The Prozac Revolution

Wonder drug of the '90s over 10 million people world-wide take the anti-depressant Prozac. With such a high prescription rate, the question must be asked -- is this really a miracle drug or is our widespread need for it the true curiosity? Henry Barrkman reports.

The Epilogue to Prozac Nation (a true account of Elizabeth Wurtzel's long battle with depression) begins with Olivia, the author's friend, taking her cat to the vet. Having diagnosed the feline as having excessive grooming disorder -- it was a depressed and self-absorbed animal -- the vet recommended Prozac.

For a little green and white capsule containing just 20 milligrams of powder (capable of increasing brain activity), Prozac has received an incredible amount of media attention.

The New Yorker ran a cartoon depicting Karl Marx on Prozac exclaiming: "Sure! Capitalism can work out its kinks!" Prozac has also been featured in Newsweek, Time and Who Weekly magazines; on television chat shows, including Ricki Lake and Oprah, and on our own 7:30 Report.

In 1994 the media hype reached giddy heights when the "Pied Piper of Prozac", psychologist James D Goodwin, appeared via satellite on Oprah. Practising in the small town of Wenatchee, USA, Goodwin was found to have referred between 700 and 800 patients to physicians for the prescription of Prozac. During the interview, he was pictured surrounded by a roomful of extremely happy patients including one 12-year-old girl who explained how Prozac had saved her life.

Prozac has also been the subject of several books, including the predominantly complimentary Listening to Prozac by Peter Kramer and the unequivocally critical Talking Back to Prozac by Peter R Breggin. Elizabeth Wurtzel's Prozac Nation, an account of being young and depressed, caused a storm of controversy when it was released in America last year.

Prozac's annual international sales are in excess of $1.3 billion. It is the most frequently prescribed psychiatric drug, and the second most commonly prescribed drug in America. Over 10 million people worldwide have been prescribed Prozac; over half of those in America. According to Peter Breggin, author of Talking Back to Prozac, "Just say no to drugs" has been replaced by "Take this drug to improve your life."

Supporters of Prozac believe it's function in increasing brain activity (by blocking the re-uptake of the neurotransmitter serotonin) leads to the improvement of a wide range of personality disorders. Prozac detractors believe the drug upsets the chemical composition of the brain which is forced to compensate for the excess of serotonin and, in the process, irreparable damage may be caused to the bombarded receptors on the post-synaptic nerve which disappear.

Prozac was first developed in 1974 but the Food and drug Administration of America (FDA) didn't approve of it as an anti-depressant until late December 1987. Eli Lilly began marketing the drug early the following year. Although it had taken over a decade to develop and test, within months of its release Prozac was well on its way to becoming the most widely prescribed anti-depressant in America. In 1990 the Australian Drug Evaluation Committee approved Prozac for use in the treatment of major depressive disorders in Australia . Since then, the number of prescriptions has doubled each year.

According to figures from the Pharmaceutical Benefits Scheme, during the last financial year, over 650,000 Prozac prescriptions had been written in Australia. The total cost? Almost $42.5 million.

The drug is lauded by those biopsychiatrists who believe in biologically determined temperament, as "the wonder drug of the '90s" for the treatment of chemical imbalances in the brain that cause unhappiness.

It is claimed that Prozac can make people who are not depressed feel "better than well" -- more confident, assertive and optimistic. Peter Kramer, author of Listening to Prozac, describes the use of Prozac in this manner as "cosmetic psychopharmacology". However, most of his claims have been based on uncontrolled case reports that could be attributed to a placebo response.

Conversely, Prozac is lamented by those Freudian pyschotherapists who believe personality is determined by events in one's past, particularly those of early childhood. Many psychotherapists regard Prozac as an ineffective Huxleyan "soma" that only succeeds in limiting self-discovery by numbing the patient to the reality of their emotions which,they believe, may in turn lead to violent actions such as murder and suicide.

After Joseph Wesbecker shot dead eight people and wounded 12 others with an AK-47 rifle in Louisville, Kentucky in September 1989, he was found to have Prozac, in addition to Lithium, low concentrations of several other antidepressants and a sedative in his blood. Survivors of the massacre and relatives of the deceased brought suits against Eli Lilly claiming: "Prozac, one of the drug manufacturer's biggest money makers, is partly responsible for the gunman's violent actions." Five months later, an article by Martin Teicher et al appeared in the American Journal of Psychiatry reporting the development of "intense violent suicidal preoccupations" in six patients who were taking Prozac.

As a result of media focus on the assertion that Prozac increases suicidal behaviour and acts of violence, the FDA in America conducted hearings on Prozac in 1991. That same year, the Royal Australian and New Zealand College of Psychiatrists issued a statement emphasising the safety and efficacy of Prozac in an attempt to allay the concerns of those patients taking the drug.

Despite the fact that there has, as yet, been no conclusive evidence linking Prozac to suicide or violent behaviour, Prozac Survivors Support Groups have been springing up in America since 1991 to help those attempting to withdraw from the drug and to aid those seeking compensation from the manufacturer, Eli Lilly. A total of 170 lawsuits has been brought against Eli Lilly by the end of 1992, and Prozac is being used as a defence in court by people who have committed crimes while taking the drug. Prozac was originally approved for the treatment of severe clinical depression, yet once a pharmaceutical has gained approval the government has no control over what it is prescribed for.

Prozac's popularity does not derive from its efficacy, but from its less objectionable side effects. Prozac is also less toxic than other anti-depressants when taken in large doses which, of course, means a reduced risk of suicide. These facts encouraged its prescription for conditions other than major depression -- conditions once the exclusive domain of psychotherapists.

Many patients with problems such as excessive sensitivity to rejection, lack of self-esteem and an inability to experience pleasure, report a dramatic response to Prozac. As a result, it has been predominantly prescribed by general practitioners, as opposed to specialists, for a wide variety of ailments including -- "winter blues", obesity, anorexia, bulimia, phobia, anxiety, chronic fatigue syndrome, premenstrual syndrome, migraines and arthritis.

Peter Kramer, a psychiatrist who had previously focussed on psychotherapy, now believes that Prozac can often succeed where conventional psychotherapy has failed and that Prozac can also be a powerful adjunct to the psychotherapeutic process. "I found it astonishing that a pill could do in a matter of days what psychiatrists hope, and often fail, to accomplish by other means over a course of years: to restore a person robbed of it in childhood -- the capacity to play ... I had come to see inborn, biologically determined temperament where before I had seen slowly acquired, history laden character," he comments.

Kramer believes that if frailty and self-destructiveness disappear in response to a biological treatment, they must have been biologically encoded. Among his many claims for Prozac are: it has transformative powers which leave patients feeling "better than well"; it goes beyond treating illness to changing personality; and that it enters into the struggle to understand the self. The enormous popularity of his book, and the continued widespread prescription of Prozac for conditions other than clinical depression, have heralded a major attitudinal shift in psychiatry. Eli Lilly was so concerned about the growing tendency to prescribe Prozac for personality enhancement that the company took out an advertisement in the March 18, 1994 edition of Psychiatric News, the official newspaper of the American Psychiatric Association. The advertisement read, in part: "Much of this attention has trivialised the very serious nature of the disease Prozac was specifically developed to treat -- clinical depression. The company does not believe that any improvement in well being indicates a change in personality."

Some castigated the move, however, saying it merely reflected Lilly's concern that an avalanche of liability suits would result from over prescription. Elizabeth Wurtzel's reaction in Prozac Nation was somewhat kinder. "At two or three dollars a pill, at the rate of two pills a day, I feel that I have already mortgaged my life to Eli Lilly. For the $11,000 worth of business I've given the company, I wouldn't mind believing that they're doing a little bit of public service."

Since its inception, the theoretical underpinnings of psychiatry have been based on the work by Sigmund Freud and his successors. Emphasis has been on the patient's insight into early childhood experiences -- the individual's struggle with anxiety being the preferred route to self-discovery. While psychopharmacology has been employed for serious mental illness since the 1950s, psychotherapy has remained, until now, the mainstay of the field. Psychopharmacology, like psychotherapy, is not yet based on a deep mechanistic understanding. Nobody really understands why blocking the re-uptake of the neurotransmitter serotonin ameliorates depression, over-sensitivity to rejection, anxiety and a host of other conditions. The most challenging problem of psychopharmacology at the moment is explaining Prozac's influence on the molecular chain of events in the brain. Furthermore, it is unknown whether Prozac actually does change personality as it has proven no more effective than sugar pill placebos in certain trials. Placebo plays a key role in scientific studies and it has been demonstrated that up to 50 percent or more of depressed patients improve on a sugar pill. Does Prozac itself make people better or is recovery the result of the a combination with psychotherapy? "In my experience," writes Kramer, "many patients, including some who may never have had a diagnosable mental illness, are better able to explore both their past and their current circumstances while they are taking Prozac."

Prozac disrupts serotonin and dopamine; two of the neurotransmitters most involved in frontal lobe function -- that part of the brain which controls empathy. Will patients be "cured" by Prozac desensitisation rather than addressing, in psychotherapy, circumstances which may lead to an understanding of their feelings of anxiety, shame, guilt, injustice, remorse etc?

"While touting the drug's capacity to reduce sensitivity to oneself and others, he [Kramer] fails to face the implications of creating a society of less in touch, less caring, and less loving human beings ... Drugs are euthanasia of the soul, but a euthanasia applied at a heightened, if anguished, moment of life," writes Peter Breggin.

The influential American psychoanalyst Elizabeth Zetzel considered the capacity for emotional growth to be grounded in the capacity a person had to bear anxiety and depression. Therefore, to use a pill to improve mood denies access to the means for growth.

Anxiety and depression have also been regarded as the driving force behind many successful artists -- Van Gogh, Hemmingway, Dylan and Leonard Cohen, to name a few. If they had been prescribed Prozac would they have created what they did, or left it to someone else?

It is, of course, impossible to know. Nevertheless, the temptation to prescribe Prozac when the results can be so startling must be great. "I was used to seeing patients' personalities change slowly, through painfully acquired insight and hard practice in the world. But recently I had seen personalities altered almost instantly, by medication," comments Kramer. The growing belief among psychiatrists that biology plays a part in less serious behavioural disorders is going to have a major impact on the way future psychiatrists treat their patients. Despite Kramer's observations of the transformative qualities of Prozac, he still regards psychotherapy as the single most helpful technology for the treatment of minor depression and anxiety. He believes that medication can speed this treatment, and can sometimes bring about remarkable transformations of its own.

Elizabeth Wurtzel, who has been taking Prozac since it was approved by the FDA, does not think Prozac is that great, but she takes it every day. "A strong hardy depression will outsmart any chemical," she writes. "All my attempts to lower my Prozac dose have resulted in an onset of the same symptoms. Even on Prozac and lithium I have had severe depressive episodes."

This is a definite problem for some patients. While Prozac is not physiologically addictive, patients are reluctant to come off medication for fear they will revert to their previous state of deep unhappiness. According to Elizabeth Wurtzel: "The trouble is the big-picture problems that have got so many people down are more or less insoluble ... So it seems fairly reasonable to anaesthetise ourselves in the best possible way. Just as our parents quieted us when we were noisy by putting ourselves in front of the television set, maybe we're now learning to quiet our adult noise with Prozac."

One has only to look at the daily newspapers or television reports to understand what she means: "Stress at work -- the crippling plague of the '90s", "Suicide is the major cause of death amongst young men", "Tel Aviv bomb blast kills 7", "Zepa Muslims told: Run for your lives" etc, etc, etc. Is, in fact, the world too difficult to deal with without Prozac or some other "little helper?" Well, in Wurtzel's opinion: "Prozac appears to be a panacea for the asking." Perhaps she's right. Order me a kilo.

Prozac Nation by Elizabeth Wurtzel Reviewed

© Copyright 1995

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