The pandemic’s true toll on mental health won’t be known for a long time, but data from the past two years indicates a rise — some of it sharp — in prescription drugs for conditions like A.D.H.D. and depression.
By Casey Schwartz
If you’re wondering which pills and how many of them Americans have relied upon to make ourselves feel better since Covid-19 arrived, the answer, in short, is yes.
“I should have gone back on medication sooner in the pandemic than I did,” said Leah Bellow-Handelman, 36, matter-of-factly. Ms. Bellow-Handelman, a nurse who lives in Brooklyn with two small children, has been on and off Prozac for anxiety since her 20s. Shortly before the pandemic, she had weaned herself off in time for her first pregnancy.
So, she wasn’t taking anything when the pandemic struck, even though her life was operating in full crisis mode: She worked at the urgent care center at Memorial Sloan Kettering in Manhattan, a cancer hospital. The emergency room is dedicated to current and former cancer patients, and many of the patients admitted to urgent care had especially severe cases of Covid and needed oxygen or intubation right away.
“We just put our heads down and did what we had to do,” she said. “We were in such autopilot disaster mode in the spring, that by the summer, that was when we really realized how intense that spring really had been.” Ms. Bellow-Handelman also felt isolated; many friends had left the city, and of those who remained some were hesitant to see her because she worked in health care.
By August 2020, her husband encouraged her to go back into therapy.
After a complicated second birth, she decided she needed more than just talk. Her therapist, she said, “was never opposed to me going back on medication, but she was trying to get me to do mindfulness and meditation — stuff that I just don’t do.”
She turned to Prozac again. Now, she said, “I’m a different person.”
The reasons behind the decision to start or restart psychiatric medication are often not reducible to simple cause and effect.
“I’m definitely medicated because of Covid, but I’m also medicated because I’m a woman who was a nurse who had babies in the middle of Covid, and a traumatic birth,” Ms. Bellow-Handelman said.
She is one of millions of Americans who started or restarted psychiatric medication during Covid’s long and dreary run. Tracking exactly which pills Americans are swallowing these days is difficult because much of this information is privately held.
But, from companies that provided data to The New York Times and from other existing research, it is possible to begin to assemble a picture of our medicine cabinets and, by extension, our mental health.
First, the broad strokes: In 2019, the Centers for Disease Control and Prevention estimated that 15.8 percent of American adults took prescription pills for mental health. During the pandemic, the National Center for Health Statistics teamed up with the Census Bureau to carry out quick online “pulse” surveys and tracked mental health prescription pill use.
The numbers they turned up echo what we already sense: We are depressed, anxious, tired and distracted. What’s new is this: Almost a quarter of Americans over the age of 18 are now medicated for one or more of these conditions.
More specifically, according to data provided to The Times by Express Scripts, a pharmacy benefits manager, prescriptions across three categories of mental health medications — depression, anxiety and A.D.H.D. — have all risen since the pandemic began. But they have done so unevenly, telling a different story for each age group and each class of medication.
Antidepressants continue to be the most commonly prescribed of these medications in the United States, and their use has become only more widespread since the pandemic began, with an 8.7 percent rate of increase from 2019 to 2021, compared with 7.9 percent from 2017 to 2019, according to Express Scripts.
IQVIA, a global health technology and clinical research firm, found that in 2021, a total of 337,054,544 prescriptions were written for antidepressants in the United States through the course of the year, representing a steady annual increase since 2017, when that number had been 313,665,918.
But for some age groups, that change has been more pronounced. Since 2017, there has been a 41 percent increase in antidepressant use for the teenagers included in the Express Scripts data (which consists of roughly 19 million people.) For this same 13- to 19-year-old bracket, in the first two years of the pandemic, there was a 17.3 percent change in anxiety medications. It had been a 9.3 percent rate of change between 2017 and 2019.
One 13-year-old rising eighth grader in Colorado currently takes the antidepressant Paxil and the stimulant Adderall. (She also takes melatonin, a nonprescription supplement, to help her sleep.)
Before the pandemic, she had started taking Adderall to help her with her A.D.H.D., but when her school switched to remote learning, she struggled. “It just felt like one of those days where you sit at home and you don’t do anything. It felt like that was every day, like I was stuck in some endless cycle of sitting in one place,” she said. “For me, everything felt a lot more pointless. It didn’t feel like I was in school — I just felt like I was in a dream. So I didn’t feel like I needed to do my assignments, because I didn’t feel like anything I did at that time actually mattered.”
Sitting with her puppy helped, but her teachers told her it was too distracting onscreen. Ultimately her mother decided to try her on Paxil.
“She’s an anxious person,” said the teenager’s mother, Ellie. “She gets stuck in her own head and her thoughts loop. She gets frustrated with schoolwork, and she doesn’t want to do it if she doesn’t think she can do it perfectly.”
“It was affecting her mental health and she was cranky and depressed, and she got her period early,” she added. “It was just so many things at once.”
Their pediatrician recommended she come off the Adderall to determine whether the Paxil worked. While she was off the Adderall, her grades slipped. She recently started taking it again. She said the main downside of Adderall comes at meal times. “Last year, when I was on it, I couldn’t eat anything, so my sister would make me smoothies so I didn’t have to chew.
“I just felt too productive to eat. I had no appetite, instead, my brain was like, ‘You have to do everything right now.’ My body was hungry, but my mind was not.”
These rising medication numbers aren’t necessarily caused only by a worsening of mental health in this country (although we know that rates of anxiety and depression have increased). Part of the uptick could be explained by the fact that, stuck at home, people finally had time to seek out the health care they had been delaying. But patients seeking help are doing so against a backdrop of isolation, restriction, uncertainty and grief.
“There’s less of a barrier culturally around using medications,” said Dr. Cecil R. Webster Jr., a psychiatrist in Boston and a lecturer at Harvard Medical School and McLean Hospital. At the same time, life in the digital age means that people expect immediacy: immediate replies, immediate delivery, immediate improvement. “We have no tolerance for slow change,” he said. “But many of the problems we are faced with demand slow change.”
Yet we’ve always had problems — and for everyone alive today, we’ve always had pills. The tranquilizers that first became popular in Eisenhower’s America were, within a few years, so commonplace as to be called “mother’s little helpers,” until they were shown to be dangerously addictive.
“The 1950s and ’60s were widely framed as the age of anxiety,” said Anne Harrington, the author of “Mind Fixers: Psychiatry’s Troubled Search for the Biology of Mental Illness” and a historian of science at Harvard. “And the ’80s and ’90s became the age of depression. And yet it’s unclear that people’s symptoms actually changed.”
The triumphant rise of the antidepressant
Prozac arrived in 1987, and just seven years later there was Elizabeth Wurtzel, the waiflike Harvard grad with the big, doleful eyes, staring out from the cover of her blockbuster book, “Prozac Nation.” An early devotee of such pills, she reported from the front lines of the new pharmacological war on sadness, an avatar of Gen X anguish and hope. (Ms. Wurtzel died in 2020 from breast cancer.)
Prozac set a new standard for the treatment of depression, but its success was tied to its predecessors. Long before there was Prozac, there was iproniazid, developed for tuberculosis but applied to depression after doctors observed the cheering effect on a group of TB patients in a hospital on Staten Island (the often-told story has it that they danced in the hallways). Iproniazid did not cure TB, but it came onto the market as something with potentially wider application: the long-sought “psychic energizer,” as Dr. Nathan Kline, a psychoanalyst who was one of its earliest champions, put it.
Prozac was developed to answer what was then the prevalent theory of depression: that it was caused by a chemical imbalance in the brain, specifically too little serotonin. Prozac and similar drugs are called selective serotonin reuptake inhibitors, meaning they block the reabsorption of serotonin in the brain.
“When these drug companies began to market S.S.R.I.s as drugs repairing a so-called chemical imbalance, if you look carefully at the early ads, they say, ‘depression may be caused by’ or ‘we actually don’t know what causes depression,’ in the fine print,” said Professor Harrington. But the Food Drug Administration made it easier for drug companies to advertise directly to consumers, and the language of “chemical imbalance,” according to Professor Harrington, “had a really big impact on how we made sense of our mental distress.”
As the psychiatrist Dr. Peter Kramer put it in “Listening to Prozac,” his landmark 1993 book that helped crystallize the cultural moment, “Prozac was on ‘Nightline’ when you went to sleep and on the ‘Today’ show when you woke up.” Within the first two years of Prozac’s existence, 650,000 prescriptions were written for it per month.
In 1993, Dr. Kramer was asking careful questions about who should use Prozac and why, but almost 30 years later, he recognizes that the dispensing of antidepressants has grown significantly more casual. Prozac, and its cousins like Zoloft and Lexapro — given out to treat depression but also anxiety, obsessive compulsive disorder and other disorders — are now a banal sight in American medicine cabinets, between the Band-Aids and the Tylenol.
“I think the reason doctors are more blasé about prescribing these medicines is that they’ve now been around for a long time and they can prescribe them without getting into trouble,” Dr. Kramer said. But there’s one more reason, too, he thinks: our growing “intolerance” for “more mild levels of depression and neurosis.”
Debates rage on the efficacy and safety of antidepressants. In a recent article in The Nation, the writer P.E. Moskowitz, echoing a longstanding concern of some prominent skeptics, points out that antidepressants are much more difficult to get off than advertised and that the chemical-imbalance theory of depression on which it all rests has never been proved.
In a study published this year in JAMA, a team of researchers led by Dr. Sadaf Milani of the University of Texas Medical Branch found that antidepressant use during the pandemic differed across genders.
Looking at data pooled from 15 million to 17 million Americans during the initial months of the pandemic, she said, her team found that rates of serotonergic drugs (prescribed for both depression and anxiety) used by women increased to a 15.18 percent prevalence rate by October 2020 (compared with 12.77 in January 2018). For men, there was a bump in antidepressant use in the first weeks of the pandemic — with a 6.73 percent prevalence rate in April 2020 (compared with 5.56 percent in January 2018). For men and women, rates of antidepressant use dropped off slightly in 2021, but remained higher than they had been in 2018.
The age of depression meets the age of distraction
Adderall, a medication that hit the American market in 1996, was created to treat attention deficit disorder, and its very name, as Alan Schwarz reports in his book “ADHD Nation,” was inspired by the phrase “A.D.D. for All.”
Adderall was nothing new: The same chemical compound had been used in previous decades as a weight-loss drug, then called Obetrol. But from a pharmaceutical perspective, it was a name well chosen. Within 10 years, more than nine million Adderall prescriptions were written. And from 2006 to 2016, use of prescription stimulants doubled.
During the pandemic, even as stimulant use among the youngest Americans leveled off slightly, the most recent data from Express Scripts suggests that these pills are being given at ever increasing numbers for young adults. Among Americans ages 20 to 44, numbers of A.D.H.D. medications went up 7 percent from 2017 to 2019, but they increased by 16.7 percent from 2019 to 2021. According to IQVIA, just under 77 million prescriptions were written for A.D.H.D. stimulant medications in 2021, nearly six million more than in 2020. In 2017, that number was 66,612,308.
In some ways it’s easy to understand why, as millions of people are burned out, lethargic and forced to focus all day on computer screens displaying a game board of talking heads with little to no true social connection (to say nothing of exhausted parents stranded with no child care, no school and no help).
Emergency legislation, passed in the early days of the pandemic, may have helped to ease the pathway to an Adderall prescription even further. The new rules lifted the requirement that doctors see patients in person in order to prescribe them certain controlled substances, including Adderall.
Newly minted telehealth companies like Cerebral, which was founded in 2020, provided customers with stimulant prescriptions after a 30-minute, online-only consultation.
The Wall Street Journal reported that the Cerebral Medical Group was recently subpoenaed. The company’s president and chief medical officer, Dr. David Mou, canceled an interview with The New York Times that same weekend.
What the therapists say
For many psychologists and psychiatrists, these numbers aren’t exactly surprising. Clinicians across the country describe the same patterns: their practices filled to capacity; patients who are in significantly worse shape than before; patients who had been stable for years, now in need of hospitalization or intensive outpatient treatment; patients who had been in psychotherapy for years, suddenly needing medication for the first time, or higher doses of the meds they were already on.
Harris Stratyner, a psychologist in New York, says that of his 70 patients, 46 of them started medications in the last two years. “A lot of patients have told me that they feel like they can’t get up in the morning,” he said.
Dr. Stratyner’s colleague (and daughter), Alex Stratyner, echoed her father’s observations. “I think what a lot of people are trying to avoid talking about is trauma: People were traumatized by Covid,” she said. “Millions of people have died. There has not been a processing on a grand scale of what it is we just endured.”
Dr. Robert Ashley, a psychiatrist in Los Angeles, said that “everyone, every day, just wakes up with 10 percent extra pressure on them.” Dr. Ashley described a practice saturated with “people who have been stable for years in therapy and they have reached a point during the pandemic where their therapist thinks they should be evaluated for medication.”
When Dr. Ashley puts a patient on an antidepressant, his typical plan is to wait until they feel better, or “normal,” which can take four to six weeks, then keep them on the medication for six to 12 months, at which point he will start to look for a good time to take them off.
“We’re hoping that the depression was an aberration in their lives and not part of a recurring pattern,” he said. “Seventy percent of my patients who are taking antidepressants are in therapy of one form or another. So the hope is also that the medication lifts them enough out of the depression that they can engage better in their psychotherapy.”
In some ways, Dr. Ashley’s vision for the ideal use of antidepressant is the exception to the rule of how antidepressants are more commonly prescribed in the United States: in a primary care setting, by a family doctor or internist, unaccompanied by talk therapy. A 2013 study found that more that 79 percent of antidepressant prescriptions were written by primary care physicians.
Without the tools of talk therapy, then, one could wonder what the logic is of the prescription. Are the pills in and of themselves a cure, that you take for a certain amount of time, then find yourself transformed? Or are they a treatment that only works as long as you are still taking them, if they work at all? Existing research paints an inconclusive picture as to how effective antidepressants are compared with placebo.
“To me, therapy is the long-term solution,” said Dr. Tina Nguyen, a psychiatrist and associate professor at the U.S.C. Keck School of Medicine in Los Angeles. “But if the severity of your depression is high, you’re not even able to engage with a therapist.”
Dr. Nguyen, whose specialty is childhood and adolescent psychiatry, described a similar phenomenon to Dr. Ashley’s: patients who need medications at higher doses than ever before.
For one teenage patient, for example, Dr. Nguyen believes that the pandemic’s abrupt lockdowns, social isolation and fraught return to school have all contributed “to the explosion of her symptoms.” Dr. Nguyen sees her multiple times a week and prescribes Prozac, Concerta, Gabapentin and Ritalin for when the Concerta wears off.
“She had symptoms before Covid.” Dr. Nguyen said. “She would have needed treatment, but I don’t know that it would have been as extreme.”
Back in Colorado, the young teenager has no plans to discontinue meds. Though her daughter is young, her mother, Ellie, isn’t concerned about the implications of the medications long-term. She herself is used to the idea of taking prescription pills over years, even decades.
“I have been on Lexapro and Prozac for as long as I can remember,” she said. “I started taking Prozac as a senior in college, and I’m turning 50 this year. I would not be able to function without it.”