The Proliferation of Prozac : Millions of prescriptions for the drug and other antidepressants are written annually. Now, doctors wonder about long-term use.
Depression didn’t settle quietly into Mary’s life.
It tormented virtually every moment of her day, making even the smallest household duty an uncomfortable and tearful task. It frightened her into wakefulness night after night. It left her confused, scared, defeated.
“I felt as if I were drowning,” the 49-year-old New York woman recalled recently.
That was a year ago. Now, things are different.
The clinical depression that clouded Mary’s life for more than a year has lifted. Her energy has returned. She smiles. She gives credit to a tiny pill that she began taking last year in an ongoing study at the State University of New York at Stony Brook.
Had Mary suffered these classic signs of depression even as recently as the mid-1980s, doctors would not have so readily prescribed a pill to lift her mood. She may have spent years on an analyst’s couch with little relief of her symptoms. The antidepressants available then were fraught with troublesome side effects and carried the danger that depressed people could overdose on them and commit suicide.
But 10 years ago, Prozac was born and with it a change in how depression was viewed: not as a complex psychological problem to be treated with psychotherapy but as a symptom that might be eliminated with some adjustments in brain chemistry. Prozac is the first generation of drugs called selective serotonin re-uptake inhibitors, or SSRIs, which help the brain make better use of the neurochemical serotonin. Depressed people seem to have an imbalance in how their brains regulate serotonin.
But as prescriptions for antidepressants surge--tens of millions are written a year now--experts are working hard to figure out just how safe it is for millions of people to be taking these medicines for the long term. The current theory, based on following formerly depressed people, is that staying on medicine prevents future episodes. (And patients can’t overdose on SSRIs.)
But experts also point to convincing evidence that certain forms of psychotherapy can help brain chemistry right itself. Brain-scan studies at Washington University in St. Louis of patients undergoing cognitive therapy for depression show the brain regions normalize with talk therapy just as they do with medicines. And there is new evidence that even monthly psychotherapy sessions may help prevent relapse just as effectively as antidepressants.
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“There are dangerous precedents in the way that anti-depressant drugs are being perceived,” said William Danton, a psychologist at the University of Nevada Medical School and co-author with psychologist David Antonuccio of an upcoming paper in the journal Behavorial Therapy. “There’s this no-fault idea that these are brain imbalances, and we’re disconnecting depression and anxiety from life experiences.”
Approved for the treatment of clinical depression, Prozac--chemically known as fluoxetine--continues to be the fastest-selling antidepressant. Managed-care companies are reimbursing 80% for psychiatric visits to obtain prescription refills, compared with 50% for psychotherapy visits. “Managed-care companies are making decisions that Prozac works better and is cheaper than cognitive therapy,” said Danton. “It doesn’t work better, and it’s not cheaper.” In their latest study, the Nevada researchers factored in relapse rate, the costs of being depressed and the effects on those who dropped out of treatment and found that SSRIs such as Prozac, Zoloft and Paxil are actually costing managed-care companies 33% more than psychotherapy, Danton said.
The ease of prescribing a drug with side effects no more troubling than temporary nausea, sleep disruptions or loss of libido has led to the family doctor becoming a new overseer of mental problems. Seventy percent of prescriptions for antidepressants are now written by primary-care physicians. What that means to people like Danton is that these physicians know of no other way to treat depression.
Some experts say Prozac is now viewed as a drug that can be used by almost anyone to help elevate his or her mood at unsettling moments. More than 17 million Americans have used Prozac since it was approved, and its manufacturer--Eli Lilly and Co.--has announced a large advertising campaign designed to increase its customer base. The prescriptions continue to climb, doubling even since 1990, with 20 million prescriptions last year alone.
“These medicines have revolutionized psychiatry,” said Dr. Steven Paul of Lilly’s research division for the central nervous system. “In many ways these medicines have helped de-stigmatize depression. . . . People don’t feel that they are on some kind of mind-altering drug.”
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Dr. Donald Klein, director of research at the New York State Psychiatric Institute in Manhattan and a professor of psychiatry at Columbia University College of Physicians and Surgeons, has prescribed many antidepressants as they’ve entered the market and says that this generation of medicines doesn’t have any effect if a person isn’t truly depressed. “It works only if there was a chemical imbalance in the brain that needed fixing,” Klein said.
More and more, people are requesting Prozac as a panacea for life’s emotional ills. “It’s the desire for people to get back to life, to function,” said Alan Clark, president of Lilly’s U.S. operations. The pharmaceutical company’s hope, he said, is to reach people who may be suffering and not know they have depression.
Scientists estimate that 18 million people suffer severe depression each year, and one in every five people will experience a depressive episode in his or her lifetime.
The diagnosis can be made if a person experiences helplessness, loss of hope, sadness, crying, sleep or appetite disturbances, or difficulty concentrating for at least two straight weeks.
Some people believe Prozac has created a new generation of depressed patients, blurring the lines between clinical depression and personality quirks that leave some people naturally gloomy.
Dr. Peter Kramer, in his 1994 best seller, “Listening to Prozac,” examined the impact of the medicine on society’s psyche and suggested it could alter the nature of the self, for example “lending the introvert the social skills of a salesman.”
After a decade of use of Prozac and related drugs, several questions remain unanswered. How long should patients be treated? Does long-term use increase the chance of a relapse once the person stops taking the medicine? How common is relapse? Do these drugs lose their effectiveness over time as the body becomes used to them? What’s the correct long-term dose? Under what conditions should a person stop taking medicine? And, finally, what is the role of psychotherapy in treating depression and preventing relapse?
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“These medicines have helped us learn a lot about depression, but there is still so much we don’t understand,” said Dr. Martin Keller, chairman of psychiatry and human behavior at Brown University’s School of Medicine in Providence, R.I. Keller is coordinating a trial at a dozen centers around the country that may help answer some of these questions. Funded by Bristol-Myers Squibb, makers of an SSRI called Serzone, this is the first large study comparing medication and therapy.
The study compares patients getting cognitive-behavior therapy to those on medicine, and a third arm of the study is testing whether a combination of both treatments will work even better than either alone.
