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2.11 The popularity of Prozac and other SSRIs

The evidence from clinical studies and from spontaneous reports of suspected adverse reactions cannot explain the explosive popularity of fluoxetine. Some of it can be attributed to the wealth of publicity in lay media - though most related to the alleged effects of Prozac in enhancing day to day living, rather than for "depression". By 1994, the extent of publicity about Prozac as a feel-good drug, and references to "cosmetic psychopharmacology" and so on, had reached such a pitch, the manufacturers decided to advertise their concern that much of this "unprecedented publicity" had "trivialised the very serious nature of the disease Prozac was specifically developed to treat - clinical depression". (SCRIP, 1994)

In a perfectly informed world, one might give no more credence to claims of personality transformation than to anecdotal accounts of aggression and suicidal ideation. But naturally eyebrows and/or expectations get raised when a US West Coast clinical psychologist puts all of his 700 patients on Prozac (Toynbee, 1995), or when an East Coast psychiatrist tops the best seller list for months with a book promoting the idea of Prozac as a key to happiness and greater fulfilment in life, (Kramer, 1993) albeit with evidence befitting "not science but soap". (Medawar, 1994)

One cannot just dismiss accounts which suggest that, sometimes, Prozac and drugs like it have astonishingly good effects, sometimes even when other treatments have failed. Few if any drugs have attracted such publicity, including an array of feature articles with headlines like these: "The Promise of Prozac ..."; (Cowley et al., 1990) "That Prozac moment ..."; (Rothman, 1994) "The pill of pills ..."; (Nuland, 1994) "The cloud over bottled sunshine ..."; (Doyle, 1994) "Power of the psychodrug ..."; (James & Camden, 1993) "With millions taking Prozac, a legal drug culture arises ..."; (Rimer, 1993) "Mind drug ‘no miracle’"; (Hunt, 1993) "Escape Capsule ..."; (Bracewell, 1993) "The Prozac Generation"; (Grant, 1994) "The Personality Pill..."; (Toufexis, 1994)

It is still not too clear what prompted this gush but, however exaggerated, it only underlines an obvious point: if a placebo can sometimes produce astonishing effects, a potent drug surely can too. If a flank of warts can both understand and respond to the suggestion they get lost, the only dangerous conclusion might be to assume that drugs like fluoxetine work exclusively and specifically by pharmacological means. They clearly don’t.

Still, the idea that Prozac sometime works like magic has to be seen in perspective. Prozac has often proved good enough and sometimes very effective, but truly magic responses would be rare and neither are they peculiar to fluoxetine. Shorter has recalled that when imipramine was first given to depressed patients in 1955, "the response was ‘absolutely incredible, so exciting’, electrifying both the hospital staff and the Geigy scientists who had been following this all with bated breath". When it does happen, dramatic relief from bad depression must clearly seem astonishing, even without the hype:

"The language in which Kuhn reported the transformation is interesting, because it illustrates how resurrectionlike the recovery from depression can be, a recovery that each new generation of antidepressant drugs believes that it alone has achieved; witness the resurrectionist rhetoric accompanying the introduction of the drug Prozac." (Shorter, 1997)

The complexities involved in unravelling pharmacological effects from a possible placebo response come across quite well in the following account in Prozac Nation (Young and Depressed in America), the memoire of a young woman in treatment for "atypical depression". (Wurtzel, 1996)

"It’s not just depression - it’s atypical depression. Who would have thought they have a name to describe what is happening to me, and one that pinpoints my symptoms so precisely ? In the book Understanding Depression, Donald F Klein MD and Paul H Wender MD characterise atypical depressives as people who ‘respond positively to good things that happen to them, are able to enjoy simple pleasures like food and sex, and tend to oversleep and overeat. Their depression, which is chronic rather than periodic and which usually dates from adolescence, largely shows itself in lack of energy and interest, lack of initiative, and a great sensitivity to periodic - particularly romantic - rejection’. Those sentences perfectly delineate my symptoms. I feel suddenly much less lonely ... Enter Prozac, and suddenly I have a diagnosis. It seems oddly illogical: rather than defining my disease as a way to lead us to fluoxetine, the invention of this drug has brought us to my disease ..."

This successful treatment, following many which had failed, began with a convincing diagnosis from a respected source, and was also linked to the name of a special drug. Expectations of the new drug were high. The patient believed that fluoxetine "is very pure in its chemical objectives" and that it "acts only on serotonin". Her doctors had high hopes for it too: they were "completely gung ho" about Prozac and "thought I was the perfect candidate for the drug" and "were all set to enrol me in a study that would have allowed me free treatment and medical care ..." But at first there were problems. The drug was slow to "kick in", but her doctor urged her to persist: "I am so certain that the fluoxetine is going to help you really soon that I have just have to find a way to keep you going through those next few days ...". The dosage was doubled but then Wurtzel attempted suicide again:

"And then something just kind of changed in me. Over the next few days, I became all right, safe in my own skin. It happened just like that. One morning I woke up, and I really did want to live, really looked forward to greeting the day, imagined errands to run, phone calls to return, and it was not with that feeling of great dread, not with the sense that the first person who stepped on my toe as I walked through the square may well have driven me to suicide. It was as if the miasma of depression had lifted off me, gone smoothly about its business, in the same way that the fog in San Francisco rises as the day wears on. Was it the Prozac ? No doubt. Was it the cathartic nature of going through a suicide attempt ? Probably. Just as I always said that I went down gradually and then suddenly, I also got up that way. All the therapy, all the travelling, all the sleeping, all the drugs, all the crying, all the missed classes, all the lost time - all of that was part of some slow recovery process that came to the end of its tether at the same time that I reached mine".

Looking back, Wurtzel concluded that "the fact that Prozac in combination with other drugs has been, for the most part, a successful antidote" was undoubtedly due to its effects on her body chemistry. It began with "years and years of bad habits", then "years and years of exogenous depression (a malaise caused by external events)". This "can actually fuck up your body chemistry so much that you need a drug to get it working properly again". This is how it seemed to work:

"It seemed that suddenly, sometime in 1990, I ceased to be this freakishly depressed person who had scared the hell out of people for most of my life with my mood swings and tantrums and crying spells, and I instead became downright trendy. This private world of loony bins and weird people that I had always felt I occupied had suddenly been turned inside out so that it seemed like this was one big Prozac Nation, one big mess of malaise"

Being able to control severe and pervasive depression/anxiety is clearly a great achievement, however accomplished and however such states arise.


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