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Treating the human condition By Ofri Shoval Tags: anti-depressants, Israel News At the neighborhood barber this week, people were talking about Big Brother and about anti-depressant pills, in that order. A., a videographer who had just had his hair cut, said he had gone to film in New Zealand for three weeks and came back with an amazing piece of trivia: There's a town there, Ashburton, that has earned itself the title of suicide capital of the world. There, of all places. Talk drifted to Israeli depression. Anti-depressants, A. says, are everywhere. Friends take them, friends of friends take them, and even some of his relatives. A man of about 50 was sitting and waiting his turn, listening quietly to the conversation while gazing at the TV. Rather suddenly, he joined in. His name is D., and he owns a computer business. D. estimates that among his circle of friends, about 30 percent are on Cypralex. These days, it's not considered something negative, people are even proud of it, defining themselves as "sensitive souls." Advertisement According to a survey conducted by the Clalit health maintenance organization, about 10 percent of the country's adult population (over the age of 20) are on some sort of psychiatric medication. Between 1 and 2 percent suffer from severe psychiatric problems and 8 percent have been diagnosed with various forms of depression and anxiety. Every year of the past decade has seen an increase of 10 percent in the consumption of anti- depressants and anti-anxiety drugs among adults. According to the survey, which included a representative sample of 500 Jewish adults in Israel over the age of 18, 1 out of every 4 Israelis is believed to suffer from depression. Women tend to seek professional help twice as frequently as men. Another statistic: In one out of three visits to family doctors an element of psychological distress will come up. Not long ago, it was assumed in most social circles that people who took psychiatric medications were not far from being hospitalized in psychiatric wards. But over the last decade, many changes have occurred in the consumption of such medications. An entire group of anti-anxiety drugs and anti-depressants has emerged, which treat what is known in the professional jargon as "soft psychiatric conditions." It is enough to be in a bad mood and not generally happy, for the family doctor - a psychiatrist is not required - to prescribe the right treatment for a more beautiful life. So people take pills to combat depression, anxiety, suicidal tendencies, agitation, shyness, negative energies, bad thoughts, a broken heart. How can this rising market be explained? The experts say it comes from hard times, pressures at work, a spoiled generation, the constant search for happiness, celebrities talking about it in the media, and especially a decline in side-effects of the medications. Nobody comes for treatment when they are happy, or because it is sexy, they say. People come for treatment when they are truly in distress. Professionals quoted in this article welcome the initiative of HMOs that train family and general physicians and pain clinics to identify common psychological disorders as a first response team, leaving psychiatrists to deal with the harder cases. Members of the public, too, for convenience and because of the stigma, tend to consult their family doctor rather than head straight for the psychiatrist's couch. The chairman of the national pharmacists association, David Paso, says that 70 percent of psychiatric prescriptions are for women. He also says he worries when patients say they have been getting psychiatric medication from their family doctor for 20 years without ever having seen a mental-health professional. "As far as the law is concerned, a doctor is a doctor, and it's true that psychological treatments are not included in the health basket, but a solution must be found for the present situation," he says. For years there has been talk of finding a place for mental health in the health basket (the regularly updated list of treatments and medications covered by national health insurance), something that has not yet happened. Hence psychological therapy still remains beyond the means of some, who can only dream about being able to afford it. One person, for example, posted this message on an Internet psychiatric forum: "I've been going around with a prescription for Cypralex for the past few months, waiting until I have the NIS 200 to buy the pills." When one Googles "Escitalopram" (the generic name of Cypralex, which is marketed in the U.S. as Lexapro), over 1 million hits come up. That is not so many compared to Seroxat or Cypramil, which produce a respectable 3.5 million hits, and nothing compared to Prozac, with no fewer than 15 million references on the Internet. The hottest ticket Over the past two years Cypralex has become the hottest of the new generation of anti-depressants. It is currently the most popular anti-depressant and anti-anxietal sold in Israel, where it has been available for four years. The cost of a monthly package of 28 pills is NIS 147. Although some anti-depressants and anti-anxietals are included in the health basket, Cypralex is not. The HMOs decided to help out their clients by reducing the price so clients with complementary insurance pay only about NIS 83-110 a month for a daily dosage of 10 milligrams, depending on the HMO. Cypralex's "older sister" Cypramil, from the previous generation, is in the health basket, at a cost of NIS 55 for a monthly dosage. Both medications belong to the selective serotonin reuptake inhibitor (SSRI) group and are similar in their action, although Cypralex works faster and has fewer side-effects. Anti-depressants and anti-anxietals only ease the symptoms; they are not a cure. As such they are like blood pressure medication and unlike antibiotics, Prof. Yoram Yovell, a psychoanalyst and director of the Institute for the Study of Affective Neuroscience at the University of Haifa, says. Therefore, when the medication is stopped, there is a risk the symptoms may return. What is special about the new generation of anti-depressants? Says Yovell: "They are certainly no more effective, but their side-effects are tolerable. In the past, one had to be very sick to take the medication, because the upsides and downsides had to be taken into consideration. The old generation - Valium, Xanax, Lorivan (Ativan) - create physiological dependence and are sometimes also addictive for those who take them regularly. Still, they are excellent medications for specific problems. People with agoraphobia or fear of flying can take them once and it will help. But today, we tend to prefer medications of the SSRI group." How can anti-depressants help people with anxiety? They are essentially two different situations. "I once heard someone say that the human situation is in fact a choice between anxiety and depression. Either you have what you want, and then you're constantly anxious it will be taken away from you, or you don't have what you want, and so you're depressed. Given this choice, personally, I prefer anxiety. "Traditionally, these are separate categories, but in fact, anxiety and depression go together. It's a kind of continuum of anxietal and depressive situations that are all connected to the same areas of the brain, and that's the reason anti-depressants also work for anxiety." Where is the red line for prescribing psychiatric medications? "That's a problematic question, because there is no clear red line between patients with serious cases and very minor cases; rather, it is a very large gray area." Are psychotherapy and drugs a luxury, for people whose basic existence is assured and who have time to deal with psychological issues? "Not at all. But when physical existence is at risk, it is very difficult to provide psychotherapy. A basic sense of security is needed for a person to be able to look inward freely." Do people in existential danger also develop depression? "That's what was once believed. I think it's not true. If people were in a labor camp and were forced to dig ditches every day, they would dig, not climb into bed. That's possible. But in contrast, some people ran to the electrified fence. There was once a view that neuroses were more common among the upper classes. That is not true." 'My mood improved amazingly' Y., a 32-year-old lawyer, has taken psychiatric drugs twice in his life. The first time was for six months before he broke up with his romantic partner, when he was depressed for quite some time. The psychological treatment he received in the year before the break-up did not bring about the desired relief. The second time was after the woman left him. He took pills for three months, that time unaccompanied by talk therapy with a psychologist. He was pleased with the outcome. The first time, Y. took Cypramil, and the second time, low doses of Cypralex. "I must say that there is a strong psychological component here, because the moment the psychiatrist gave me the prescription for the pills, my mood improved amazingly, even before I took the first one. A friend of mine has been a little depressed for years now and is in therapy, but the pills don't help him," Y. said, adding: "Look, it's been a long time now that you haven't had to be crazy to take pills. The better your socioeconomic situation is, the more open and aware you are and the more you want to improve your quality of life." Y. says that is the reason many people in the media and the performing arts take the medications. Y. himself is not on stage, but he often encounters people who are. He is surrounded by many people in their 20s and 30s who have been on medication for years. There are also those he calls "natural people," who will not take psychiatric drugs because they do not want to ingest chemicals. A., 41, works in the media. For three years he has been on Viepax, a new-generation drug. The pressure he was under at work made him feel that his stomach was churning. He lit a cigarette, started surfing the Web, and typing in names of illnesses. He was convinced he had cancer. His head was heavy, as if it was floating, he felt weak. He seemed to be functioning normally, but he knew something was wrong. He even went to the emergency room, where a doctor told him he was getting over the flu. Since he had never had the flu, he knew that was not the problem. His family doctor prescribed tranquilizers, which A. decided not to take. For as long as he had been married, his wife has been treated with anti-depressants and anti-anxiety medications. One evening he was alone with the kids, and after he put them to bed he decided he had to do something about his situation. So he went to his wife's psychiatrist. "The psychiatrist talked to me; he said it seemed to him I was having a kind of anxiety attack. He explained what the side-effects [of the medication] would be. All my friends know I take pills and I don't have a problem with that. The wife of a friend of mine also takes them and I have a friend who takes them sometimes. Today, the pill really helps me, although I am dependent on it. If I don't take my daily half a pill, I'll feel the symptoms again - but I will have to stop it some day. I don't feel comfortable about living with the pills all the time." '700,000 people' In 2003, after Prof. Yovell returned from a stay of few years in the United States, he was of the impression that Israeli society lacked the openness toward psychiatric medications that he had found abroad. What about today? Yovell: "Psychological problems have become more legitimate in Israel in recent years," he concedes. "There is less of a stigma. The series 'In Treatment' has contributed a lot, bringing psychological treatment into people's living rooms. It's a process of societal maturation. Statistics show that in recent years, 8 to 11 percent of the population in Israel have taken pills to treat a psychological problem. We're talking about approximately 700,000 people. It's not that we're sicker, but rather we are more aware. People are less hesitant. They need to suffer less before they get up and say, 'That's it; I'm going for treatment.'" Could you have a person who comes to you for treatment, say, of shyness? "Let's say that would be a slight psychological problem. My grandfather, of blessed memory [the philosopher and scientist Yeshayahu Leibowitz] used to quote the French philosopher [Francois de] La Rochefoucauld, who said: 'Every person is better at courageously bearing the pain of others.' It's like a doctor who gives a person an injection and says 'This won't hurt.' Well, it doesn't hurt the doctor. "In other words, it is not easy to be slightly depressed. With regard to shyness, there is a common psychological condition called social anxiety. These are people who live among us and don't realize their potential. Shy Yossi sits in the back of the class and keeps quiet. These things take their revenge and decide a person's fate. In a case like this, if a pill can help, I think that's excellent." Clinical psychologist Dr. Dany Rudy finds great openness to the use of psychiatric medications in his practice. "People are going for psychological treatment and taking medication as naturally as they go to university. I've had a few cases where people with anxious personalities suggested during treatment that they take medication. I hadn't thought about it before they asked, but they were right. The cultural situation today creates a great deal more anxiety than in the past. There was a time when a person lived in his little village and when his horse kicked his son, it was sensational. But only the locals knew about it. Today, in the global era, you open the newspaper and you read about a pregnant woman who died of a bacterial infection. There is constant panic that is impossible to avoid. It expresses itself in anxieties and hypochondria." Dr. Margalit Goldfracht, a family physician in Haifa and director of the department for the advancement of quality in medicine in the Clalit HMO, says she does not believe there is enough openness among her patients and is concerned that often they are not aware of their real problem. "They come to me complaining of a stomach ache, a headache, a backache; they say 'I feel weak; I don't feel well; I've lost weight; I've gained weight.' They aren't making it up; clearly their psychological distress is manifesting itself physically, but the whole idea is to pinpoint the source of the real problem. A young women came to me with severe back pain. We did a CAT scan and found nothing. I asked her, 'What's happening in your life?' She answered that her boss had gone crazy, that he was yelling and everyone was afraid. She began to take anti-anxietals and anti-depressants, and it helped her a great deal - the pain went away. Later, the boss also took pills, which led to an improvement in the atmosphere." "This area works a lot according to trends," notes the psychologist Roee Semna, of the Tamuz Institute for psychological counseling and treatment, who runs a psychology forum on the Ynet Web site. "People can drag depression around for 15 years and think that this is the way life looks. Suddenly they take a pill and life changes completely for the better. So they want to let everyone know. That's how a buzz is created, and the social taboo begins to erode. "That makes me very happy, but it bothers me to see, here, too, the 'instant' culture. I heard of kids having stomach-reduction surgery. People want to have everything quickly these days; they have this fantasy about a wonder-pill that will solve all their problems. If a patient decides to give up treatment because he doesn't have the strength to deal with the psychological pain, we have a problem. On the other hand, some people get stuck in treatment for years and are not willing to take pills that will alleviate the situation. That's bad too. The optimal situation is a combination of drug therapy and psychological treatment." "The idea of happiness is a media fantasy," says the psychiatrist Haggai Oren, director of the Abarbanel psychiatric hospital. "People don't come for treatment because they want to be happy, but rather because they want to suffer less. My patients tell me: 'I am functioning less well; I don't feel spontaneous; I'm not fulfilling myself; I am stuck in my job,' and mainly, 'I deserve more.' That's the complaint of the 21st century - we are narcissists. But if there is no decline in functioning or increase in suffering, I don't write a prescription." 'What did the doctor say?' Yovell says he is also aware of a link between values and faith and happiness. "There are societies where if you go to sleep and the children have had their supper, you're happy. But something has changed in the system of expectations. There was a time when people didn't talk about marriage for love and didn't expect to be happy. For a religious Jew, for example, happiness is often found in keeping the commandments. That is real. There are many studies that show that religious faith guards against depression. Or, for example, the generation that established the state. There was great faith in the ideal, in continuing it. It is no coincidence that psychoanalysis was born in Vienna after the Austro-Hungarian Empire broke up, at the end of the 19th century, in a society that had undergone a crisis in values." Yovell also has ultra-Orthodox patients. That is progress he ascribes to rabbis who are more open to psychiatric treatment and changes in Haredi society. "More and more I hear that the rabbi says: 'What did the doctor say? Do what the doctor says.' "Among Haredim, psychological problems were a terrible stigma for years. Since it lowers the chances of a good match, they drag around very severe psychological problems. It's easier for them to take medication than to go for therapy, since pills are something medical. You have an illness - you take a pill. Psychological treatment begins to touch the fundamentals of a person and his or her place in society, and that touches the root of your identity. In ultra-Orthodox societies, it is very important for individuals to fulfill their place in society and not to get all kinds of individualistic notions into their heads. That's the reason they want their psychotherapist to be Orthodox." Despite openness among rabbis in ultra-Orthodox society, traditional social codes have not changed. Stigmas and taboos are still the name of the game, certainly with the cloud of a poor match hanging over the heads of those with psychological problems. As a result, there are those young people who still buy their medication in another city, and who even prefer to buy at a private pharmacy, rather than at their HMO facility, despite the economic burden it entails - anything to avoid a stain on their genetic legacy when it comes to finding a spouse. In Internet forums dealing with depression and psychological problems, people generally reveal the most personal and delicate issues, and receive a virtual hug from others who post. Few responded to a request for an anonymous interview of people on anti-depressant or anti-anxietal medication. Surprisingly, two ultra-Orthodox women, who frequently visit the Walla forum, responded positively, perhaps because it was clear that no one in their immediate circle would read what they wrote. N., 20, from Haifa, has seven siblings, and is to become a kindergarten teacher. On Passover, exactly a year ago, after handing in the last assignment in her study program, she began to feel her heart beating faster and had difficulty breathing. She was given inhalation treatment in the belief that she had a cold, and when that didn't work, she was sent for a lung x-ray. Nothing was found. Her family doctor gave her tranquilizers, which she said made her feel "drugged." After a few nights of insomnia, she would go to her parents' bed. She did not leave her home for a period of four and a half months. Someone at the Internet forum suggested she see a woman psychiatrist in Bnei Brak. She did so, and was told she was suffering from a depressive crisis due to the end of her studies. The psychiatrist also prescribed Cypralex for her. Says N. today: "My parents were not really involved. We are not an emotive family. Today I feel alright, thank God. I have come back to myself." She adds sadly: "Because I am from an ultra-Orthodox home, I'll have trouble getting married. If I'm introduced to a nice boy, and I want to marry him, it can't get out that I took pills. If we get married and afterward he finds out I took pills, he'll divorce me." Y., a 25-year-old Jerusalemite, from a Haredi family of 12, has gone in and out of depression since she was 15. She was also psychologically abused as a child, and has tried to commit suicide a number of times. She has distanced herself from her family, and at present no longer observes the Sabbath. She sees a psychiatrist once a month and is taking Cypralex, which she says has restored balance in her life. She knows many people in her ultra-Orthodox neighborhood who she believes are undiagnosed - her mother, for example. "If you ask me, she has psychological problems. She takes tranquilizers, but she is undiagnosed. Do you know how many people are going around acting like they are normal? During the time I was [looking for] a match, I went out with three guys. My mother told me right away I would have to 'settle,' because I'm fat. Do you get it? The pills aren't even mentioned, because that's a secret. If a guy knows, there will be no match. "I asked the rabbi when I should tell a guy about the pills. He said after things heat up, after the third date. But I haven't gotten to a third date. I've left the ultra-Orthodox circle. I have an ultra-Orthodox woman friend who went out with a guy five times, and everything was going well. On the fifth date she told him she was taking pills for psychological problems, and the guy bolted, of course. Now she is being offered only the real crazies." Use of anti-depression and anti-anxiety medication is much lower among children than among adults. But Prof. Avi Weizman, head of the research unit at the Geha Mental Health Center, is still concerned over the declining age at which children begin taking anti-depressants, something he says is a global phenomenon. During World War II, the age of the onset of depression was thought to be 40 or older, he says, today it is not rare to see depression and suicidal tendencies among children and adolescents. How do you explain the change in the age of the onset of depression? Weizman: "The first explanation is sexual maturity at an earlier age, among both boys and girls. It is believed that this speeds up the onset of depression at a young age. The second explanation is life in a demanding and competitive society, which leads to great pressures, smoking and the use of alcohol and drugs. Depression among children can be very dangerous, because they still don't have the insights adults do. We all experience frustration and rejection, but children tend to respond in a more extreme manner. A particularly narcissistic child won't accept anything less than perfection. He will be frustrated, won't be able to enjoy an achievement, and will respond impulsively. Amazingly, medication is less effective among children than among adults." A national health survey conducted during 2003-2004 showed that the percentage of people taking medication for emotional problems in Tel Aviv was relatively higher than in other cities in Israel. For example, 82,000 Tel Avivians had taken such medication as opposed to 18,000 Jerusalemites - a rate 4.5 times higher. Yovell believes that in this area, as in so many others, Tel Aviv is a bubble. "People in certain circles in Tel Aviv might go around thinking the whole world is on pills. The stigma is greater the farther you get from north Tel Aviv, and the more in the country's hinterlands." However, even in Tel Aviv, with its trend to openness, no one was willing to be quoted using their full name. Yovell says the population group suffering most from anxiety and depression are young women at puberty and those raising children, particularly stay-at-home moms without help. He notes a study of post-partum depression that found that almost half the women surveyed who experienced such depression had gone undiagnosed. He is convinced that Israelis are undertreated: "When it comes to psychiatric medication, the situation in Israel is quite similar to that of Europe and the United States. That says a lot about us, in terms of a high level of psychological strength, because people in Israel live under much more pressure, and the price of the pressure of security issues is much greater. There are indications that in Israel, as in the U.S., only one out of every two people suffering from depression will receive any treatment." What are the societal implications of the continuing increase in the use of medications? "In a society where the pill has come out of the closet, we become more tolerant people. If we used to talk about the pain of the other, now we can say 'this person is not copping out; she is depressed. This child is not a bad child, he's anxious, he's shy.' The better we treat our psychological problems, the stronger a society we will be. People mistakenly think that if we take more pills, we are getting crazier. On the contrary, we are taking better care of problems that were not diagnosed in the past. "Anyone who lives with a person suffering from depression," says Yovell, "knows how destructive it can be for the family, the person's career and their brain. Therefore, it is much better to treat it when the problem is just beginning." Bookmark to del.icio.us   Hebrew harmony Watch American Idol star Adam Lambert singing in Hebrew Top recipes exposed Try the cheap way to eat in some of Tel Aviv's top restaurants

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