The Multiple Anxieties of Getting Older: Tranquilizers and the Ambivalence of Effect

Abstract

Most studies on benzodiazepines emphasize overconsumption and warn of addiction, especially by older adults. This article is about the avoidance of benzodiazepine medications by ‘aging’ women living in a Brazilian village. This case study helps to support our central concern: to call attention to the ambiguities that exist in discussing these medications, and to stress the importance of a multilayered understanding of effect. We argue that benzodiazepines, like other psychopharmaka, induce bodily sensations that, at least in part, correspond to and are shaped by the situated self-image of individuals in distress.

Keywords:

• aging
• anxiety
• benzodiazepines
• Brazil
• effect

ACKNOWLEDGMENTS

We would like to thank Dominique Béhague and Junko Takanaka for organizing the panel “Psychopharmaceutical subjectivity, industry, and historical contingencies,” at the 2011 AAA meeting in Montreal, as well as Emily Martin and Lawrence Kirmayer for their stimulating comments. The collaboration between the two authors was made possible by a FRSQ grant for the MéOS research group (Le médicament comme objet social). We greatly appreciate the kind and helpful comments made by the three reviewers.

Notes

The Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR) incorporates within anxiety disorders generalized anxiety disorder, social anxiety disorder (or social phobia), specific phobia, panic disorder with and without agoraphobia, obsessive-compulsive disorder, posttraumatic stress disorder, anxiety secondary to medical condition, acute stress disorder, and substance-induced anxiety disorder (American Psychiatric Association 2000). The more inclusive criteria accepted for the forthcoming DSM-5 will, Frances Allen (2012) suggested “obscure the already fuzzy boundary been Generalized Anxiety Disorder and the worries of everyday life. Small changes in definition can create millions of anxious new ‘patients’ and expand the already widespread practice of inappropriately prescribing addicting anti-anxiety medications” (no page).

In a recent study, King and Esseck (2013) found that three factors influence regional differences for psychotropic medication use in the United States: access to health care, insurance coverage, and pharmaceutical marketing. This may also explain the differences regarding regional differences in British prescription patterns of benzodiazepines, given that there are no significant differences in the prevalence of mental health problems across the country (Weich et al. 2003). In Brazil, it would explain the North-South difference (better financial capacities of the households and better access), but not the importance benzodiazepines have in Santo André with its difficult access and restricted financial resources of its inhabitants. National politics regulating benzodiazepine prescriptions are another factor, although they depend on the implemented systems of control, such as electronic administration of patient files. There are many legal and illegal possibilities of ignoring those regulations, such as visiting different physicians, illegal selling either on Internet or in pharmacies, using the black market, and others.

See, for example, National Institute of Aging (2012): http://www.nia.nih.gov/health/publication/biology-aging.

Today, major health organizations such as the American Psychiatric Association or the British National Institute for Health and Clinical Excellence principally recommend using the newer antidepressants, SSRIs, for the treatment of anxiety disorders. However, SSRIs often take several weeks until any benefits are felt, and benzodiazepines, because of their immediate effect, are still being recommended for acute and short-term interventions (e.g., Cloos and Ferreira 2009). The current recommendations, privileging the use of SSRIs, mirror a more recent change in the history of anxiety drugs. Depression and anxiety are conceived as comorbid in most cases, just as Sigmund Freud suggested, and SSRIs are found to treat both anxiety and depression. One of the strategies for the acceptance of SSRIs as the new non plus ultra in mood disorder treatment was that warnings against dependency-creating benzodiazepines should be incorporated into the marketing strategies (Horwitz 2010; Lakoff 2005; Rose 2006). It was later found that SSRIs also cause physical addiction (and so-called discontinuation syndrome), although this is not widely known (Healy 2002:169–171; Murray 2006). Also, the controversial possibility of a higher rate of suicide associated with SSRI consumption means that SSRIs are not necessarily the ideal alternative to benzodiazepines. And, finally, SSRIs may cause anxiety in some cases, despite that they are marketed as acting against anxiety (Brambilla et al. 2005).

The authors conclude: “The community-based participants were not passive recipients of benzodiazepines; they regularly weighed up the costs, the risks of side-effects, dependence, and potential social alienation against the benefits, and most decided that benzodiazepines improved their quality of life” (North et al. 1995:643). Social psychologist Joke Haafkens (1997) disagrees. He called these practices “rituals of silence.” Pharmaceutical companies take advantage of fragile individuals (mostly women), while prescribing doctors, even after having recognized the potential dangers of this drug group, and knowing about the social stigma associated with benzodiazepines, continue to prescribe and promote these drugs to (addicted) patients.

“The term ‘embodied molecules’ describes the experienced ‘cultural chemicality’ of medications. … Effects stemming from group experiences consequently influence how the informed individual experiences the medication he or she takes [through] … the materiality of the drug (its molecules), the reacting body, and the socio-cultural context in which the effect takes place” (Leibing, forthcoming).

São Paulo and Rio de Janeiro are respectively the tenth and twelfth most expensive cities in the world (Heatley 2011).

The data about Santo André are the result of an ethnography: AL stayed on four occasions in the village, each visit lasting around one month. Informal interviews with the nervous women, some men, local healers and two doctors (MDs) in the closest major town, as well as observations, sometimes participant observations, were the main methods used to understand local practices of care and self-care at the beginning, while later the focus was on the women's nervousness.

All quotes from individuals living in Santo André, and those stemming from the Brazilian literature, were translated by AL.

With the arrival of the DSM-III in 1980, depression and anxiety were distinguished as diagnostic entities, and drug treatment was separated accordingly. Shorter and Tyrer (2003) observed that this

obscured the notion that certain drug classes were effective for both anxiety and depression, particularly the benzodiazepines. With the decline of the benzodiazepines in the 1980s, anxiolytic therapy was placed on the back burner and antidepressants rushed into the spotlight, in the form of selective serotonin reuptake inhibitors. In the world of pharmacotherapy, anxiety and depression had become as different as chalk and cheese. (159) The current recommendation privileging the use of SSRIs mirrors a more recent change in the history of anxiety drugs. Depression and anxiety are once more believed to be concurrent in most cases, but different from the pre-DSM III period, now they are treated with antidepressants: “Because they so often go hand in hand, anxiety and depression are considered the fraternal twins of mood disorders,” wrote a health reporter (HealthyPlace.com 2009; emphasis added).

Additional information

Notes on contributors

Annette Leibing

ANNETTE LEIBING is a medical anthropologist (PhD, University of Hamburg, Germany) who first taught at the Federal University of Rio de Janeiro and is now a full professor at University of Montreal. She does research on topics related to aging, psychiatry, stem cells, and others, many of these topics located in Brazil.

Johanne Collin

JOHANNE COLLIN, PhD, is a sociologist, historian, and full professor at the Faculty of Pharmacy of the University of Montreal. Her research program is entirely devoted to the history and sociology of medications. She has published numerous books and scientific papers, which have earned her many honors including admittance to the Académie internationale d'histoire de la pharmacie in 1999 and reception of the Eliot Freidson Outstanding Publication Award (coauthored) in medical sociology in 2001.