The emergence of Prozac, the brand name for the selective serotonin re-uptake inhibitor (SSRI) fluoxetine, in the late 1980’s has marked a revolution in the treatment of depression and other related disorders. Unlike its’ predecessors, the tricyclic antidepressants and MAO Inhibitors, which were for decades the only available antidepressant drugs, Prozac is not just a name familiar only to long-suffering patients and their relatives – it became an über-brand, part of a mainstream vocabulary, a symbol of the quick-fix culture.
This drug, which appeared as a much more effective and less harmful alternative to older antidepressants, has changed our perception of mental illness and our attitude to life in general. The stigma of certain psychiatric diagnoses, such as depression, has been removed – suddenly many more people are willing to complain about their emotional state to GPs and to seek treatment, which, according to a Department of Health report, resulted in a 173% increase in prescriptions of antidepressants between 1991 and 2001. On the other hand, according to the data from 298 UK general practices, the incidence of diagnosed depression dropped by almost 50% between 1996 and 2006.
So who are antidepressants prescribed to and why?
The 'miracle' cure
The reason for such enthusiastic reaction to the appearance of a new drug on the market was its relatively low toxicity and fewer side-effects, compared to other drugs (the MAO Inhibitors were potentially toxic when combined with certain foods, such as cheese, and the tricyclics were almost always fatal when taken in large doses, especially when combined with alcohol). Furthermore, it was soon discovered that other symptoms which sometimes co-occur with depression can also improve during treatment with Prozac. This led to the wide-spread prescription of Prozac as a miracle drug likely to cure most psychological ailments.
In words of Dr Simon Sobo, director of Psychiatry at the New Milford Hospital, USA: ‘Prozac has been successfully used for obsessive hair-pulling, panic disorder, eating disorders and social and other phobias. It has proven useful to people to free themselves from addictive relationships; to dispel doubts about performance; to overcome obstacles that once seemed impossible. I have even added it to my watering can and found geraniums grow better on it.’ He was clearly joking, but only on the last point. He did not mention that even obesity, gambling addiction, compulsive shopping and pre-menstrual syndrome (PMS) can also be helped by this drug.
The blurry line between 'normal' emotions and mental disease
This increasing trend of prescribing antidepressant drugs for practically any psychological problem raises several important issues, the most obvious one being: do all these people who are being prescribed antidepressants really need them?
‘In recent years we have been encouraged to view more and more problems that were previously considered to be normal and manageable parts of the human condition as mental diseases that require treatment’, says Dr Joanna Moncrieff, a Senior Lecturer in Psychiatry at the University College London. She claims that pharmaceutical companies are involved in promoting awareness of conditions such as depression or social anxiety disorder (characterized by excessive shyness and lack of confidence) and that they sometimes deliberately over-estimate the prevalence of such disorders in order to increase the market for their drugs. The result of such campaigns is to turn the common perception of shyness or unhappiness from personal difficulty to a psychiatric condition.
Dr David Healy, director of the North Wales Department of Psychological Medicine and one of the UK’s top experts on antidepressants, goes a step further. He believes that the drug industry has turned its attention to depression because the once highly profitable market for drugs used to treat anxiety was greatly reduced after it was discovered that they can be highly addictive. It seems that the escalating rates of use of antidepressants may therefore have more to do with marketing strategies than with any real benefits to mental health.
Benzodiazepines were widely prescribed in 1960s and 1970s as the treatment for a variety of symptoms, including anxiety, nervousness/restlessness and insomnia. Nowdays their use is much more limited and they are usually prescribed for only brief periods of time.
Antidepressants can save lives
Most of the opponents of such wide-spread use of psychiatric drugs do not overlook the fact that Prozac and other antidepressants can mean a difference between life and death to some individuals who suffer from clinical depression. This debilitating disorder, which may, at some point in life, affect around 10% of men and up to 25% of women in the UK, is related to changes in brain structure and function - changes which can be improved by antidepressant medications. Although social factors must be considered in determining the origin and treatment of all psychological disorders such as depression, changing social factors will not always prevent or cure them.
While psychological interventions such as the cognitive-behavioural therapy (CBT) can be as effective as antidepressants in the treatment of mild to moderate depression, severely depressed individuals lack the motivation to even begin to engage in psychotherapy. Considering the very high risk of suicide in this patient population (around 15% of depressed individuals eventually kill themselves), the importance of drugs, which may get the patients out of a state of deep depression and thus make them more responsive to psychological interventions, is unquestionable.
However, considering the relatively low therapeutic value of antidepressants when prescribed to individuals who do not meet the diagnostic criteria for severe major depression, the justification for the increasing trend of prescribing drugs to such patients is far less clear. Such patients suffer from symptoms which are not debilitating to begin with and which can be resolved equally well - or even better - without drugs. Also, there are the adverse side-effects of Prozac and other SSRIs to consider, the most common being nausea, headache, insomnia, nervousness/agitation and sexual dysfunction, while more severe adverse effects have also been reported.
The Brave New World
The wide-spread prescription of Prozac and other SSRIs to individuals who may be undergoing a particularly stressful time in their lives, such as divorce or bereavement, or who may simply lack confidence or ability to adjust to life's challenges, also poses important ethical questions:
Do these drugs merely act as pain-killers, relieving the emotional pain but not treating the injury which caused it?
Don’t people need to learn how to cope with the life's challenges?
Shouldn’t we attempt to change our life and the societal problems which are often at the root cause of low mood and of many other emotional difficulties, rather than simply stop feeling so negative about them?
Furthermore, can everyone be expected to become confident and well-adjusted? If everyone’s character ‘flaws’ and negative mood could be smoothed out by medication, will we end up with a society where individuality is lost, where the ability to experience happiness or sadness is blunted – a society reminiscent of Aldous Huxley’s Brave New World, where a fictional drug anesthetized citizens into a content unawareness?
‘We are encouraged to aspire to narrow norms of behaviour and taught that anything else is not only undesirable but unnatural or diseased. We are encouraged to think that changes should be effected not by ourselves on our environment, but by technology on ourselves’, concludes Moncrieff.
The increasingly popular and scientifically validated mindfulness-based approaches to mental health are an obvious alternative to this narrow view of the human potential. Such approaches place an emphasis on what is called mindful acceptance, the ability to acknowledge and accept thoughts and feelings without judgement. Mindful acceptance, of course, does not mean resignation, but it's about enabling people to become more accepting of and kind to themselves - a healthy foundation for any personal development. Not surprisingly, mindfulness training has been found to produce a variety of psychological, physical and social benefits.
However, there are other points of view. Antidepressants, when used at appropriate doses, do not dampen normal emotional responsiveness, they merely keep it from getting out of hand. Also, the improvement in mood and confidence may actually result in longer-term changes in personality, interpersonal relationships and, ultimately, the ability to cope with life, claims Dr Robert Trestman from University of Connecticut, USA.
Trestman suggests that a more positive outlook on life (even if it is only induced by the antidepressant and not by some other, more substantial change in their life) will enable better interactions with other people. In turn, the new relationships that develop at this time will continue to provide support and to promote positive mood, sense of acceptance and confidence to deal with life problems even after a person stops taking antidepressants.
The final verdict on antidepressants is yet to come...