Depression is often chemical, not emotional, the experts say. And they’ve cooked up a pharmaceutical New Deal.
The first sign that something had changed in John Edwards* was the way he sounded on his answering machine. Before, his recorded greeting had been a dull, almost threatening, monotone that identified him only by his phone number, made none of the usual promises to call back and practically challenged callers to “leave a message–if you like.”
The new message picked up with a bright “Hi, this is John.” It sounded downright … friendly. Which is to say, exactly the way John really is, but only once you get past his stern outer armor.
The difference between message one and message two can be summed up in a single word: Prozac.
Remember Prozac? The trendy miracle-worker of the late ’80s? Then came the backlash, in which Prozac was alleged to make some users violent or suicidal. Having been put on a pedestal and quickly knocked off again, Prozac seemed to disappear from sight. But after those fears about safety proved largely unfounded, it came back riding a tidal wave of popularity. Prozac has been prescribed for nearly 6 million people in the United States, 10 million worldwide. “Even with the scares, Prozac has always been well regarded by psychiatrists,” remarks Peter Kramer, M.D., author of the best-seller Listening to Prozac. “Within three years of its approval, it became the most widely prescribed antidepressant drug, and it still is today.”
It’s estimated that depression will strike approximately 10 percent of American men at some point during their lifetimes. (New research links depression in men to prenatal exposure to DES, a drug widely prescribed in the ’50s and ’60s for pregnancy complications.) The National Mental Health Association says depression now outdistances heart disease in costs to society: nearly $44 billion annually in treatment and loss of productivity.
Part of the reason for Prozac’s instant appeal as a depression medication is that it’s not considered addictive and produces fewer side effects than older antidepressants.
Prozac is not without critics, however. Some psychiatrists believe that any drug so widely prescribed should be regarded as suspicious. “Prozac’s being used way beyond what it was intended to treat, and that is major depression,” says Boston psychiatrist Keith R. Ablow, M.D. “I feel that in the current health-care environment, the kinds of gains patients are making through psychotherapy might never be achieved if medication is offered as a complete cure.”
Other reservations include the reality that long-term side effects are unknown. Indeed, new information on Prozac and other antidepressants suggests that there are some side effects that may have been underestimated in early studies. Among them: delayed ejaculation (in some cases the inability to ejaculate at all), decreased sex drive and even impotence. “It looks like the incidence of sexual problems is higher than first thought,” says Richard Balon, M.D., associate professor of psychiatry at Wayne State University. In a study, Dr. Balon found that 43 percent of patients on antidepressant drugs experienced sexual difficulties ranging from decreased libido to painful ejaculation. Not everyone taking antidepressants has sexual problems, but it’s an issue worth considering.
Side effects notwithstanding, most Prozac supporters say what’s extraordinary about the drug is that it allows many people who might not pass the clinical test for depression to lead fuller lives. Taking it–especially in conjunction with psychotherapy–can be like flipping a switch that turns black and white into Technicolor. “Look, I feel funny using words like this,” says one man. “But Prozac has allowed me to rediscover the joy in life.”
Others say they have developed more confidence and greater selfesteem on the drug. And, unlike the previous antidepressants, Prozac and other drugs that work in similar ways not only erase the pain; they also leave patients more agile mentally, with a heightened ability to feel emotions. “A typical response is, `This is the way I always thought I should feel,’ ” says Dr. Kramer.
Some people seem to spontaneously heal long-standing problems. They give up selfdestructive habits, start functioning more efficiently at work, renew their personal relationships. “I was astonished to find that a pill could sometimes do in a matter of weeks what psychiatrists hope, and often fail, to accomplish by other means over the course of years,” says Dr. Kramer.
Take the case of David Petersen, a surgeon, who’d been held back all his professional life by his plodding, self-effacing style. This is not someone you’d think of as depressed, but someone you’d probably call exceedingly shy. And it was costing him. On Prozac, he found himself more confident; he was able to make snap decisions; and just as important, others came to view him as more assertive, dynamic, competent.
In some quarters, the accomplishments of Prozac and a newer group of kindred drugs have caused a certain amount of philosophical hand-wringing. One can’t help but wonder whether a quick drug fix is a morally correct choice. “I would hate to think we are headed toward a time when relieving some symptoms of depression passes for understanding one’s life,” says Dr. Ablow.
Then there is the whole question: Isn’t the richness of our emotional life impoverished by the notion that feelings can be controlled with chemicals? If we take pills to correct the darker, cynical, brooding aspects of our personalities, aren’t we suppressing part of who we really are? Aren’t we in danger of becoming a vacuous nation of annoying smiley-faces?
Some people even question whether Prozac may have some detrimental effect on the creativity of artists, writers and musicians, who, as a group, seem to suffer from depression more than other people. Said one doctor: “Imagine if Woody Allen was depressed and taking this medicine–some of his movies might have been awfully upbeat.”
Many doctors sympathize with these concerns, but they and their patients approach the matter from a different perspective. Depression, they say, isn’t a normal mood state, but a disease that demands treatment. Lawrence Cohen, Pharm.D., associate professor of pharmacy, psychiatry and behavioral sciences at the University of Oklahoma, urges that we view antidepressants the way we view a drug like insulin: as an antidote to a chemical imbalance, not as a crutch.
Another reason to take depression seriously: New research from the Centers for Disease Control and Prevention has linked the disorder with heart disease. A study of 2,832 people found the risk of fatal heart disease was one and a half times as great in those people who reported depressed feelings as it was in those with low or no such feelings.
Since all of us face blue moods from time to time, the question then becomes, how do we know if antidepressants would make us feel any better? There are two answers to that question, the old answer and the new one. The old answer is that you’re officially depressed when four or more of the following problems persist for long stretches of time: feelings of darkness, lack of energy, low sex drive, self-deprecation or guilt, indecision or irritability, and changes in normal sleeping and eating patterns. The new answer is that if you think you might be depressed, or if you feel that you’re always on the verge of losing life’s struggle, talk with your doctor about trying Prozac or another similar drug. “It’s not an upper,” says Francis Mondimore, M.D., of Carolinas Medical Center in North Carolina and author of Depression: The Mood Disease. “If you don’t have the disease, it won’t make you feel any better. If you do have the disease, however, taking it can be a remarkable lifealtering experience.”
Of course, the core idea underlying treatment with antidepressants is that depression isn’t strictly a problem of emotional maladjustment. Research into how the brain works reveals that mood disorders may be engendered by off-kilter mixes of a few important brain chemicals. Antidepressant drugs help rebalance those mixes by unclogging mental pathways in the brain, keeping mood-governing signals racing along at a normal, efficient clip. They’re a sort of cerebral Gumout that boosts the flow of neurotransmitters in the brain to make you mentally sharper, more energetic–more alive.
What makes drugs like Prozac so effective is their highly targeted effect on the neurotransmitter serotonin, which is perhaps the most important moodgoverning chemical messenger in the brain. Prozac boosts levels of serotonin by preventing its absorption into body tissues after it delivers a message–hence the reason for its being called a serotonin reuptake inhibitor.
Because it affects only one neurotransmitter instead of several, as earlier chemical antidepressants do, it is generally believed that Prozac’s side effects are mild by comparison. As a result, many doctors consider it appropriate to use Prozac in treating low-grade mood disorders. The risks of doing so, say doctors, are relatively minimal, though there may be some side effects, including anxiety, insomnia and the sexual problems mentioned earlier.
Older antidepressants had a much more profound effect on the body. The most common category of drugs, tricyclics, are fatal in overdose and can cause heart attacks in men with cardiovascular problems. Another category, monoamine oxidase inhibitors (MAOIs), could trigger a potentially fatal reaction with a chemical found in high amounts in ordinary foods like aged cheese and some types of beer and wine.
The relative safety of Prozac and other newer medications makes them particularly useful in treating men, since depression in men is often harder to diagnose than in women. This may be because admitting that we’re suffering doesn’t exactly match the image of rock-solid provider we’re taught from childhood to project. “When you’re depressed, you’re not in control,” points out William Potter, M.D., chief of the section on clinical pharmacology at the National Institute of Mental Health. “You’re less sharp, you lack energy, your sex drive dwindles, you feel you can’t handle matters on your own–all sorts of things associated with being an active man are affected.”
To compound things, it’s common for men to first experience depression just when we’ve typically shouldered the full weight of life’s burdens. We’ve bought the house, started the family, established the career. If the weight gets too heavy, we don’t know what to do–and we certainly don’t want to admit to a possible mental illness. “At first I figured I had a vitamin deficiency,” says Peter Hutchinson, a partner in an Arizona law firm. “Then I was sure the problem was lack of exercise. I went on diets, took up running, read self-help books. Nothing made a difference until I tried Prozac.”
Until recently, Prozac was the only antidepressant drug that singled out serotonin. Two new drugs, Paxil and Zoloft, were approved in 1992. The main differences among the new Prozaclike drugs are their side effects. Zoloft, for example, is less likely to cause anxiety than Prozac. Paxil is more likely to make you lethargic. (A third drug, Effexor, which recently won FDA approval, is being hailed as a high-octane Prozac alternative with fewer side effects.) Dr. Balon suggests that if your depression medication is doing a number on your sex life, you might ask your doctor to try you on one such as Wellbutrin, which functions differently from the serotonin reuptake inhibitors.
In many cases, the drugs work best when taken in conjunction with some form of talk therapy. Putting these two approaches together is 80 percent effective in overcoming depression. Says Hutchinson: “I’d been in therapy for a long time, but it was only after I started with Prozac that it actually kicked in. Suddenly, I felt I could take charge and make real changes in my life.”
Taking charge. That, in the end, is the promise of drugs like Prozac: to help you take charge of your mind, your feelings. Once those things are better, everything else can fall into place. Of course, the good things that might happen in your life as a result-greater success, a better love life–can’t be packaged in a pill. That part is up to you.
Blues Breakers - Drugs that lift low moods
Drug: Prozac (fluoxetine hydrochloride); Chemical type: Serotonin-selective reuptake inhibitor; Daily dose: 20 mg; How often taken: Once daily; Monthly cost*: 20 mg/day, $60; Possible side effects: Anxiety, insomnia, weight loss, chills, nausea, diarrhea, delayed ejaculation, decreased sex drive
Drug: Zoloft (sertraline hydrochloride); Chemical type: Serotonin-selective reuptake inhibitor; Daily dose: 50 to 200 mg; How often taken: Once daily; Monthly cost*: 50 mg/day, $54; Possible side effects: Nausea, diarrhea, weight loss, dizziness, insomnia, sweating, delayed ejaculation
Drug: Paxil (paroxetine); Chemical type: Serotonin-selective reuptake inhibitor; Daily dose: 20 to 50 mg; How often taken: Once daily; Monthly cost*: 20 mg/day, $52; Possible side effects: Lack of energy, insomnia, sweating, agitation, tremors, nausea, delayed ejaculation
Drug: Wellbutrin (bupropion hydrochloride); Chemical type: Aminoketone. Delivers results for some depressives who don’t respond to serotonin reuptake inhibitors; Daily dose: 100 to 450 mg; How often taken: 2-3 times daily; Monthly cost*: 150 mg/day in 2 doses, $31; Possible side effects: Seizures, agitation, insomnia, dry mouth, headache, nausea
* Costs based on prices for bottles of 100 pills delivering the lowest available dose.
