The Hedgehog Review

The Hedgehog Review: Vol. 17 No. 3 (Fall 2015)

Naming the Modern Discontent

Joseph E. Davis

The Hedgehog Review

The Hedgehog Review: Fall 2015

(Volume 17 | Issue 3)

When he published his dramatic, book-length poem The Age of Anxiety in 1947, W. H. Auden gave an enduring diagnostic name to the emotional malaise of the postwar era. To be sure, anxiety was not a new concept or concern. It had figured centrally in the work of the Danish philosopher Søren Kierkegaard, acquired wider notoriety in the turn-of-the-century outbreak of a catch-all collection of nervous symptoms labeled neurasthenia, and become the subject of best-selling self-help books during the Great Depression. After World War II, however, anxiety became the defining disorder of the times. It was the name for the manifold fears, struggles, and uncertainties of life in a rapidly changing world, with new perils and new expectations, shifting social and work conditions, and an intensified emphasis on individuality. In what is “almost universally regarded as the Age of Anxiety,” Time observed in a 1961 cover story, “The Anatomy of Angst,” “the greatest single cause of anxiety” may be a “kind of compulsory freedom.” This was a freedom that required self-creation, constant effort, and productivity—in sum, the overcoming of limitations in the restless pursuit of possibilities.

Yet within a mere three decades of its Time, Inc., apotheosis, anxiety was dethroned, its position as the signature affliction of the Western world appropriated by depression. How had Sovereign Anxiety fallen? Among the many explanations, three are especially noteworthy.

First, from World War II through the 1960s, Freudian psychoanalytic ideas were in the ascendency in the United States. For Freud, anxiety was the chief characteristic of the “neuroses”—the common worries, psychological problems, and psychosomatic complaints of otherwise normal people. When Freudian theory was challenged in the 1970s, so was the fundamental, explanatory role of anxiety. Depression, hitherto considered a rare psychotic disorder but favored by the up-and-coming neuropsychiatrists, was accorded a new and prominent place in the diagnostic hierarchy, albeit in expanded and redefined form. What had formerly been called “anxiety” was increasingly labeled “depression.”

Second, when the first psychopharmaceutical blockbusters—Miltown, Librium, then Valium—came on the market beginning in the mid-1950s, they were labeled and promoted as “minor tranquilizers” or “antianxiety” medications. Advertisements promised relief from a wide range of daily problems, from stress, insomnia, and fatigue to “marital tensions,” psychosomatic complaints, “inadequacy,” and much more (see sidebar). For the next two decades, the minor tranquilizers dominated the market. In 1971, some 15 percent of Americans reported using one in the previous year. However, as these drugs fell out of favor in the late 1970s, assailed by the media for being addictive or for being used to help keep women in their place, so too did the “anxiety” they were prescribed to treat.

Finally, in the late 1980s a new class of drugs came on the market, the selective serotonin reuptake inhibitors (SSRIs), of which the first was the iconic Prozac. These drugs were labeled “antidepressants” and marketed as the energizing replacements for the sedating Valium. Ads promised that they would provide relief from insomnia, fatigue, sadness, anxiety, and much else (see sidebar). Diagnoses of depression increased rapidly, and sales of these antidepressants soon eclipsed those of the tranquilizers. And though there was no Auden to announce the change, a psychiatrist writing in Psychology Today declared that the “Age of Anxiety” had become “the Age of Depression.”

But here was the curious thing: While the conditions have different names, the forms of suffering characterized by anxiety and depression have much in common. Not everything, of course, but many of the key symptoms that defined anxiety were the same as those that came to be associated with depression. These included nervous tension, fatigue, sleeplessness, distractibility, and somatic complaints. Tellingly, three-quarters of prescriptions now written for antidepressants are for conditions other than depression, including anxiety syndromes, back pain, headache, and sleep disorders. Further, both anxiety and depression converge around the problem of “compulsory freedom,” to use the Time coinage of a half-century ago. Depression might even represent an intensification of this peculiarly modern challenge to the self—one characterized by a lack of energy and productivity, a sense of inadequacy, an unhappiness at not measuring up or fitting in, a weariness with all the effort.

There are reasons to think the Age of Depression might be passing. The patents for the SSRI drugs with real cultural status—Prozac, Paxil, Zoloft—have all expired, which has led to their replacement by generics and little-noticed alternatives. Seeing less potential for profit, many pharmaceutical companies have discontinued new research and put far less money into marketing antidepressants. Another class of patented and more profitable drugs, the so-called atypical antipsychotics, have sometimes been marketed as antidepressants, but these medications shift the center of gravity toward other disorders. And at least since the early 2000s, the SSRIs have received a lot of bad publicity, from concerns about their potential addictiveness and side effects—leading to Food and Drug Administration safety warnings for pediatric use and class-action lawsuits—to scientific challenges to their efficacy. With less marketing push and more controversy, antidepressant prescribing has slowed, and “depression” may have less appeal as an all-purpose category.

Nothing about this change, I should note, has much to do with the real suffering of individuals, or even with some decisive change in the types of suffering that people have experienced over time. Rather, what the move from anxiety to depression suggests is a change in how clinicians and patients characterize what appear to be similar discontents and challenges. The change in language I am suggesting—and I am not the first—reflects contingencies, such as professional orientations and the availability and reputation of particular classes of drugs, more than any seismic shift in the actual character of mental distress or social expectations.

The language might be changing again. One possibility is a return to anxiety. The media campaign against Valium is long out of memory, and Xanax, a chemical cousin of Valium, is the single most frequently prescribed psychiatric drug on the market. Others of its class are also widely used. Certainly, the symptoms these drugs treat have not diminished. It is not uncommon to hear claims such as “forty million American adults suffer from anxiety disorders.” Popular coverage is beginning to appear again. A 2012 cover story in New York magazine, for instance, was titled “Xanax: A Love Story,” and asked “what happened to Prozac Nation?” As age-defining disorders go, however, anxiety lacks the neuro-appeal that now seems mandatory. And the greatest use of antianxiety medications is concentrated among the middle-aged. Perhaps hinting at their awareness that this might be the last gasp of an old story, the editors of New York chose a retro, comic-book-style image for their Xanax cover.

There is another possible way forward, this one using another popular category of disorder—attention deficit—that covers some of the same symptoms associated with the other two categories of affliction and is virtually defined in terms of the discontents of “compulsory freedom.” Ads for the drugs that are prescribed to treat attention deficit hyperactivity disorder (ADHD) promise help for frustration, feelings of being overwhelmed, lack of mental focus, restlessness, forgetfulness, and, most centrally, an inability to live up to one’s potential (see sidebar).

Further, ADHD is considered a neurobehavioral condition, and has undergone a progressive redefinition from a childhood disorder to a lifelong disorder (with less and less emphasis on hyperactivity). The percentage of children with a diagnosis has been rising inexorably for many years. The Centers for Disease Control and Prevention reported growth of approximately 5 percent each year from 2003 to 2011, when some 11 percent of all children between the ages of four and seventeen (6.4 million) had received an ADHD diagnosis.

But the sharpest rise in recent years is among adults. Prescription data from drug management companies show that the number of adults on ADHD drugs grew dramatically in the decade ending in 2010. For women ages twenty to forty-four, the rate of use rose 264 percent, and for men in the same age range by 188 percent. By 2012, women ages nineteen to twenty-five had a higher rate of medication use than girls from four to eighteen. If antidepressants were the psychotropic of the Baby Boom generation, the same emblematic status appears to have been conferred on ADHD drugs, taken, with or without prescriptions, among Millennials. Estimates vary, but some surveys have found that as many as one-third of students on selective college campuses have tried an ADHD medication illicitly to improve performance. Consumer spending on ADHD medications has correspondingly increased, and in recent years has risen at a greater annual rate than expenditures on any other traditional class of pharmaceuticals. This growth is expected to continue.

The Age of Depression may well become the Age of Attention Deficit. If so, we will have come full circle. The poet Auden lived what he called “the chemical life.” For twenty years, beginning in 1938, he began each day by taking a drug. But it was not to quell “anxiety.” Rather, referring to the drug as one of the few “labor-saving devices” in the “mental kitchen,” he used it to sustain his workday discipline. The drug was Benzedrine. It is the grandfather of the drugs, from Ritalin to Adderall to Dexedrine, that we now know as medications for ADHD.

—Joseph E. Davis

Reprinted from The Hedgehog Review 17.3 (Fall 2015). This essay may not be resold, reprinted, or redistributed for compensation of any kind without prior written permission. Please contact The Hedgehog Review for further details.

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