DRUG THAT STILL FUELS DEBATE

The 'Prozac lifestyle' is deeply worrying, says Michael Smith

IN January 1989, Britain's first prescription for Prozac was written: a
decade later, the anti-depressant's green-and-white capsules have become
the world's third biggest selling drug. More than a billion tablets are
consumed every year, earning its American manufacturer, Eli Lilly & Co,
$2.5 billion dollars in 1997. Yet Prozac has been more than a commercial
success: it somehow managed to capture the imagination as well as the
markets.

Although effective antidepressants have been around since the Fifties, the
older drugs are "non-selective": they work by influencing a number of
different brain chemicals at once. Unfortunately, this broad action causes
a wide range of side-effects - sedation, dizziness and a dry mouth are
common - which many patients cannot tolerate. Worryingly, the older drugs
are also potentially lethal in overdose.

In 1982, Lilly discovered a compound called
(+-)-N-methyl-3-phenyl-3-[(alpha, alpha,
alpha-tri-fluoro-p-tolyl)oxy]propylamine hydrochloride, which not only had
little effect on other brain chemicals but was safe in overdose. They
wisely renamed it to the snappier "Prozac", released it in the US in 1987
and have never looked back since.

Like most other antidepressant drugs, Prozac's effect gradually takes place
over two to four weeks. People who had felt bleak and empty begin to feel
interested in themselves and their surroundings again; in addition to
changes in mood, they also experience an increase in energy, a better
quality of sleep, improved appetite, and a return of libido.

Research has also established that Prozac can also help in the treatment of
obsessive-compulsive disorder and bulimia nervosa.

These are powerful therapeutic effects. But why should Prozac in particular
have been so fEAted? It wasn't the first drug of its kind on the market,
and isn't any more effective than its competitors: yet it became a media
sensation. Forty-three books and countless articles have been published
with "Prozac" in their title.

The drug's leap from the prescription pad into the global consciousness in
the Nineties was hastened by early rumours of beneficial effects, even in
people who weren't sick

Lilly always insisted that Prozac only worked if your serotonin levels were
"abnormally" lowered by a depressive illness; but plenty of punters
disagreed. There was a "buzz" with Prozac, they said, which increased
motivation, creativity and concentration.

Internet discussion groups hummed with plaudits from thrilled
Prozac-takers: architects felt more innovative; programmers more focused;
actors especially intense. A feeling of agitation common on starting the
drug may have been mistaken for a creative "buzz"; others may have blamed
Prozac for unrelated problems in their lives. It's certain that Prozac's
reputation will also have had a powerful placebo effect, whether for good
or for ill.

This debate hinged on a deeper issue: who is to say what "depressed" really
is? Severe depression - which can cause psychotic symptoms such as
delusions and hallucinations - is clearly a serious brain disease.
(Fortunately, antidepressants work particularly well in such cases.)

But what of less severe symptoms? Is it normal for overworked parents to
become miserable insomniacs, or for the stress of keeping your business
afloat to make you lose weight? Some argue that this kind of unhappiness
and burnout should be classified as "illness" and treated with drugs.
Others are wary of such an all-inclusive medical model, and insist that we
shouldn't attempt to cure problems in living with pills.

Those who have experienced, or cared for, someone with a depressive illness
will be glad of Prozac the antidepressant. We accept that our brains - in
the same way as our kidneys or lungs - can become sick and need treatment.
Yet few would be comfortable with a "Prozac Lifestyle"; the use of
psychotropic drugs not to treat sickness, but to manipulate our feelings
and personalities. New developments in psychopharmacology mean that this
debate is likely to become more intense in future years.

Prozac may have been the first drug to dramatise the chemical
interdependence of brain and mind, but it certainly won't be the last.

Dr Michael Smith is a psychiatrist based in Glasgow.