Sunday, March 4, 2018

Prozac: Pro and Con

It’s been in use for decades now, but mental health professionals are still debating the value of Prozac and other SSRIs. When the little capsules hit the market, the press was chockablock with stories about the new miracle cure. Patients who had spent years on the couch opining about their childhood traumas suddenly felt better. They felt a lot better. Psychotherapy had made them depressed. Prozac made them happy. Who could argue with that?

Besides, talk therapy was not providing anything resembling effective treatment for depression-related illness. Clearly, Prozac was oversold. Right now, it is being, somewhat unfairly, derided. And yet, compared to what was on offer at the time from psychoanalytically oriented insight therapy, it seemed like a cure.

True enough, cognitive therapy had proposed its own radically new way of treating depression, but it was not in very wide use and most therapists were averse to treatments that were of shorter duration. Besides, therapists who had been trained for a decade or so to search for an elusive meaning to symptoms did not quickly cotton to the notion, promoted by the cognitivists, that symptoms were bad habits, not redolent of meaning, and largely impervious to the storytelling and mythmaking that had been therapists’ stock in trade.

One notes, in passing, that the great Doctor Freud largely ignored depression. True, he wrote a largely useless paper on it once, but his theorizing emphasized anxiety, not depression.

Still, Prozac has not been in use for a very long time and we do not really know the long term effects. We are now beginning to see that these pills have a downside. And we owe it to psychologist and patient Lauren Slater to have analyzed the problem and shared some of her experience. The New York Times reviews her new book, Blue Dreams:

In “Blue Dreams,” a capacious and rigorous history of psychopharmacology, the psychologist and writer Lauren Slater looks at the fact that despite our ravenous appetite for psychotropic medications (about 20 percent of Americans take some psychotropic drug or other), doctors don’t really understand how they work or how to assess if a patient needs them. In the case of antidepressants, two-thirds of patients taking an S.S.R.I. (Prozac, Zoloft, Celexa, etc.) would improve on a placebo alone.

Still the misconception that depression is a matter of “low serotonin” persists. “There is no proof that a depressed person has a chemical imbalance,” Slater writes. “When you choose nevertheless to put that person on a medication that will alter neurotransmitter levels in his or her brain, then in effect you are causing a chemical imbalance rather than curing one.”

Assuming that the data are true, it is sobering for those who have been prescribing these pills to note that a placebo works equally well in two-thirds of the cases. This still suggests that the medicine helps a third of patients. 

At the least, the new studies challenge the media-driven orthodoxy—to the effect that depression is a chemical imbalance. They also tell us that the pills have been marketed to death, overprescribed and overused. I believe, without too much further evidence, that the psychiatric profession has done the same with all past medicines, from Valium to Lithium to Thorazine.

Anyway, seeing depression as a chemical imbalance serves some ignoble purposes. First, it tells people that they are not responsible for their conditions. Second, it tells them that there is nothing that they can or should do to alleviate their depression. Third, and perhaps most importantly, it assuages the guilty consciences of the psycho professionals who have failed to treat depression.

One suspects that the last was the most important reason for the chemical imbalance theory.

Slater testifies to her own experience with Prozac. One might say that it was not all bad. The Times summarizes:

For 35 years, Slater has taken one psychotropic medication or the other. Her 1988 book “Prozac Diary” documented the relief that medication brought her, at the age of 26. She’d long been suicidal and suffered from eating disorders, obsessive compulsive disorder and a depression so crippling, she was hospitalized five times between the ages of 13 and 24.

Prozac “hurled me to heaven,” she writes in “Blue Dreams.” “I lived a gilded life, rich and buttery, producing books and babies as fast as I could, because I knew the Prozac would wear off, and eventually it did.”

Given her experience with psychiatric treatment, you understand that Slater has reason to be thankful for Prozac. And that those who touted it as a miracle cure were not completely fantasizing.

How is she doing now, nearly thirty years later? Unfortunately, not very well:

She found another drug cocktail that eased her symptoms. But at 54, she writes, “my body is in the shape of an octogenarian with issues.” Her memory is shot. The antipsychotic she takes causes insatiable hunger and her weight has ballooned. She has diabetes. Her kidneys are failing. Her feet are covered in weeping sores and her eyesight is in trouble.

The drug Slater relies on is called Zyprexa. Curiously enough it’s the same drug Andrew Solomon described taking almost 20 years ago, in his National Book Award-winning history of depression, “The Noonday Demon: An Atlas of Depression.” He writes of the relief and anguish the drug brought him with eerie similarity, of having to choose his mind over his body.

I am hardly qualified to tell you whether or not the SSRIs produced Slater’s current medical condition. We should be clear... she is claiming that the overuse of SSRIs produced a chemical imbalance that can only be treated with an antipsychotic called Zyprexa.

Of course, Zyprexa is not an SSRI. It is not an antidepressant. It is an antipsychotic, which is not at all the same thing. One finds it slightly strange that Andrew Solomon, while being considered a champion of SSRIs, was not taking an SSRI.


whitney said...

People seem to think that the purpose of life is to be happy yet it is so obvious that can't possibly be true. Everyone around you will grow old and sick and die until you eventually suffer the same fate. Once you realize that life is suffering and then you die, you end up being a lot happier

sestamibi said...

"It’s been in use for decades now, but mental health professionals are still debating the value of Prozac and other SSRIs."

"Still, Prozac has not been in use for a very long time and we do not really know the long term effects."


Assistant Village Idiot said...

@ sestamibi - I can partly answer that. Medications that have clear, narrow effects can be followed for relatively few years and their effects known. The brain, however, has re-adaptations, so that if you change one thing, something else moves - not necessarily to counteract the effect you were seeking (though that happens a lot), but in response to some other signal. It might worsen the side effects. It might improve the side effects. It might reveal some other effect. This last is what happened with Prozac, which was developed and prescribed for depression, but turned out to be great for OCD. Something similar happened with Prazosin, which started as a blodd-pressure medicine, but was found to reduce nightmares. This led to its being prescribed for PTSD, because at least the poor bastard could get a good night's sleep. And sleep, we are learning, is as important as your grandmother said it was; the electrification of the night world has a higher coast than we imagined a century ago.

I took Prozac as an off-label use for OCD in the late 80's and it was magic. I had been in two-and-a-half years of therapy, which gave me great insight but no relief. Fluoxetine brought relief in four weeks. I was on it for a decade, but went off twice because I did not like the effect of the drug removing both the very highs and the very lows emotionally. I felt that wasn't the human experience we are designed to have. I eventually went off it, willing to endure both the OCD symptoms and the chronic mild depression to get a fuller experience. That's easier to do if you know you have the med as an escape hatch if you need it.

Yet now that has an unanticipated side effect. Depression is like aging, and has bad physical effects. Chronic mild depression is actually worse for your body than occasional severe depression(!) Did I make the right trade-offs? I don't know. Life is trade-offs.

Redacted said...

"There are no solutions. There are only tradeoffs."
--- T Sowell

Truer words were never spoken.

Re side effects... consider the unanticipated side effects of the blood pressure drug Viagra.

Anonymous said...

Whitney, you are absolutely correct. Only recently has our species come to see suffering as an exception — a disease that must be removed at all costs.

We only grow through suffering.

We only grow when we realize we cannot have everything.

We must choose which path is best with the finite time we have.

Father Time takes care of the rest as we suffer and our bodies break down. The young do not realize this, which is why they are suckers for all these lies, frivolously wasting their best years of energy, health and faculties.

This is the story every generation tells about the next, yet today — our time of hubris — we don’t listen to elders admonishments about that which is fleeting. We would be wise to follow their guidance about suffering and the meaning of life. Not that we should live like they did, but instead find the fullness of all we can create in this life. That wisdom seems to be lost.

As my fanorite (and old) college economics professor warned us, “We are Roman farmers with an electrical grid... never forget that.” And I haven’t. At the same time, I have a clue what life might be like when/if the power goes out: lots and lots of suffering. We haven’t conquered it, and believing we have is our greatest arrogance.