A Prozac Backlash

Miracles are hard to come by, but to many Americans Prozac looked just like one. Introduced in 1987, the new antidepressant took the market, and the public imagination, by storm. Not only was it easier to prescribe than the other available treatments, but it seemed to alleviate a wider range of afflictions, from depression and anxiety to bulimia and obsessive-compulsive disorder. Best of all, it didn't cause the weight gain, low blood pressure or irregular heart rhythms common to many treatments. In just three years, Prozac became the nation's top-selling antidepressant (a title it still holds, with nearly a million prescriptions being filled every month). Instead of complaining about its price - 20 times that of older drugs - happy customers lined up to bear their testimonials. "Prozac has made us a celebrity," says Eugene L. Step of the Indianapolis-based Eli Lilly & Co., which makes the drug. "I have become a far more avid viewer of talk shows." But the talk-show chatter has lately taken a radical new turn.

Self-described "Prozac survivors" now appear on "Donahue" to accuse the drug of turning sane people into murderers and self-mutilators. Scores of unhappy customers are filing lawsuits against Lilly, seeking huge awards for misfortunes they blame on Prozac (box). Some are using the drug as a criminal defense, saying they shouldn't be held accountable for crimes they committed while taking it. One activist group, an offshoot of the Church of Scientology, is even demanding that the Food and Drug Administration remove Prozac from the market. Lilly, meanwhile, is standing staunchly by its product, and psychiatrists have lost little of their initial enthusiasm. Many fear the current uproar will scare patients away from a potentially lifesaving treatment. "This drug is transporting a lot of people from misery to well-being," says Dr. Jerrold Rosenbaum of Harvard Medical School and Massachusetts General Hospital. "A flurry of sensational anecdotes shouldn't stop that."

The horror stories vary in texture, but they share a common theme. Joseph Charles Gardner Jr. started taking the drug in December 1988 to ease the depression that had settled over him after his father died of a heart attack. The 32-year-old resident of St. George, Utah, had always been quiet and conservative, serving as a Mormon missionary, attending Brigham Young University, holding jobs as a schoolteacher, a sheriff's deputy and a medical worker. Everything changed during 1989. Acquaintances say Gardner became restless and irritable after he started taking Prozac, and took to hanging out in bars. In April of that year, he married a Nevada casino worker named Nancy Snow, but she left him after three weeks. By the end of the year, he had twice tried to kill himself with overdoses of barbiturates. "People thought something was wrong," says his lawyer, Alan Boyack, "but nobody ever associated it with Prozac. He just kept taking this drug on the advice of his physician, and he starts going dingy."

Nancy Snow's divorce became final in September 1989, but Gardner didn't want to let go. The following July he approached her in a St. George bar and her best friend, a 32-year-old nurse named Janice Fondren told him to leave her alone. Gardner was enraged. Later the same week, according to police, he showed up armed at Fondren's apartment. After a brief argument, he allegedly shot her through the heart, drove 22 miles to a remote section of the Shivwit Indian Reservation and left her naked body in the dirt. Gardner is now in a state hospital, where court-appointed psychiatrists have found him temporarily incompetent to stand trial. If he is finally arraigned, his lawyer says he will admit killing her, but will attribute his behavior to Prozac.

Rhonda Hala didn't kill anyone during the 18 months she took Prozac, but she blames the drug for nearly killing her. The 41-year-old Long Island secretary says she had never had any serious problems until late 1988, when a hospital psychiatrist prescribed Prozac (along with a muscle relaxant and later a tranquilizer) to alleviate the aftereffects of major back surgery. After 10 days on the drug, Hala says she became unbearably restless. "You sit down and every nerve in your body has to move," she recalls. "You feel like you're going to jump right out of your skin."

Then came an unaccountable longing for pain, which she satisfied by tearing at the flesh on her thighs, arms and torso. Over the next year she gouged herself with anything she could lay her hands on - screws, bottle caps, shower hooks, tacks, pens, razors. She had a dozen scenarios for suicide, but death was never the main objective. "I had to hurt," she says. "I never thought of taking an overdose of drugs. That would have been too painless." Last year, after her doctor took her off Prozac, Hala says she promptly stopped mutilating herself.

Today she is one of roughly 60 clients from around the country for whom Leonard Finz, a New York personal-injury lawyer, is filing separate suits against Lilly. Finz's Prozac plaintiffs include everyone from the widow of rock star Del Shannon, who killed himself while taking Prozac in February 1990, to the families of several men killed by Joseph Wesbecker of Louisville, Ky. Wesbecker, a 47-year-old pressman with a history of psychiatric problems, was taking Prozac and several other medications in September 1989 when he stormed through the Standard Gravure printing plant with an AK-47. He shot 20 co-workers, eight of them fatally, before taking his own life. That Prozac caused the massacre is, to Finz, self-evident. "Lilly," he claims, "had its finger around the trigger of Joe Wesbecker's rifle. "

Juries will have to decide whether Lilly is legally to blame for this carnival of misfortune. Scientists, meanwhile, are grappling with the more important question of whether Prozac can actually make people suicidal and violent. The evidence is still open to different interpretations. On at least two points, though, there is no debate.

The first is that depression itself can cause suicide and violence, even in people receiving treatment. Fully 15 percent of all clinically depressed patients end up taking their own lives. Since no antidepressant - neither Prozac nor any of the alternatives - has more than an 80 percent success rate, it stands to reason that some users will continue to think and act erratically. "Prozac tends to be used by people with psychiatric problems," says Dr. W. Leigh Thompson of Lilly Research Laboratories. "Some people with psychiatric problems happen to be violent."

Experts also agree that virtually any antidepressant could prompt a depressed person to act on impulses he already harbored, simply by making him restless. Roughly a quarter of all antidepressants users experience jitteriness and agitation as side effects. Various antidepressants can also cause an unbearable muscle restlessness called akathisia. Most people don't become violent or suicidal just because they feel restless. But the sensation can be too much for a mentally ill person to bear.

The question is whether Prozac, unlike other antidepressants, can directly induce violent or suicidal thoughts - thoughts that don't stem from an underlying illness. Dr. Martin Teicher, of Harvard Medical School and McClean Hospital, believes that it can. Teicher became something of a celebrity last year after he published a paper in the American Journal of Psychiatry, describing a strange thing that happened in his clinic. Six patients, depressed but not suicidal, had suddenly developed an "intense, violent suicidal preoccupation" after taking Prozac for two to seven weeks. Teicher couldn't rule out depression as the source of their self-destructive impulses - all six patients had considered killing themselves in the past. But their suicidal thoughts came on so suddenly during treatment that Teicher suspected Prozac had actually caused them.

Other researchers have since reported a handful of similar cases. In a recent letter to The New England Journal of Medicine, doctors in Syracuse, N.Y., described two previously non-suicidal patients - a depressed man and a depressed, bulimic woman - who became suicidal within weeks of starting Prozac. According to the letter, the obsessions receded after they stopped taking the drug. And last month psychiatrists at the Yale Medical School's Child Study Center reported the emergence of intense self-destructive thoughts in several adolescents receiving Prozac for obsessive-compulsive disorder. The Yale researchers, led by Drs. Robert King and Mark Riddle, speculate that by disrupting production of the chemical messenger serotonin, Prozac may directly affect the brain's ability to regulate aggression. But they couldn't be sure that the patients' underlying conditions weren't the real culprit. Besides suffering from obsessions and compulsions, the report said four of the six children had been depressed or suicidal in the past.

Do these case reports reflect a unique, Prozac-related syndrome? Should violent thoughts be counted among the drug's direct side effects? The obvious way to find out is to study large groups of patients. But when researchers have gone looking for the "Teicher syndrome," they haven't found it. In one of Lilly's clinical trials, researchers randomly assigned 3,065 depressed patients to Prozac, a placebo or one of five other antidepressants. At the beginning of the six-week treatment period, all seven groups were equally prone to suicidal thoughts. By the end of the trial, the Prozac group was the least suicidal of the seven. More recently, in a one-year study, researchers at Rush-Presbyterian-St. Luke's Medical Center in Chicago monitored 100 Prozac users and found no increase in the risk of suicide or violence. And two Boston psychiatrists have just published results from a survey intended to gauge suicidal thinking among 1,017 patients treated with various antidepressants during 1989. Drs. Maurizio Fava and Jerrold Rosenbaum, both of Harvard Medical School and Massachusetts General Hospital, found that no drug was associated with significantly more suicidal thinking than any other. A number of patients became suicidal while receiving treatment, but never in the sudden, inexplicable manner Teicher described.

Maybe Prozac does make some people crazy; the available evidence doesn't settle the question. But if the Teicher syndrome is real, it is exceedingly rare - too rare to show up in studies designed to detect it, and too rare in the view of most psychiatrists to warrant big changes in prescribing practices. Teicher hopes that future research will enable doctors to predict how individual patients will react to the drug. But even he has no plans to stop prescribing it in the meantime. Antidepressants are not cough drops. Dr. Joseph Lipinski of Harvard Medical School and McLean Hospital likens them to loaded pistols. They all pose hazards. But until better treatments come along, Prozac remains a vital weapon against a formidable illness.

A Prozac Backlash | News