What antidepressants are saying 30 years after the publication of Listening to Prozac

IIn 1993, I published Listening to Prozac, a book that grew out of my clinical experience prescribing a then-new class of drugs that were thought to relieve depression by affecting the way the brain handles the neurotransmitter serotonin.

Some of my patients have reported strong favorable drug reactions, first with Prozac and soon after with Zoloft. On medication, patients were more confident, less anxious and less pessimistic. They felt better than they had even before the episode of whatever we were treating, depression or increased obsessiveness. One patient said that she was finally herself, as if, without the new drug formulation, she would never have been who she was. In the book I tried to explain how these effects can occur and then discuss the implications for medical ethics and society as a whole. How malleable is the self? How open are we to technologies that could change that?

Listening to Prozac became a national and international bestseller and has remained in print ever since. The book is now available in a 30th anniversary edition with a new foreword and afterword in which I update the science and consider changes in the cultural status of antidepressants. In short: We rely on them more and respect them less.

When I wrote the book, the responses reported by my patients required explanation. In the early 1980s, I worked for the federal government, heading an agency that oversaw a wide range of mental health research. I turned to the experts I was working with at the time, in fields ranging from cell biology to animal ethology, in hopes of understanding how the compounds developed to treat severe depression might affect personality. I drew on that research for the book and continued to explore the implications for medical practice. If these or future drugs could alleviate a trait like shyness that, while not abnormal, is unpleasant and socially disadvantageous, should physicians use them to that end, engaging in what I have called cosmetic psychopharmacology?

I predicted that new drugs would lead to new prescribing habits, perhaps through what I called diagnostic creep, an apparent justification for treating increasingly mild forms of depression. But even I didn’t expect the magnitude of Prozax’s impact. In the late 1980s, perhaps one in 50 Americans received a prescription for an antidepressant each year, and the duration of treatment was generally a matter of months. Recently, use has risen to more than one in seven, with some patients remaining on the medication for decades.

Widespread adoption and the passage of time have led to the rejection of antidepressants in their main role, in the treatment of mood disorders. Patients in antidepressant survivor groups complain on social media about the side effects of the drugs. Within the professions, the anti-psychiatry movement has come together, arguing that antidepressants are little more than placebos with side effects and that serotonin use in the brain does not play a significant role in depression. I discuss these objections in detail in new essays in Listening to Prozac, and also in my previous non-fiction book, Ordinarily Well. My opinion is that we have been quite lucky with the drugs in terms of side effects and very lucky in terms of the main effects. They have eased the suffering of millions of patients.

Perhaps unexpectedly, there is less dispute about the better-than-good effects on temperament, and again, I seem to have underestimated this phenomenon. Research conducted after I wrote Listening to Prozac suggests that it and similar antidepressants are particularly effective at alleviating introversion and a personality trait called neuroticism, an amalgam of negative thinking, unpleasant self-consciousness, and emotional vulnerability and instability. Personality effects may be more pronounced than antidepressant effects and may be partly responsible for them. No one disputes that serotonin is involved. A similar shift occurs throughout the animal kingdom, where manipulation of serotonin can predispose males to alpha status. When Prozac enters the water supply, which it unfortunately does, regularly and in large quantities, certain fish can become overly bold and, therefore, vulnerable.

Today, the question I get most about hearing Prozac is whether I have continued to witness dramatically good responses to antidepressants over the years, an outcome that my patients and I have called better than good. The answer is: less often, but not for the reasons you might think.

When Listening to Prozac became a bestseller, my clinical practice changed. I saw patients in a private office in Providence, Rhode Island and enjoyed treating patients with a wide range of diagnoses.

But whatever my intentions as an author, I thought I wrote about reshaping the modern sense of self, readers saw my book as a resource for understanding depression and turned to me for help with complex and often difficult forms. mood disorders. As much as I tried to keep my patients local and diverse, I liked being a doctor in a small town, the practice became more and more national and specialized.

People sought me out because they had a bad time in other places. I was rarely the first doctor to give a patient a drug like Prozac. I have only occasionally treated first and second episode depression, uncomplicated by other psychiatric conditions.

My experience was an extreme version of what happened in psychiatry. If a family doctor has written prescriptions for antidepressants and patients have found relief, as happens in the vast majority of cases, they may never see a mental health specialist. Like me, my fellow psychiatrists mostly treated the rest, the patients who were not helped, or only partially helped, simply by prescribing.

When I worked in public health, starting with the Carter administration, one of our goals was to get primary care physicians to recognize and treat depression. Doctors managed Prozac more easily than previous antidepressants. It was those generalists who now saw that patients were gaining assertiveness and social competence.

Meanwhile, the medical profession’s understanding of mood disorders has changed. Depression is defined by a cluster of symptoms of deep sadness, obsessive self-blame, slowed thinking and speech, problems eating and sleeping, suicidal thoughts, loss of ability to experience pleasure, and more. In the 1980s, if a patient’s depressive episode resolved, if her sleep, appetite and energy improved and she returned to being passive, pessimistic and socially withdrawn, the drug had done its job. But after seeing patients on the new antidepressants doing better around the world, doctors now often considered melancholic temperament a residual disease.

And residual disease can be harmful. One of the major changes in the past three decades has been in physicians’ awareness of chronic low-level mood disorder and the risk it carries not only for suicide but also for routine poor life outcomes, including limited success in love and work. The once sharp division between depression as a disease and depressed temperament began to blur, so that some of what I understood as personality change became embedded in the physician’s picture of routine recovery from depression. This diagnostic bracket struck me as conceptually wrong thinking about those bold fish, but sometimes clinically justifiable.

Nor were the patients neutral on this topic. Certainly some of what is controversial about current long-term prescribing practices stems from patient preferences. Even between episodes of mood disorder, some patients who are prone to depression find that they feel better on medication and worse.

I stopped treating patients five years ago and have been writing full-time ever since. Until then, I continued to see dramatic favorable responses to antidepressants. But more often I heard or read about them. Readers have often written, and still do, to tell me that they resemble this or that patient in the vignettes of my books. And people who are considered more socially competent with drugs sometimes share their experience in the press or on social media.

Not too long ago, I was asked to endorse an insightful non-fiction book by journalist Rachel Aviv. She expresses skepticism about medication, and often about mental health care in general. As a journalist, Aviv was known for reporting on the difficulties some patients report when they stop taking antidepressants.

But Aviv writes so in the book, Strangers to themselves he had a life-changing response to one of Prozac’s younger cousins, Lexapro. After a long hesitation, when she was taking the medicine, Aviv decided to get pregnant. Then, because of the fetus, she undressed and then she could no longer remember why she wanted to have a child. Back on medication, she found motherhood to be natural again. Afterward, Aviv found herself a better parent to her children when she was on the medication, although as she wrote her book, 10 years after being introduced to the drug, she was tapering off again.

I continue to collect stories of personality change on medication. Some cases, like the case of Avivs, are seen as mixed blessings. The bright side of the welcome is tainted by concerns about what being on medication means, for the mind and body, and for the patient’s identity. How complex are the interactions between drug use, life choices, and family functioning! These patient narratives assure me that 30 years later, the question at the heart of listening to Prozac remains fresh and relevant, that of drugs and the nature of the self.

Peter D. Kramer is the author of the latest novel Death of a Great Man. He is professor emeritus of psychiatry and human behavior at Brown University.

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