The Career of a Celebrity Pill
As Prozac's long reign comes to an end, experts are questioning its legacy
Who would have thought, back in 1987, that a small, green-and-cream-colored pill would become not only the most famous drug ever but a cultural icon? The subject of scholarly analyses, talk show conversations, and comedians' monologues, the antidepressant even made the cover of national magazines. Psychiatrist Peter Kramer parlayed the drug's popularity into a national bestseller, Listening to Prozac, portraying it as a true celebrity with a career of "renown, followed by rumors, then notoriety, scandal, and lawsuits, and finally a quiet rehabilitation."
Before Prozac, the brain chemical serotonin was relegated to obscure medical journals, and emotional disturbances were viewed as something far more complex than chemical imbalances. Nowadays, psychotherapeutic drugs are the third-largest category of drug sales; antidepressants are advertised on television and routinely prescribed by internists; and there are support groups for depressed dogs, some of which take Prozac.
Well, the Age of Prozac is about to end--certainly symbolically but perhaps also in very practical ways. After 13 years, the medication's patent expires in August, and any drug maker will be free to market the unique chemical formulation as a generic drug. It is not entirely coincidental that with the end of Prozac's reign of exclusivity, a number of critics are coming forward to question not only this famous drug's legacy but the exuberance of biological psychiatry more broadly. A spate of new books--Harvard psychiatrist J. Allan Hobson's Out of Its Mind: Psychiatry in Crisis; anthropologist T. M. Luhrmann's Of Two Minds: The Growing Disorder in American Psychiatry; and psychoanalyst Elio Frattaroli's Healing the Soul in the Age of the Brain, to name just a few--underscore the limits of biological psychiatry and drug treatments for the mentally ill. "If my neurotransmitters made me do it, then everything I don't like about myself has a solution that lies outside myself," says Frattaroli. "That is ultimately a very debilitating way of thinking." Harvard psychiatrist Stephen Bergman goes further: "When you line up all the forces that act in psychiatry today, it's pretty scary. The alignment is . . . not in the patient's best interest."
On the rise. Indeed, psychiatric drug sales are expected to grow from $23 billion in 2000 to nearly $42 billion by 2005. At the recent annual meeting of the American Psychiatric Association in New Orleans, the pharmaceutical industry sponsored dozens of symposiums on the newest pharmacological treatment for every mental illness imaginable--mostly in conjunction with fine dining. Between meals, participants could stroll the exhibit hall, where drug company representatives handed out everything from tote bags to CDs and Mardi Gras masks to nearly 13,000 potential prescribers. In 2000, pharmaceutical companies sponsored 22,838 events promoting antidepressants alone; that's up 31 percent since 1999. That same year Eli Lilly grossed $2.6 billion in Prozac sales. Prescriptions for all antidepressants rose from 40 million in 1988 to 120 million a decade later.
It was not always this way. The sea change occurred when Prozac, the first of a class of drugs called selective serotonin reuptake inhibitors, or SSRIs, appeared. Before then the most common drug treatment for depression--called tricyclics--required carefully calibrated doses, had unpleasant side effects, and could be fatal if taken improperly. General practitioners rarely fooled around with the tricky medications; even psychiatrists did not prescribe them freely. While SSRIs also produce some serious side effects, they have proved remarkably effective with some patients, and, most important, they carry almost no risk of overdose.
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.
[Chart data are not available.]
[Chart labels] Annual sales
This story appears in the August 6, 2001 print edition of U.S. News & World Report.