The Career of a Celebrity Pill
As Prozac's long reign comes to an end, experts are questioning its legacy
Ironically, new research now indicates that Prozac and its chemical cousins may actually be less effective for some patients than the older antidepressants. And for reasons that are not fully understood, these drugs don't work for everyone. Even when they work initially, they sometimes lose their potency with regular use--a phenomenon called Prozac poop-out. Withdrawal from SSRIs--other popular versions include Zoloft, Paxil, and Celexa--can be severe; side effects include flulike symptoms, tearfulness, and anxiety. These symptoms, some experts note, sound very much like depression itself, and indeed such "relapses" are often treated with more drugs.
Paradoxically, many of the most seriously mentally ill are not receiving drug treatment, while many others who are merely unhappy are. According to Kramer, since the advent of Prozac the "bar has been lowered for what constitutes an emotional disorder that needs drugs, and it has been raised for what constitutes successful treatment." In the past, no doctor would treat mild depression with medication; counseling--from a mental health professional or a pastor--was the treatment of choice. And where the measure of successful treatment for depression was once alleviation of debilitating pain, today patients want--as Kramer phrases it in Listening to Prozac--to feel "better than well."
Insurance companies have encouraged doctors to write prescriptions and leave the talking therapy to the less expensive social workers, psychologists, and other counselors. Today many psychiatrists with large managed-care caseloads see 160 patients a week. Rare is the therapist like John Evaldson of Santa Fe, N.M., who sees 35 patients a week and spends most of his time listening and talking. Many efficacy studies support his therapeutic approach. For example, a 1992 study of patients treated for depression found that therapy alone helped as many people as did therapy with drugs. And fewer people dropped out of treatment.
No ordinary organ. The overselling of neuroscience has created a philosophical problem as well. Harvard psychiatrist David Osser acknowledges that mental disorders are in part brain disorders and can be ameliorated in the same way as, say, a liver disorder. But the brain is not and will never be just another organ, he insists, for the simple reason that the mind resides there. "The understanding of the mind, and how it operates--how we think and acquire our values--may go beyond science," he says.
This reappraisal, in broad paraphrase, is the recurring theme of many of the new critiques, most of which come from psychiatrists themselves. While enjoying greater prestige because of their newfound biological bona fides, psychiatrists must now confront the possibility that they have given up their most unique strength. As psychoanalyst Joseph Schwartz writes in Cassandra's Daughter, an hour in therapy teaches us "that human relationships are central to our development and growth." They are also, often, the source of pain that may be alleviated by a drug but only truly resolved by the talking cure. The "mumbo jumbo on the couch," in other words, may have been as tonic as serotonin drugs--even if poorly understood and lacking an industry to market it.
Freud anticipated this juncture. "Let the biologists go as far as they can," the father of psychoanalysis once wrote, "and let us go as far as we can--one day the two will meet." Of course, even Freud could never have predicted the appearance of the first celebrity drug.
The price of wellness
Sales of psychotherapeutic drugs have soared since 1987.
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[Chart labels] Annual sales
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