Living Under the Sign of Prozac
For the one and only time during the conversation, the psychiatrist on the other end of the phone has broken out of his demeanor of detached calm: "Don't polarize," he almost yells. "Don't polarize the issues." The doctor is referring to the use of antidepressant medications and my effort to write something about it. He is right. The issues should not be polarized. Prozac and other antidepressants appear to have been helpful to many people--including, in the past, myself. But this same psychiatrist has also just told me that these drugs are "toxic to mind and body" and should, as "a standard of practice," be prescribed only as "a last resort." How then to question Prozac without polarizing? And what to do about the fact that the landscape has already been polarized? What follows is a partial record of my attempt to investigate the ways in which these psychoactive antidepressant drugs are currently used, discussed, marketed and managed. The frail hope is that in writing this, I will be able to illuminate some of the ways in which we as a society articulate, adhere and adapt to what might be called pharmaco-logic.PROZAC LOGICSpeak the word "Prozac" today and most Americans will immediately understand to what you refer: a drug of recent origin, considered relatively safe, tried and taken now by millions of people, most often to counteract depression, helping many of them to feel better in their lives. In the United States last year, 43 million prescriptions were written for Prozac and similar drugs--Zoloft and Paxil. In affluent Marin County, Calif., the use of Prozac is now so pervasive that it is referred to simply as Vitamin P. In France, which has one-quarter of the population of the United States, a similar number of prescriptions were made out. In less than a decade, the prediction made by Dr. Peter Kramer in his best-selling book, Listening to Prozac, has come true: "Modern psychopharmacology has become, like Freud in his day, a whole climate of opinion under which we conduct our different lives." We live today under the sign of Prozac. More than a drug, it is a system of understanding and explanation that, like orthodox Freudianism before it, will brook no contradiction. And so it becomes increasingly difficult to discuss the issue of Prozac--of pharmacologic intervention in the neurochemical lives of larger and larger masses of Americans--in any logic outside of Prozac. Prozac's pharmaco-logic is undeniable. We feel bad. Science and medicine have suggested that in some way our brain's neurochemistry must be involved. A drug that alters our neurochemistry so that we do not feel so bad is available. We take it. With medical and moral side effects minimized so as to make it safe, we believe ourselves to have achieved an approximation of the ideal drug as imagined by Aldous Huxley: a drug with "all the advantages of Christianity and alcohol, and none of the defects." And yet ... there are quibbles, qualms, questions. They cannot be enunciated in a comprehensive manner, for they, too, live under the sign of Prozac. For now, they can only be exhibited in documentary form, as a series of encounters, quotations, contestations. Their fragmentary nature testifies to the circular perfection of the neurochemical argument: For even as you read these words, they, too, may be interpreted as only a series of neuronal interactions disappearing into the next moment of synaptic activity. Disclosure of the use of antidepressant medications by a public personality is now considered a public service. Dick Cavett, Rod Steiger, Florida Gov. Lawton Chiles and Alma Powell have all made such disclosures. In a recent issue of Newsweek, CBS's Mike Wallace declares, "I will be on Zoloft for the rest of my life." Newsweek, whose 1990 cover story launched Prozac's high public profile as "a breakthrough drug," is owned by Katherine Graham, a Sponsor of the National Alliance for Research on Schizophrenia and Depression. We may be grateful that such public figures reveal their own situations so as to reduce the isolation felt by those suffering from similar problems. But could it also increase the isolation of those who refuse it? Might we need to ask what happens to the reporting of a story when such powerful media figures are also personally involved? Country singer Naomi Judd, recently interviewed on a prime-time television show, tells the story of her retirement from the stage due to a potentially life-threatening case of hepatitis. After withdrawing from performing, she began to experience repeated panic attacks. Now, with the help of a Christian therapist and Zoloft, she is fine. As long as the Zoloft assures that I have enough serotonin in my bloodstream, she tells the interviewer and tens of millions of Americans, everything will be OK. Judd is telling her story because she wants to help others know that they are not alone. But there is a problem: We probably have a more precise understanding of how Christian faith works than how Prozac, Zoloft and these antidepressant medications do. It is a stunning fact that deserves at least a few moments contemplation: No one, not Naomi Judd nor Mike Wallace nor the doctors writing these prescriptions, knows how Prozac, Zoloft or any of the other antidepressant medications "work." They are known as SSRIs--selective serotonin reuptake inhibitors--for their action in the brain enhances the amount of the neurotransmitter serotonin being actively transmitted from one nerve cell to another. But it is entirely unclear how this causes a shift in mood. Prozac and like drugs begin their action on the neurotransmitters within minutes or hours of being ingested. Yet the effect on mood does not occur for weeks. Nobody understands it. In fact, some antidepressants don't effect neurotransmitter reuptake at all. The most common response to this potential concern is that we didn't understand the action of aspirin until recently. Indeed, there are many medical interventions whose scientific understanding is less than clear. But might there be a difference when we target drugs to the brain? An equally common response is, you wouldn't deny insulin to a diabetic, would you? The analogy is entirely false, for insulin, like lithium, replaces a naturally occurring element in the body. Psychoactive drugs are something else. The heart of the concern is whether we can have a grasp on the consequences of long-term use of these drugs if we don't know where to look for their action. Recently I asked this question to a renowned advocate of "neurotechnology," Dr. Paul Churchland, philosopher of the neurosciences at the University of California, San Diego. After describing an instance in which another psychotropic medication had unexpected adverse results on motor control, Churchland said, "The same thing could happen with Prozac. The experiment is much larger, so if we're going to get some results, I think they'll be robust." He continued, "They won't be welcome, of course, and I hope they don't happen. We'll have to wait and see. It's something that's in the hands of fate." Fate thus far has decreed that the percentage of people experiencing sexual dysfunction--delay or inability to achieve orgasm--caused by Prozac is significantly higher than official predictions of 10 to 15 percent. Most reports are finding levels of 30 to 40 percent, and a recent study found rates may be as high as 75 percent. While the side effects of these drugs on the cardiovascular and urinary systems are of added concern, there are also mounting efforts to manage and minimize the cognitive impairments that can show up--including short-term memory loss, word-finding problems, poor concentration, disorientation and even delirium. It seems fate has also determined that some of these side effects are being addressed with additional drugs.THE PROFITS OF FATEWhat if it is not fate but economic forces that are driving the rapid proliferation of prescriptions for these drugs? A gentle Sacramento, Calif. psychologist is explaining to me in his trained, soft, neutral tone that he has left the private practice of psychotherapy and joined a managed care health system. I ask him how many clients he referred for psychotropic medication when he was in private practice. Ten to 15 percent, he tells me. How many clients do you now refer for psychotropic medication? I ask. Seventy to 80 percent, he says. This transition in practice is being repeated hundreds of times a week across the state and nation. The appeal of pharmaco-logic is powerful, for it relocates the discussion of our moods and behavior away from "us" and gives us power over "them." I can remember sitting in a couple of graduate level seminars on psychopharmacology. Taught by one of the nicest men in the world, we were bombarded with an ever-quickening cascade of graphs, pie charts, schedules, diagnostic categories, dosage requirements, decision-trees, outcome scenarios, a device for anything calculable. At the end there is a sense of exhilaration, for you feel that you have learned something real, hard facts. Just like Naomi Judd, you begin talking to friends and strangers about serotonin. But, in truth, you know nothing more about the biology and neurochemistry of depression than when you entered. And it may be years before you are willing to confront the questions that you buried. A local businessman described to me how a loved one had experienced a decisive and not wholly desirable personality change upon taking Prozac. Looking down at his desk, his question quietly arrived, taking me by surprise: Why are there so many depressed people? In a way it is the real question, one that the scientists have asked, but only as a way station on their road to neurobiological study. In 1984, one of the pioneers in the study of depression, Dr. Gerald Klerman, wrote: "The earth's resources are limited, the human population is expanding uncontrollably, and recent sociopolitical movements have proved themselves incapable of creating the utopian futures promised by their ideologies. Those historical changes seem to be associated with an apparent increase in the incidence of affective disorders, particularly depression ..." The New York Times science writer and best-selling author of Emotion Intelligence , Daniel Goleman, calls rising rates of depression, "a cost of modernity." Citing studies showing that the risk of depression is 10 times greater for those born after 1945 than for those born in the first decade of this century, Goleman quotes experts who attribute this increase to the loss of family, religion and community--all seen as stressors potentially affecting neuronal development. France's leading neurobiologist, Jean-Pierre Changeux, surveying the avid consumption of psychotropic medications in his own country in 1983, asked the question this way: "The forms of architecture we enclose ourselves in, the working conditions we endure, the threats of total destruction with which we menace our life, the malnutrition we inflict on the majority of our fellows--do all these favor a balanced development and functioning of our brain? It is very doubtful. After having destroyed our environment, are we not now destroying our own brains?" I have been unable to locate a single paper by an investigator in the neurosciences recommending social action on these problems. When I asked Dr. Richard Lewontin, a prominent Harvard geneticist who has argued forcefully against biological determinism, why this would be so, he replied wryly: "That's not their business."DEPRESSING BUSINESSThat business should enter into scientific and professional issues seems, at first, absurd. Upon reflection, of course, it seems absurd that it should not. For however much we attempt to organize our knowledge in a manner protected from economic motives, we are a society organized by business, for business. Prozac now produces more revenues ($1.5 billion in 1995) than all but the anti-heartburn drug Zantac, which was recently made available over the counter. The antidepressant Zoloft is No. 5. And another, Paxil, is moving up quickly. Eli Lilly & Company, the manufacturer of Prozac, produces almost a quarter of its total revenue from Prozac alone. Though Lilly is No. 171 on the Fortune 500 list, it is No. 2 in profits. Lilly's increase in revenues and profits is now due almost entirely to Prozac, and the pressure is on to produce as much as possible before a generic form is available. The business stakes are high and getting higher. The helping professions, which are the intermediaries for these drugs, are increasingly recognizing themselves as businesses in a changing marketplace. In its fight for market share, the American Psychological Association has made obtaining the right to issue prescriptions its No. 1 priority. "Psychologists have the opportunity--and the obligation--to make the world a little bit better for generations to come," wrote the APA's lead legislative strategist, Patrick DeLeon, in January. "Prescription privileges provides an illustrative case example." Even the clinical studies are not free from business. In an important study published last year concerning the controversial question of Prozac's effects on suicidal behavior among those with "anxiety disorders," one finds the footnote that the study was "supported in part by the Upjohn Company and Eli Lilly and Company." Why would the most prestigious universities in the country risk even the appearance of a conflict of interest in conducting a study on Prozac financed in part by the manufacturer of Prozac? The question is even more urgent when one finds that the study's conclusion, which supports Eli Lilly's contention of no adverse impact, is based on data whose ambiguity leaves much to the interpretation. I happened to run into a famous former psychiatrist with a great deal of experience with drugs, Ram Dass (a.k.a. Dr. Richard Alpert). I asked his opinion on the matter. He told me that he had recently given a talk to the Sonoma County Psychiatric Association. "What a depressed group of people they are," he said. "They trained to help humanity and they find themselves just giving out drugs." Addressing the larger issue, he said, "You can't blame the drug companies for wanting to sell their drugs. You can't blame the clinicians for wanting to help someone with their suffering."NEUROMANHuman suffering is at the heart of the matter. I ran into an old friend who told me that after many months of being pressured by her therapist, she had begun taking Prozac. Her therapist was "pushing" Prozac for her child as well, she told me. Her face told of the agonies of the pressures and of her decision. Who should be taking it and who shouldn't? The official list of who should be taking it is growing. Not only are more and more "disorders" being treated with these medications, but the target groups are expanding. School-age children and the elderly, particularly those in nursing homes, are now being actively studied for large-scale intervention.And even those with typical personality traints deemed problematic are being promoted to for "treatment." "The SSRIs are alerting us to the fact that we may need to broaden our notion of what constitutes clinical depression, rather than say Prozac is good for everything other than depression," proclaimed Dr. David Kupfer, chairman of psychiatry at the University of Pittsburgh School of Medicine.A character in Jean-Luc Goddard's film Alphaville says: "Nearly every day there are words which disappear because they are no longer allowed. In their place, one must put new words to correspond to the new ideas. And you know, in the last few months, some words have disappeared that I liked very much." Words are disappearing because the trajectory of phamaco-logic is toward the collapse of any explanation other than the neurochemical. The neuroscientists assert the need for a genuine scientific explanation. All the rest--desires, attitudes, intentions--are now classified as so much "folk psychology." The UC San Diego neurophilosopher Paul Churchland foresees the time when we will be so finely attuned to our own neurochemical states that we will describe ourselves in this manner as well. In a self-deceptive way, we are already there. Naomi Judd does not tell us that her confrontation with her mortality made her anxious; instead, she talks about her serotonin. Whether it's serotonin or other neurotransmitters, we are talking about our brains, our central nervous systems, the architecture of which is even more unique than our genes. Yet, where the Human Genome Project has devoted 1 percent of its $3 billion budget to analysis and discussion of potential ethical issues, there is no similar organized discussion about our active intervention in the brain's neurochemistry. A quarter century ago, the novelist Stanislaw Lem imagined the conditions in a future "chemocracy," where "psychem" drugs determine all experience. In that world, even advertisements come in the form of drugs--drugs that "have no effect upon the organism but merely suggest the use of various other psychem products." Lem's main character considers the meaning of the fact that these advertising drugs are even necessary: "Apparently then there are people, like me, who require such persuasion. An encouraging thought." An encouraging thought at a time when encouragement is needed.