biopsychosocial.” What it means is that our individual biology contributes to our mental state, but so do psychological factors like our relationships and our thought patterns, and social factors like our culture, the neighborhoods we live in, our support networks or lack of them. It means that these variables are all in play, and that to treat an emotional problem well, we need to look at all three. The best intervention could be in any of those areas, or in more than one. The best intervention could be in any of those realms, or in more than one. It doesn’t make good sound-bite material, and it doesn’t have a huge commercial apparatus behind it, but I think it’s a much more thoughtful, hopeful, and widely applicable way of looking at the problem.

Dobbs: You describe your own generation, which you define as people born from the mid-’70s to the early ’90s, as the first to literally be raised on psychiatric drugs. Any predictions for the next generation?

Sharpe: When I talked to people who are in college right now, I found them to be more blasé about medication use than my peers and I were. They’re more open about it, and see it as less of a big deal. That makes sense, because these drugs have been around since they were born. At the same time, they seemed unclear on the difference between ordinary negative feelings and clinically significant mental disorder. Having perspective and admitting to vulnerability isn’t exactly what people in their late teens and early twenties have ever been known for.

Still, I was struck by the way that these students were primed to assume that feeling lonely, confused, sad, or academically inferior was abnormal, something to be hidden away. They seemed less tolerant of negative emotions and more ready to use medication to nix them.

There may be a backlash against psychiatric medication coming. We’ve seen that a bit in the press, with Irving Kirsch’s work about the placebo effect and all the publicity it’s generated. But the statistics, which admittedly lag behind by a couple years, have yet to show that pushback translating into behavior in terms of people using less medication.

Assuming that medication use stays high, I think it’s likely that this generation may start to make less of a distinction between the idea of using a drug to treat a mental disorder, and simply using a drug in order to deal with something negative, or to change the way you feel. That intrigues me; I think it might actually be a healthier attitude, to take a utilitarian stance toward these drugs, to focus on the ways they can help rather than dwelling on the diagnoses — here’s what I have; here’s what’s wrong with me — and to have buying into a specific notion of illness be the prerequisite for getting these drugs and the relief they provide. The next generation might be more fluid.

Dobbs: I have to ask you about a recent piece in The Atlantic Health channel that was essentially a pushback against the pushback — a defense, as the author put it, of antidepressants in the face of critiques from you, Marcia Angell, and others. The author, Maura Kelly, starts off by saying the mere title of your book made her want to put up here dukes; later she portrays your stance as ambivalent rather than dismissive. Did her essay seem a fair treatment?

Sharpe: Yes. She represented me as a critic of antidepressants, but not the rabid critic she was expecting, and that’s about right.

I think one thing that piece illustrated nicely is the potential difference between starting antidepressants as an adult and starting them young.

Kelly was saying, ‘Look, antidepressants help people; they helped me; they’re this wonderful thing, and I don’t understand why you people are trying to shoot holes in them.’ Kelly has a story that was similar to that of a lot of adults who start antidepressants: she was in therapy for years; therapy was helpful but not that helpful; she went into crisis and finally overcame whatever inner resistance she had about trying antidepressants, and they were great — she wished she’d tried them sooner.

I very much respect that story, and many others have one like it. Part of what I’m on about in the book is that for people who start medication as teens, or even younger, the story is different. For them, using medication is often not their choice or not their idea. They don’t have the experience of trying other remedies for years and then reaching a point where they say, ‘You know what, these things aren’t working, this problem isn’t going away, and I’m going to take it seriously now and try something new.’ They haven’t necessarily had a chance to sort out what’s the turmoil of growing up and what might be deeper or longer lasting. Sometimes it’s very obvious that an adolescent is dealing with a real mental problem that goes way outside the realm of teen angst. But in other cases it isn’t always so clear. So for some of the people who start young, the narrative ends up not being one like Maura Kelly’s, of, ‘I had a problem, and then I used my own agency to find a solution, and it was wonderful.’ It’s more like, ‘Someone thought I had a problem, and this thing was given to me, and maybe it helped me or maybe it didn’t, sometimes it’s hard to tell, and if I stayed on it for years then I’ll never be quite sure, either what was the matter in the first place, or how I would have developed if I hadn’t tkaen this drug.’ It’s a singular experience, but it’s becoming more and more a hallmark of our time. That’s what I was trying to capture in the book.

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Katherine Sharpe writes for  n+1, Washington Post magazine, GOOD, Seed, ReadyMade, The Village Voice, Scientific American Mind, and other publications. Find more of her work at her website. She’s also on Twitter and Facebook.

*Disclosure: I knew Katherine Sharpe slightly from her tenure as community manager at ScienceBlogs while I was blogging there, and from bumping into her at a conference or two.