The Promise of Prozac
The Promise of Prozac
By: Geoffrey Cowley
Date: March 26, 1990
Source: G. Cowley, K. Springen, E. A. Leonard, K. Robins, and J. Gordon. "The Promise of Prozac." Newsweek (March 26, 1990): 38-41.
About the Author: Geoffrey Cowley is a senior editor for Newsweek magazine. After earning a B.A. in English from Lewis and Clark College in Portland, Oregon, and an M.A. in English from the University of Washington, Cowley worked as a reporter and feature writer at The Seattle Times, then an editor at The Sciences. He joined Newsweek in 1988, where he has written extensively about global health trends.
"The Promise of Prozac" was published in Newsweek in 1990, about four years after the 1986 market launch of Prozac, the first antidepressant medication in the selective serotonin reuptake inhibitor (SSRI) group. The article outlines theories about Prozac's mechanism of action in relieving depression and how this proposed mechanism altered the public's perception of mental illnesses, such as depression, phobias, and obsessive compulsive disorder (OCD), so they were seen as physical illnesses rather than character flaws.
The Newsweek article outlines Prozac use grew rapidly because it is generally better tolerated by most patients for long-term treatment than are older antidepressant drugs, such as tricyclics and monoamine oxidase inhibitors (MAOIs). With the launch of Prozac, the authors explain, it became possible for most people to use a pharmaceutical treatment for depression indefinitely, with few or no side effects. Since Prozac relieves depression in about 60 percent of patients taking it, the only drawback for the overwhelming majority using the drug has been its cost, which has often been covered by health insurance.
The article ends by raising possibilities regarding the ways in which psychopharmacology might not only treat diagnosed mental illness, but also equip people to cope more effectively with the stresses of ordinary life, including relationships and work. At the outset, the authors note that such use by "healthy" people could result in unintended long-term negative consequences, including certain drug side effects. Nevertheless, the article concludes that the relatively benign safety profile of Prozac has encouraged speculation regarding how pharmaceuticals could alter personality in ways that could benefit people and society.
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Although the Newsweek article "The Promise of Prozac" was written several years ago, the issues raised in the article are still cogent. One of the psychiatric experts cited in the article, Peter Kramer, went on to write about many of the themes explored in the article. In 1993, he published Listening to Prozac, which became a best seller, and in 2005, he published Against Depression, a polemic against the tendency to find virtue or value in depression. Kramer's ideas are now at the center of controversy over the nature of depression.
The significance of "The Promise of Prozac" lies in its characterization of depression and other disorders, as well as ordinary personality traits, as biological conditions that can be altered with psychopharmacology. The article does not explore the origins of depression or other mental qualities such as wit or insight, but their origin seems to be of little consequence. Whatever factors are involved in the development of depression, the article suggests that the biochemical state of the brain might be altered using drugs such as Prozac to improve mental and emotional functioning. This improved functioning could include greater powers of concentration and attention to detail, enabling people to better fulfill social roles in work and interpersonal relationships. Drugs might also produce greater emotional resilience in people, helping them to fix problems creatively without being overwhelmed by negative feelings about past failures or traumas.
The publicity exemplified by the Newsweek article and Kramer's books about new generation antidepressants—mainly selective serotonin reuptake inhibitors (SSRIs), such as Prozac (fluoxetine) and Paxil (paroxetine)—led to an explosion in the use of these drugs. A report by the U.S. Department of Health and Human Services in 2000 revealed that by 1998, SSRIs had captured 62 percent of the massive Medicaid market for antidepressants, a market which grew 40 percent from 1995 to 1998. Most of this growth was due to SSRI prescriptions, which did not supplant the older antidepressants (tricyclics and monoamine oxidase inhibitors). Rather, SSRIs expanded the demand for antidepressant treatment.
Many of the patients using SSRIs might not have been prescribed drug treatment five years earlier and would only have received psychotherapy. A large part of this growth in SSRI prescriptions is due to the ease with which family doctors are able to prescribe them, since these medications come in a standard dose. Prescribing the older antidepressant drugs, which require the dosage to be precisely adjusted for each patient, is usually the province of psychiatric specialists.
Many of the issues raised in the Newsweek article and the books of Peter Kramer are philosophical in nature and have not been tested—and, indeed, would be difficult to test—in clinical trials. The U.S Food and Drug Administration (FDA) has not approved the use of the SSRIs to "improve emotional resilience" or "enhance concentration," except in the context of clinical depression. There is, as yet, no evidence beyond the anecdotes and testimonials mentioned in "The Promise of Prozac" and Kramer's books that such drugs can improve peoples' personalities when the individuals taking them do not meet the criteria for clinical depression.
Furthermore, the use of SSRIs for depression is "empirical." Physicians prescribe them because they have been shown to be effective in treating depression, but the mechanism by which they work is still not known. There is increasing evidence that prolonged, untreated depression results in a loss of brain cells, increased physical illness, higher death rates, and other deleterious biological consequences. However, there currently is no evidence for the way in which depression might produce these effects.
There is a corresponding lack of evidence in experimental psychology for claims that Prozac or other drugs improve activities of daily living in people not diagnosed as depressed (or as having other mental disorders, such as phobias, attention disorders, anxiety, etc.). Yet the pressures on people in contemporary Western society may cause more and more of them to ask their physicians to prescribe drugs that might boost their ability to perform successfully.
In 2004, the FDA required manufacturers of Prozac and other antidepressants to include a "black box" warning statement (the FDA's strongest warning) on their packaging and labeling. This warning states: Antidepressants increase the risk of suicidal thinking and behavior (suicidality) in children and adolescents with major depressive disorder (MDD) and other psychiatric disorders. Anyone considering the use of [Drug Name] or any other antidepressant in a child or adolescent must balance this risk with the clinical need. Patients who are started on therapy should be observed closely for clinical worsening, suicidality, or unusual changes in behavior. Families and caregivers should be advised of the need for close observation and communication with the prescriber."
Kramer, Peter. Against Depression. New York: Viking, 2005.
――――――. Listening to Prozac. New York: Penguin Books, 1993.
Shank, Joshua Wolf. Lincoln's Melancholy. Boston: Houghton Mifflin, 2005.
U.S. Department of Health and Human Services. "Access and Utilization of New Antidepressant and Antipsychotic Medications, Chapter VI, Patterns of Antipsychotic and Antidepressant Utilization in Medicaid, 1995–1998." 〈http://aspe.hhs.gov/health/reports/Psychmedaccess/chap06.htm〉 (accessed October 30, 2005).