Carl Elliott, Tod Chambers
Prozac as A Way of Life
The University of North Carolina Press
2004 PB, 224 pages, $19.95, 0-8078-5551-0
Prozac, as Carl Elliott writes in the introduction to Prozac as a Way of Life, may have begun life as a brand name for the active ingredient fluoxetine, but it now does duty, metonymically, for all the selective serotonin reuptake inhibitors (SSRIs), and, by extension, for an entire lifestyle. When people say Prozac they may well be talking about something else, for Prozac has been so successful since it was first put on the market that it has reared offspring: Paxil (paroxetine), Luvox (fluvoxetine), Zoloft (sertraline), Effexor (venlafaxine) and Celexa (citalopram). And the number of disorders which these drugs are licensed to treat has broadened well beyond depression to include conditions all but invisible until the 1990s: social phobia, panic disorders, eating disorders, post-traumatic stress disorder and sexual compulsions. When Eli Lilly's patent for Prozac expired in 2001 it was marketed under a different name, Sarafem, as a treatment for ‘premenstrual dysphoric disorder’.
Prozac as a Way of Life, in 11 essays by different hands, is an unusually literate attempt to get beyond the pointillism of case reports and take the measure of the world that made Prozac and the world that Prozac is making. Prozac has been with us long enough now for it to have gone the way of all drugs: first its acclamation as the universal panacea, its media boosting, the slow emergence of doubt, media quickening of doubt and backlash (we are currently between stages 4 and 5). If Prozac has the ability to alter feelings and actions, reshaping what we call empathy, the bonds of mutuality between individuals, then it has the ability to reshape the fabric of life itself. What can be said about the place in society that SSRIs have come to occupy? Is Prozac the symptom for which it pretends to be the cure? How can Prozac be a liberating drug, as many of its supporters suppose, when its use increases dependency? If the bulimic consumption of antidepressants betrays an essential lack, what is it people are missing? And then there is the libertarian argument: if every culture has its licit psychoactive substances, from betel nuts and kava to alcohol and nicotine, why should the medical profession be the sole guardian of access to SSRIs?
Depression is our contemporary diagnostic black hole. Consider the statistics: from being a rare diagnosis (affecting perhaps 50 people per million) in 1957, when the first antidepressant was discovered, the estimated number of depressed persons in 1970 was estimated at 100 million worldwide. In France alone, the number of depressed patients on treatment increased by 1 million in the 1980s. Prescriptions for SSRIs increased by 20.9% in a single year (1999–2000) in the US. According to WHO, depression and cardiovascular disease are the two major public health problems of the third millennium. Prozac has excited the philosophers and ethicists in a way that imipramine did not (exemplified by Peter Dramer's best-seller Listening to Prozac). Clearly, we are facing a phenomenon not just of medical or sociological importance, but an anthropological ground change, and a mutation in the very way we think about ourselves.
The key essay in the collection is David Healy's ‘Good Science or Good Business?’, in which he mooted the possibility of a link between Prozac and suicide: it led, controversially, to the rescinding of his appointment to a post in Toronto. Healy outlines how the thalidomide disaster in the 1960s shaped the emergence of the ‘disease states’ required in order to secure FDA approval. For years the pharmaceutical industry has been putting vast resources into gathering and disseminating information to influence treatment lobbies and how doctors prescribe. Most GPs are naïve realists, that is, we treat our patients in good faith, assuming them to be genuinely ill; and patients present with genuine symptoms (they must since we've just checked them off). Yet Healy suggests that Prozac is less likely to ‘work’ when its effects are evaluated using patient-based, non-specific quality-of-life instruments rather than clinician-based rating scales. So what order of phenomenon are we dealing with? Can it be that modern psychiatry is based on something like a category error, the persistence of the bacteriological model of disease in a situation that really calls for an Aristotelian concept of mind as shared?
What I therefore missed in Prozac as a Way of Life was the broader historical overview. One thread running through the book is the (American) search for the authentic self, although those who chase the drug bandwagon are manifestly slaves to a conformism that makes the whole idea of authenticity look bogus. The Victorian personality — disciplined, rule-observant and respectful of authority — survived until the 1950s, and perhaps longer in Britain (which was barely affected by the 1968 revolution); the new individual of the age of bounty is caught on the rack between what is permitted and what is possible. Choice is the thing. The price of the ticket for liberation from ascribed identities, rituals, practices and even family links is free-floating disorientation. For the one condition that describes our life is its optionality. At the heart of Western civilisation is less an idea than an aspiration: the heresy of the total emancipation of the individual from society, even from external reality itself. Paradoxical as it may sound, the more private it becomes, the more the sovereign self is forced to model its behaviour on others.
But the book adopts the right approach towards an understanding of how depression has become an epidemic: it is essentially a cultural, not a medical or political issue. As Robert Burton suggested in 1621, in his solid classic of the English language The Anatomy of Melancholy, one of the symptoms of melancholia is not to know its cause.
- © British Journal of General Practice, 2005.
