Prozac information
(by Internet Mental Heath)

Guide to mental-health medications
(by the National Institute of Mental Health)

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A decade of Prozac - continued

Some economists have estimated the social cost of depression at more than $40 [billion a year, with about a third of that amount attributable to doctors' fees, therapy, and medication, and the remainder coming from the indirect costs of things such as absenteeism and reduced productivity. But for the 16 million Americans who suffer from depression each year, such financial considerations may seem irrelevant. Living without Prozac, or Zoloft or Luvox, many of those taking the drugs say, would be like inhabiting a dark, sensory-deprivation chamber.

Looking back, Ken Heideman is not surprised that depression has plagued him throughout his adult life. As a 4-year-old, Heideman heard his father stab his mother to death in the next room. He was then removed from his family home in California and sent to live with his grandparents in Massachusetts.

Still, despite Heideman's severe trauma, it wasn't until more than a decade later that he heard the echoes of the brutal event that had disrupted his childhood. As a sophomore at the University of Vermont, he was a star student, a social success, and an avid runner. Then he injured his heel, temporarily putting an end to his daily runs. Heideman's injury kept him from pursuing his beloved family home in California and sent to live with his grandparents in Massachusetts.

Still, despite Heideman's severe trauma, it wasn't until more than a decade later that he heard the echoes of the brutal event that had disrupted his childhood. As a sophomore at the University of Vermont, he was a star student, a social success, and an avid runner. Then he injured his heel, temporarily putting an end to his daily runs. Heideman's injury kept him from pursuing his beloved 38, has a new home, a fiancee he plans to marry this fall, and a job he likes. It's hard for him to imagine life without Effexor, an antidepressant introduced by Wyeth-Ayerst in 1994, which combines Prozac's ability to boost the brain chemical serotonin with a similar mechanism that boosts the brain chemical norepinephrine.

For Lisa Lambert, of Lexington, life was also unbearable without the new drugs - not because of her own depression but because of the depression of her son Matthew, now 15. Irritable, insomniac, and dour for almost as long as his mother can remember, Matthew found that his mood lifted with various tricyclics. But his parents took him off the drugs because they made his hands shake, his heart race, and his face turn chalky white. On Zoloft, Matthew has had all of the good spirits but none of the physical ailments.

``He fishes and bikes and even applied for a volunteer position for the summer,'' Lambert says. ``It's a lot different from the kid who was so depressed he stopped going to school.''

But Prozac hasn't become a household word because of its effectiveness in serious cases of depression such as these. Although the SSRIs have significantly decreased the cost of treating those with major clinical depression, they have also been credited with making us, generally, a happier nation, with fewer bouts of sadness and despair. In Listening to Prozac, Peter Kramer says that Prozac not only made many of his patients less depressed, but it actually helped them to better pursue job promotions, new friends, and steady romantic partners.

But the new drugs don't deserve all the credit for people's improved moods. Even Heideman says that much of his happiness - perhaps even more than what Effexor gives him - comes from the hard work he has done in therapy, taking apart his earliest childhood trauma and understanding what has triggered his various depressive episodes.

Heideman's experience proves what many people ignore but what major medical studies continue to stress: that antidepressants work best not just gulped down mindlessly but in combination with some sort of psychotherapy. ``It's not that I don't think these are miracle drugs,'' Heideman says, ``but I think they need to be used the right way. They're for people with real clinical depression, not people who want to be more talkative at cocktail parties. They shouldn't just be handed out as the next great designer drug. That just takes responsibility away from people for making their own happiness and adjusting to the realities in their lives.''

Dr. Barbara Masley treats patients with every imaginable health problem. As a primary-care practitioner for a booming Beth Israel Deaconess Medical Center clinic located in downtown Boston, Masley spends her days monitoring diabetics' insulin levels, doing breast exams and Pap smears, and treating dozens of people with various benign ailments - from allergies to stomachaches to sinusitis.

Increasingly, though, Masley has added to her list of professional duties a task previously confined to the realm of specialists. Before the advent of Prozac, she admits, she wasn't inclined to prescribe antidepressants, worrying that they were too potent to be prescribed by someone without specialized knowledge. But these days, Masley finds herself spending more time sitting with her patients and discussing the symptoms of clinical depression. Often, she sends them out with sample packets of Zoloft.

Whenever she prescribes an SSRI, Masley says, she warns her patient about the drug's potential side effects, then tries to schedule a follow-up appointment one month later. And always, she says, she tells them that she's less familiar with the medications than are the psychotherapists who have prescribed them for years. ``If the drugs don't seem to be working,'' says Masley, ``or if we try several medications and they don't work, I tell them they should probably see a psychiatrist.''

Since the advent of Prozac and the other new antidepressants, family doctors - not psychiatrists or psychopharmacologists - have become the most likely practitioners to prescribe them. According to a 1993 study by psychiatrists at Columbia University College of Physicians and Surgeons, general practitioners prescribe about 63 percent of the new antidepressants.

That worries some people. In part, the specialists fret about overprescription, even by cautious and thoughtful general practitioners. Because the new drugs are easy to monitor, doctors are more likely to experiment with them. And because they're relatively cheap, doctors see them as a low-cost means of treating depression in an era when there is pressure from insurers to keep costs down.

Although a typical month's dosage of Prozac costs between $75 and $150, that's far less expensive than a month's worth of weekly therapy. As Masley points out, extensive talk therapy is not covered by many of her patients' insurance companies. And she certainly doesn't have the training or the time to hash out her patients' psychological problems. In her crowded office, she feels the clock ticking, as patients clog her waiting room and appointment slots get briefer and briefer.

``The bottom line is that these drugs are so simple to use and so relatively free of side effects that, even without really understanding a patient's problems, a physician may prescribe the drugs, because there's not a lot to lose,'' says Dr. Don Lipsitt, chairman of the psychiatry department at Mount Auburn Hospital, in Cambridge.

Supporters of the new drugs argue that the fear of overprescription is unfair and inaccurate. The real problem, they say, is that so many people with depression still aren't getting treatment. ``On the whole, depression remains an underdiagnosed, underrecognized disease,'' says Dr. Cathryn Clary, senior associate medical director for Pfizer Inc., which produces Zoloft. Indeed, recent studies report that more than one-third of Americans with depression remain untreated.

Others argue that it's silly to nit-pick about overprescription when the drugs continue to make the vast majority of patients feel better. ``It's easy to throw up our hands and worry that we're prescribing too much Prozac,'' says author and psychiatrist Peter Kramer. ``Maybe the real issue is that our culture doesn't give people ... a sense of community, support, and connection. These drugs treat what ails us.''

Doling out a relatively innocuous drug to a slightly depressed patient is only one part of the problem, though. General practitioners like Masley have little time to follow up with patients over long periods - or to learn about the drugs' rarer side effects. What happens, critics wonder, when a patient on Prozac goes home with the cherished new pill and ends up feeling nauseous, manic, or even suicidal? Will that person know enough to make the connection between the side effect and the new medication? Will a busy doctor have a spare moment to check in before a patient's next biannual appointment, and, if he does, will he understand the litany of complicated side effects a psychiatric drug can cause?

For most people taking the new antidepressants, whether or not a doctor checks in, may not really matter. To date, there is no strong evidence that these drugs have killed anyone; early reports that Prozac caused the suicides of a number of seriously depressed patients have been discredited. And, clearly, the SSRIs, in their relatively brief life span, have boosted a lot of people's spirits.

But at the same time, the drugs certainly have fallen short of the original claims. After a decade of listening to Prozac, it has become clear that it is not a pill that will magically erase the woes of anyone willing to pop it.

In fact, Prozac and its counterparts have turned out be like most other pharmaceutical agents - important evolutionary steps in medical therapy, but neither the solution for every individual nor necessarily the best solution available.

Clinicians say that the side effects that may appear as the drugs are used over time probably will be relatively minor. Certainly, no data so far indicate that they will prove life-threatening. But if doctors continue to prescribe the drugs so readily, could the drugs actually limit, rather than expand, the life experiences of these patients? Are the new antidepressants, when overused and when used without complementary talk therapy, a bit like narcotics, numbing people into accepting dire situations without requiring them to develop key coping skills?

``New drugs are a lot like new diets - or new boyfriends and girlfriends,'' says Appleton. ``You're really enthusiastic at the start about this sexy new thing in your life, and then, after five years or so, you begin to know all of their faults. That's how it is with these new antidepressants. They're getting to be middle-aged now, and we know all their faults. That doesn't make them worthless by any means, but it makes us all the more measured in our enthusiasm.''