THE SHRUG DRUG

Prozac has changed people's lives and transformed the medical profession's
approach to mental health. Elizabeth Wurtzel, author of Prozac Nation and
one of the early beneficiaries of the drug, assesses its legacy 10 years
after it first became available to her

When I woke up this morning - and let's be honest here, it was more like
this afternoon - I began my day by swallowing two Prozac capsules. I also
took some lithium, the salt substance that was long ago established as an
antidote to manic depression and other mood disorders. On top of that I had
a pink caplet called Depakote, the brand name for valproic acid, an
anti-seizure remedy once prescribed for epilepsy, but now used to combat
mood swings. And finally, I chased down the other pills with a
blood-pressure medication called atenolol - my 92-year-old grandmother also
takes this - to alleviate the Parkinson's-like handshake that I get from
taking all these drugs.

Later in the day, probably with dinner, I will take nortryptaline, a
tricyclic anti-depressant, one of the pre-Prozac variety that acts on the
dopamine and neuropene phrine systems of the brain. At the same time, I
will down my evening doses of lithium and Depakote, along with some more
atenolol for the kind of shakes that by dinnertime can make it awfully hard
to get a fork and food to my mouth, and have been mistaken by many for
delirium tremens.

Strangely, although this crazy salad of pills makes me exhausted and
lethargic all day, I often cannot get to sleep at night. My energy level is
mysteriously invigorated at midnight. So, in an attempt to get my circadian
rhythms attuned to the rest of the world's, sometimes I take Ambien, a
non-narcotic, non-addictive sleep remedy that seems to have a blackout,
knockout effect. Tomorrow morning, I will wake up and do the same thing
again. I have been doing this - different pills, same routine - for the
past 11 years.

If you have any doubt that Prozac has changed the world, consider the drug
regimen I am on. And consider the chemical cocktails so many people have
been taking since Prozac was launched in 1988. In just one year - 1997 - 65
million anti-depressant prescriptions were filled in the US alone. More to
the point, Prozac has swelled the market for psychotropic drugs. Its
minimal side-effects allowed physicians to prescribe it, if not exactly on
a whim, then at the first note of a patient's pained whimper. And then, if
Prozac was not sufficiently effective, other medications could be prescribed.

Suddenly there were all these doctors whose entire practice involved a
prescription pad and the occasional use of a blood-pressure monitor. They
called themselves

psychopharmacologists, and all they did was try to get the right mix of
medications to keep patients relatively sane. Although no one really knows
how these psychopharmaceuticals work, the existence of experts resulted in
a tendency to pretend there was real know-how in a process that is mostly
trial and error marked occasionally by alchemy: one pill was said to be
good for the rejection-sensitive, another for those with object-constancy
problems, and blah blah blah.

In spite of my tendency to mock psychopharmacologists, I saw one for a
period when I was not in therapy with a medical doctor - I referred to him
as the Pusherman. And it's difficult to say which is worse: a specialist in
prescriptions, or a general practitioner who gives Prozac to a patient he
barely knows because, well, it probably won't hurt and it may help. And
this kind of thing happens a lot. In the US, where there is no National
Health Service and the doctor's duties are dictated by insurance companies,
Prozac has been a perfect solution to the financial unmanageability of
mental health care - indemnifiers would no longer cough up for therapy
sessions, but they would gladly pay for a pill.

Essentially, Prozac became the shrug drug, it was one big "why-not?" The
Food and Drug Administration, which controls the licensing of drugs in the
US, eventually endorsed it to cure obsessive-compulsive disorder, obesity,
attention deficit disorder - a whole range of emotional bogeymen. And this
may well be Prozac's permanent legacy: it medicalised mental health, even
when the damage was rather mild, the symptoms fairly slight.

Suddenly, you did not have to jump out of a window or run through the
streets wearing nothing but your knickers for your behaviour to be worth
more than just the talking cure. Often the therapist would suggest a visit
to a psychopharmacologist for a consultation, with the assumption that
until you were lifted out of your misery by biology, all the Freudian work
that could be accomplished five days a week would not help at all. The
depression itself was pushed out of the way, and your real fears could be
explored. The little green and white pills delivered emotional expediency.

When I first went on Prozac, none of this was so. My trouble, the complaint
I carried with me until my third year in college, was that I was crazy,
that I felt waves crashing in my head for reasons I didn't know - but in
spite of the persistence of emotional emergency, no one was going to listen
to my plea as long as I was ambulatory. There was, I had no doubt, a fierce
physicality to my depression - I knew it because I felt it - that no
discussion of the slights I experienced in the playground at the age of
three or the Picassovivid dreams I was awakened by each night could
possibly penetrate. And I knew there was some medicine for these feelings.
I knew there had to be because if not I was going to have to kill myself. I
believed, as anyone who is depressed but resists suicide must, that there
was something that could be done for me. I was a student then, with all the
resources of a large university at my disposal, and I went from doctor to
doctor, begging for a medicinal cure.

No one would help me.

Though a variety of classes of antidepressant was available and would
certainly have helped me before Prozac, it wasn't until that drug arrived
that a psychiatrist saw fit to offer me chemical aid. At the time I was
sufficiently ill to be staying at the college infirmary, and still Prozac
was the first antidepressant I was given. When I think now of how much
sooner I could have been paroled from this prisonhouse of the mind, I am
often angry, deeply angered for all the missing years.

Of course, the world is now completely turned on its head in its
relationship to medication. In 1995 I participated in a college panel that
essentially asked, "Prozac - pro or con?" For me, this was a ridiculous
question: Prozac made people - sick, miserable people - feel better. It
treated a mental state that I knew to be nothing less than a deleterious
disease. It was astonishing for me to hear student opposition to the drug's
use. It was difficult for me to understand its controversy in general,
because to me it has always been simple: I felt a deep debt to the inventor
of this lifesaving pill. But these students were upset by its
depersonalising effects, by the way that when they went to their health
services seeking therapy or emotional support of any kind, all they got was
a Prozac prescription. They felt like toddlers being stuck in front of the
television by a nanny who didn't care for them, rather than being hugged by
a parent who did.

And when I went on a tour to support my book Prozac Nation, I'd frequently
sign copies for teenagers - 14- or 15-year-olds - who would tell me that
they were on Zoloft, but they were switching to Paxil, or they were on
lithium but the new doctor thought they should try Depakote. And it was
through meeting these young people that I started to understand the
frightening, Huxleyan nightmare Prozac could create. You see, I, in a
sense, had to work to earn my Prozac. I had spent years trying every other
form of help that was available and I had lived for so long in complete
darkness. I did not have to wonder if Prozac was necessary - I knew. But
drugs were now being handed out so liberally that each wretched little pill
represented a resentment, a neglect, a shrug.

Dr Sterling, the psychiatrist who first put me on Prozac, and who was a
wonderful therapist in every way, now runs a mental health clinic in
California. No long-term therapy goes on there - in fact not much
counselling of any kind goes on there. What does happen is a lot of
prescription writing. When Sterling sees people to refill their drug orders
she gets a chance to talk to them and find out what they need to cope by
way of medication. And she builds up some sort of bond with patients over
time. In her limited capacity, Sterling feels that she is doing some real
good. "Now, instead of some people getting a lot of help, a lot of people
are getting some help," she says.

But it isn't like it was with me, and she says this is her choice: seeing
suicidal patients with extreme needs exhausted her and deprived her of any
emotional wherewithal for her husband or her children. It's not just
patients who are desperate for

whatever relief Prozac can provide - doctors, too, are overwhelmed. The
needs that their deracinated, unstable and alienated clients bring to
therapy in an age of divorce are almost too much to be handled without
non-human intervention.

Recently there was a newspaper article about "uplift anxiety", examining
how recovery from depression with Prozac and other drugs "can bring a new
array of personal problems, from social uneasiness and crises of identity
to professional and marital strains". I understand this - one of the
reasons I believe that medication must be taken in conjunction with some
sort of therapy is that Prozac is helpful, but the miracle of overcoming a
depression requires a more strenuous overhaul than any pill can contain.
But the article still seemed absurd - after living under the weight of
depression for many years, the lightness of life seems a very luxurious
problem. I don't believe there is such a thing as too much joy.

Besides, these popular notions about Prozac tend to overstate its
transformative power. No antidepressant is a happy pill, and if you emptied
out a Prozac capsule, cut its contents into lines and snorted them up, you
would not get high. Dream on! All this family of drugs has ever offered is
access to the part of a person that wants to be happy, but has been
cordoned off. Once you get through those velvet ropes, it is up to you to
learn to enjoy the party.