The Culture Of Prozac

SHE HAS NEVER SUFFERED FROM DEPRESSION, AND SHE'S not one to pop pills for fun. So why would a successful, 43-year-old public-relations executive take Prozac? Helen Baker of Chicago (who wants to be identified by this pseudonym) takes it to give herself an edge. Like any busy professional, she often juggles competing priorities. Faced with looming deadlines and a dozen calls to return, she used to find herself paralyzed. "I would be unable to focus," she says. "I would end up waiting until the last moment to get things done." Now that she's on the antidepressant, she not only handles job pressures more gracefully but sports a more buoyant personality. She recently found her hand shooting up when a nightclub comedian asked for a volunteer from the audience. "I couldn't believe I got up there and wasn't nervous," she says. "I was being open and making people laugh. In the past, I might have wanted to do it. but I wouldn't have done it without Prozac."

No one has tried to count the number of people who fit Helen Baker's profile, but her experience is a parable for the '90s. Compared with the anti-depressants of the past-obscure compounds that only psychiatrists and their patients could name-Prozac has attained the familiarity of Kleenex and the social status of spring water. The drug has shattered old stigmas. Americans now swap stories about it at dinner parties, joke about it in cartoons and essays and recommend it to stressed-out friends and relatives. For those with modems, there's even a computer bulletin board devoted to the drug. Introduced in 1988 by Eli Lilly & Co., Prozac now boasts worldwide sales of nearly $1.2 billion a year. Doctors, most of them nonpsychiatrists, write nearly a million prescriptions a month, and the recipients are often healthy people seeking nothing more than a cheerier disposition. "Prozac helps people think in new ways," says Chicago psychiatrist Marc Slutsky. "It helps you get out of ruts. It helps people who are obsessively driven to loosen up a little." The question is whether that's an appropriate use for a mind-altering drug with unknown long-term effects.

Prozac's popularity is not hard to fathom. Though the drug and its chemical cousins Zoloft and Paxil are no more effective than older treatments for depression (the success rates are 60 to 80 percent), they're vastly easier to use. The most common older drugs, known as tricyclics, have little effect at low doses and quickly become toxic at higher ones. Finding the middle ground can require weeks of blood monitoring. Even at therapeutic doses, the tricyclics leave many users feeling fat, sluggish and constipated. Prozac and family can take three weeks to bring results, but because they bolster just one of the brain's many signaling molecules (serotonin), anyone can safely start at a standard daily dose. Most patients can weather Prozac's common side effects, but they're not trivial. In addition to jitteriness and insomnia, many users experience nausea and poor appetite. And though sexual side effects were--once dismissed as rare, recent studies suggest that more than a third of all patients experience a loss of libido or difficulty reaching orgasm. No one has found a way around such drawbacks, but drug makers are now developing compounds that promise faster action against depression and higher success rates.

Depression is just part of the Prozac story. One reason the drug has become cultural currency is that folks are using it for just about everything but hang-nails. Though depression is still the only condition for which it's currently licensed in the United States, doctors are directing it at such socially topical concerns as gambling, obesity, premenstrual syndrome (PMS) and fear of public speaking. Dr. Asha Wallace, a family practitioner in Needham, Mass., started treating her PMS patients with Prozac three years ago on the advice of psychiatrists she knew. "There were no real side effects," she says, "and the patients love it." Dr. Michael Lowney's patients love it, too though they take it for chronic back pain. "I've tried some of the other serotonin enhancers," says the Massachusetts osteopath, "and I find they're helpful too." Encouraged by studies linking low serotonin levels to violent behavior, some clinicians even speculate (to the dismay of social critics) that the drugs could be used to soften criminals' antisocial impulses.

For now Prozac's most popular unapproved target is "dysthymia," or chronic discontent that falls short of clinical depression. Like most dysthymics, 40-year-old Annette Dawson (a pseudonym) has always gotten along passably without medication. Her friends think of her as stable, not moody. But until she started taking Prozac last June, she often felt hobbled by self-doubt. "It was my therapist who felt I ought to investigate Prozac," she says. Dawson resisted at first-"I didn't like the idea of taking a drug"but she now counts herself a convert. "I'm not as introspective as I used to be," she says. 'And now that I'm introspecting less, I'm not bothered as much."

Many experts would consider her story a triumph. Treatable psychiatric problems are far more common than most people realize, they say, and the rise of the Prozac culture shows that we're confronting the epidemic. Though Prozac hasn't been thoroughly tested as a treatment for dysthymia, small studies suggest it might help more than half of all sufferers. Dr, Roy Young, a Los Angeles internist, says he himself has seen dysthymics transformed by the new antidepressants. "When you see that kind of result," he says, "the hard thing to know is whether the drug should ever be stopped." Dr. Robert Birnbaum, director of psychopharmacology at Boston's Beth Israel Hospital, agrees. "I can't just dismiss the [mildly depressed] person as looking for a quick fix," he says. "if anything, depression is undertreated."

Not everyone is so sanguine. The evidence to date suggests that the new antidepressants are remarkably safe: they're nontoxic at high doses: they don't appear addictive, and because they don't produce a high they make unlikely candidates for abuse. But because their long-term effects are largely unknown, some experts worry that millions of people are basically selling as test subjects. Many medications, including Valium and thalidomide, have shown their true hazards only after coming into broad use. "People have to factor that risk into their decision making," notes University of Chicago psychiatrist Daniel Luchins. Dr. Sidney Wolfe, director of the Public Citizen Health Research Group, figures the unknown dangers are worth risking if you're clinically depressed, but not if you're merely unhappy.

A second concern is that drugs will become a substitute for fixing what's wrong with one's life. Unhappiness stems naturally from many situations, offering a potent incitement to change. As Columbia University medical historian David Rothman writes in the current New Republic, "some people may believe that they have fulfilled their potential, satisfied their ambitions and mastered the skills of relationships [through Prozac]. Many others may be skeptical." Most psychiatrists seek the cause of a person's discontent, bad job, bad boss, bad marriage--before prescribing a pill, but the family doctors who now prescribe Prozac are less practiced confessors. In a 1993 survey, researchers at the Rand Corporation found that fewer than half the general practitioners treating depressed patients had spent three minutes or more discussing their problems with them. Specialists, too, are reaching more quickly for the prescription pad. As medical plans cut back on coverage for psychotherapy, says Birnbaum of Boston's Beth Israel, psychiatrists feel pressure simply to "medicate and then monitor side effects."

The ultimate question, assuming that the new antidepressants can safely banish unpleasant feelings. is whether we really want to be rid of them. in his recent best seller, "Listening to Prozac," Rhode Island psychiatrist Peter Kramer describes how his own patients have grown "more confident, popular, mentally nimble, and emotionally resilient" on the drug. Yet, as Kramer acknowledges, there's something a little creepy about using chemical agents to give evervone a Dale Carnegie demeanor. Prozac might have brightened Hamlet's outlook ("Think not of the sky as spotted with cloud but as partly sunny," be chirps in one humorist's reverie) and softened Marx's dour views ("Sure! Capitalism can work out its kinks!" he gaily concedes in a recent New Yorker cartoon) but it would have made both figures forgettable.

Although many patients are thrilled with their Prozac personalities, some find it disconcerting to be shielded from their sorrows. Jackie McMann of Los Angeles (not her real name) took Prozac while mourning the death of her 21-year-old son. "I felt better," she says, "and my friends saw an immediate difference. But I still don't like to have my mind altered. It short-circuited my grieving." McMann stayed on the drug while regaining her emotional balance, but some don't. Dr. Randolph Catlin, a campus physician at Harvard, says several of his patients have dropped the drug, even while responding to it. Dr. Keith Ablow, a Boston psychiatrist and a columnist for The Washington Post, describes the same phenomenon. He recalls a patient who suffered terrible abuse as a boy, doused himself with drugs and alcohol as an adult and wound up seriously depressed. His mood quickly brightened when he started taking Prozac. Yet as Ablow tells it, "he worried that he was living out his life without a core understanding and might never be able to gain it." Painful as it was, the patient went drug-free and has never regretted it.

Introduced just six years ago, Prozac is now the world's top-billing antidepressant, and similar drugs are finding markets of their own. Because the new treatments are prescribed so widely, industry analysts expect the growth in overall sales to continue.

_B_Drugs of the '90s_b_ NAME: Prozac HOW IT WORKS: Enhances the effect of the mood-enhancing brain chemical serotonin, by blocking its reabsorption by cells. PROS AND CONS: Like its cousins Zoloft and Paxil, it's safer than the older antidepressants, and easier to tolerate. Can cause nausea, diarrhea and a loss of sexual function. NAME: Effexor HOW IT WOEKS: Enhances both serotonin and norepinephrine, a second chemical messenger affecting mood. PROS AND CONS: With its broader effect, Effexor should help some depressed patients who don't respond to Prozac. Side effects are similar. _B_Drugs from the '50s_b_ NAME: Tricyclics HOW IT WORKS: Unlike new drugs, they bolster several brain chemicals, including dopamine. PROS AND CONS: Narrow margins of safety and effectiveness. Common side effects include grogginess, headache, constipation and weight gain. NAME: MAO Inhibitors HOW IT WORKS: Achieve roughly the same effect as the tricyclics, but by different chemical means. PROS AND CON: In addition to fatigue, dizziness and constipation, they can cause deadly surges in blood pressure if taken with certain foods.


Prozac: $1.2 billion Paxil: $250 million Zoloft: $457 million Other anti-depressants: $1.2 billion