Prozac: The little pill that could

Prozac was the drug that took North America by storm in 1988 and ’89, the first of a new class of antidepressant medications known as SSRIs — selective serotonin reuptake inhibitors — a technical mouthful to convey their still not completely understood effect on neurotransmitters in the brain.

American psychiatrist Dr. Peter D. Kramer — describing the transformation of patients who’d become “better than well” — called it cosmetic psychopharmacology, a catchphrase that captured media attention. Prozac swiftly became “the little pill that could.” It made the cover of Newsweek; it was the subject du jour on talk shows; and it enjoyed the fastest acceptance of any psychotherapeutic medication ever — 650,000 prescriptions a month just over two years after its introduction. And, while it did cause side effects, they were fewer than those caused by other antidepressants.

Instant change

Best of all — Prozac was remarkably effective. Kramer described its effects on his patients in a 1993 book, Listening to Prozac. He was used to seeing their personalities change slowly, “through painfully acquired insight and hard practice in e world… But recently, I had seen personalities altered almost instantly, by medication. Prozac… was the main agent of change.” In fact, the drug was “transformative for patients in the way an inspirational minister or high-pressure group therapy can be…”

But all was not quiet bliss on the Prozac front. A firestorm of controversy was about to erupt, “a backlash,” Kramer writes, “in the great American [and Canadian] tradition of tarnishing the idol’s lustre.” People were taking Prozac not just for depression, but for weight loss, binge eating and postpartum blues. “They were women mostly,” Kramer notes, “and the question arose, was Prozac another Miltown or Librium, the `mother’s little helper’ from which we expect too much and about which we know so little?”

The real “media three-ring circus” set up its tents on Prozac’s doorstep, though, after a report published in the American Journal of Psychiatry in February 1990 linked Prozac to suicide. Other sensationalistic reports followed, blaming Prozac for violent episodes, even murder. There was a rash of lawsuits and the inevitable media exploitation, like the Donahue show titled Prozac — Medication That Makes You Kill.

Since then, the alarmist studies have been shown to have been flawed, the lawsuits have gone wherever groundless litigation goes after it’s been shot full of holes, the supposed links between Prozac, violence and suicide have been effectively disproved, and the media has moved on in search of new villains and victims.

Now that the TV lights have been turned off, Prozac can be seen for what it is — a very effective, though hardly perfect, medication for the treatment of various mood disorders, chiefly depression. Like all drugs, it has side effects, among them nausea, loss of appetite, insomnia, drowsiness, fatigue, rash, dizziness and headaches. It also has a long half-life that makes its use inappropriate for some people, including some seniors, who metabolize medications more slowly. On the other hand, Prozac isn’t addictive, it’s almost impossible to overdose, and there’s no apparent withdrawal syndrome.

What remains is Prozac’s apparent ability to transform personality, at once a seductive and a worrisome power. There are also unanswered (and, for some time, unanswerable) questions about its long-term effects; some drugs do have unknown or late-appearing (tardive) side effects, especially those taken over a long period of time.

And not all Prozac detractors stole quietly away. One of the drug’s most vocal opponents is American psychiatrist Peter R. Breggin, who claims he’s never started a depressed patient on antidepressants. Out of personal tragedy, he believes, may come revelations that can lead to “breathtaking changes… life can evolve into something much better. This frequently happens in [psycho]therapy, but thus far I’ve never seen it happen on a drug.”

In his 1994 book, Talking Back to Prozac, What Doctors Aren’t Telling You About Today’s Most Controversial Drug, Breggin (with Ginger Ross Breggin) argued that “life is becoming a contest between pills — exemplified by Prozac — and life itself. People are… abandoning the struggle to embrace life for the ease of swallowing a pill.”

Breggin sees enormous costs — physical, psychological and emotional — attached to that choice. He argues that Prozac “disrupts two of the neurotransmitters most involved in frontal-lobe function — serotonin and dopamine — and in that process can rob us of our sensitivity, self-awareness and capacity to care or to love… Put simply, SSRIs are anti-empathic agents. That means they are anti-life-anti-human life in the fullest sense.”

Holy writ to Breggin is hogwash to a huge number of others, including Washington Post reporter Tracy Thompson. In her 1995 book, The Beast, A Reckoning With Depression, Thompson described her lifelong struggle with a depression so profound it reshaped her life and personality, affected her most intimate relationships and changed the course of her career. It was a force, she writes, “something that has slipped outside the bounds of natural existence, a psychic freight train of roaring despair. For most of my life, the Beast [her depression] has been my implacable enemy, disappearing for months or years, then returning in strength…” Yet even as Thompson was writing those words, the Beast had been brought to heel with “an array of new antidepressant drugs” and a trusted psychiatrist. The key was Prozac, which did what previous antidepressants had done imperfectly: “It altered, or restored, the fundamental functioning in my brain. It didn’t make me well. It made it possible for me to get well… Life did not get easier, but living did.”

Thompson was still Thompson. “The difference was that I felt sturdy. Resilient. Not happy, not blissed out, not numb, not hyper. Just myself.” She found a renewed capacity to see beyond her own emotional needs. For the first time since she’d known her lover’s children, she was able to reach out and offer comfort when they were feeling blue. Her experience with Prozac, in other words — like so many others’ — was exactly the opposite of the Breggin description of antidepressants as “anti-empathic agents.”

“Drugs were not a miracle cure or a replacement for therapy,” Thompson writes; “they were what enabled me to derive the maximum benefit from therapy, which was hard work. Drugs are tools, nothing more — but that is no small thing. To a person scaling a cliff, a grappling hook is the difference between life and death.”

Dr. Martha Donnelly is Mount Pleasant Legion Professor of Community Geriatrics for the Department of Family Practice at the University of British Columbia in Vancouver. She doesn’t hesitate to prescribe antidepressants, including Prozac, when they’re appropriate: “You have to distinguish between mild and more severe depressions, because drugs have taken over with more severe depression, and rightfully so, in my view. If you have milder symptoms, clearly with some psychological origin — some sort of stress, grief, something like that — then drugs may not help, but psychological therapies may be very helpful.” Donnelly believes in a holistic approach to the treatment of depression, but, “when you’ve got seriously ill people, usually the drugs are first,” she says. “You get them better biologically, so their symptoms aren’t so terrible. When they’re a little more stable, then they’re capable of doing psychological work. But trying to get somebody into psychological work when they’re psychotically depressed or they’ve lost 60 pounds and they’re in fear of their life — that doesn’t work.”

As to which antidepressant should be prescribed, that’s a highly individual matter. Some doctors argue that all the SSRIs are pretty much equivalent, with slight variations in side effects, but Prozac does have a long half-life, which makes it problematic in certain cases. “There’s no question that it’s a good drug,” Donnelly says, “but I don’t recommend it to the older population as the first choice of an SSRI, because it does stay in your system a long time, and older people metabolize drugs less well.”

Over 50s

For patients over 50, she generally recommends one of the newer SSRIs — fluvoxamine (Luvox), sertraline (Zoloft) or paroxetine (Paxil) — because they have a shorter half-life and because, she says, “they may not interfere with the metabolism as much. It’s not clear from evidence that one is better than the other… there isn’t a whole lot of literature on the choices. And some people still use Prozac with the elderly as well.”

SSRIs aren’t perfect; there are side effects associated with their use, but they’re relatively benign compared to some of the potentially fatal side effects of previous antidepressant drugs. And, with even newer medications making their way into clinical practice, doctors now have a huge arsenal of medications at their disposal.

There are no miracles. Thompson still has times when “the old despair” overtakes her, weeks when she can’t lift herself out of “a low-grade funk.” At such times, she worries that the cloud that hung over her for so many years is back. And then it passes.

Thompson is slowly learning new ways of navigating through the entanglements of the everyday, discovering ways to find her road when she occasionally loses her way. She has no illusions about “the Beast,” no sense of triumph over it; she suspects they may be “life partners.” But that’s not so bad: “I have an ordinary life,” she says, “and although some might think this is dull, I tell you it is sweet. Ordinary life is a miraculous thing.”