Jill S. is 34. She holds a degree in art history, lives in a 4,000-square-foot house in west Little Rock, and considers herself lucky to be able to stay home with her three children until they’re old enough for school.
So why is Jill depressed?
She doesn’t know, and neither does her doctor. What both of them do know is that by swallowing a tiny beige-and-green pill in the morning, Jill can “take the edge off” the rest of her day. She no longer feels tired, the relentless “blue fugue” that gripped her is lifted, and after months of what she looks back on as “monsterhood,” she enjoys being around her children again.
The pill Jill takes is Prozac, the most widely prescribed antidepressant in history. If you’re not a user yourself, you almost certainly know people who are and for whom the drug has proven almost a miracle.
Since its introduction in 1987, Prozac has become as much a staple in Arkansas medicine cabinets as it has everywhere else in the country. Nationally, doctors write more than a million prescriptions for it a month.
The irony is that many if not most of the pill’s users are people like Jill; educated and financially comfortable.
“I couldn’t prove it, so don’t use my name,” a psychiatric nurse in Little Rock said, “but I’d bet if you could lay a map of Prozac use over a map of Arkansas, you’d find the densest concentration in Pulaski County, and the densest there in west Little Rock.”
If such a pattern exists, one reason for it might be that the pills are expensive, costing up to $2 apiece, or about $700 a year. Another possible explanation is that the affluent, in general, have better access to health care.
But depression is no respecter of status. Doctors at the Veterans Administration
Medical Center in North Little Rock, say more than 40 percent of the 3,750 patients treated there each month suffer from depression and that many use Prozac to alleviate it.
Use at private psychiatric facilities is also heavy. Dr. Richard Owings, medical director at Charter Hospital in Maumelle, estimates that about half the patients at that hospital come because of depression, and that in addition to other therapy, most of them end up with a prescription for Prozac.
Owings points out that many patients only take the drug for six months or so, to alleviate a temporary depression.
But he also adds, “there are people who cannot have a good mood without it.”
Users are quick to point out that Prozac doesn’t provide a recreational “high,” like Valium and other psychoactive drugs that are subject to abuse. In fact, the effects can be unpleasant for people who are not seriously depressed.
But for those who do benefit from Prozac, the results can be dramatic. Some users have described it as a firm but gentle lift out of despair.
Elizabeth Wurtzel, a New York Writer who was headed to a mental institution after years of depression and finally a suicide attempt, was finally given Prozac, which at the time had only recently been introduced.
“This may sound ridiculously simplistic,” she later wrote, “but within a couple of weeks after I fist began taking the drug daily, I woke up one morning and felt fine. And I’ve been fine ever since.”
Thousands of Arkansans have experienced similar relief. “Depression, notes Dr. Don E. McMillan, chief of pharmacology at the University of Arkansas for Medical Sciences, “is a very common problem.” No one
understands exactly why that is, though most psychiatrists agree that the factors are often complex and can include changes in body chemistry, personal loss, an unhealthy lifestyle, or simply, as Owings put it, “something inherent in the human condition.”
What is known is that when certain mood altering chemicals in the brain become imbalanced, depression results. One of those chemicals, serotonin, helps a person keep calm. The breakthrough that has changed so many lives came with the discovery that the chemical in Prozac, fluoxetine hydrochloride, can hold the brain’s chemistry in balance by maintaining the level of serotonin.
Other antidepressants tended to affect many brain chemicals, prompting unwanted side effects such as weight gain, blurred vision, dry mouth, and blood pressure and heart problems. Prozac users suffered none of those problems, though about 20 percent do experience a slight weight loss.
Two other reasons account for the drug’s burst of popularity: It is about ten times harder to overdose on Prozac than other antidepressants, and it isn’t considered addictive; both factors that make doctors comfortable about prescribing it.
As every “Geraldo” watcher knows, however, the drug has not made its gains without controversy. In 1990, a psychiatric researcher at McLean Hospital in Boston reported that six of his patients on Prozac had suddenly developed intense suicidal fantasies.
Within months of that report, a few other patients complained of experiencing terrible urges to harm themselves while taking the medication.
Since then, more than 100 lawsuits have been filed against Eli Lilly, Prozac’ s manufacturer, seeking reparations for violent acts that were allegedly committed by people while under the drug’s influence.
The widow of rock star Del Shannon, who killed himself in February 1990, is suing Lilly. So are the families of several men killed when a coworker came in and shot up the printing plant where they worked with an AK-47.
But such incidents have not shaken the confidence psychiatrists and other doctors have developed in Prozac. “People take Prozac because they’re depressed,” notes UAMS’ McMillan. “Sometimes, depressed people kill themselves. It’s unfortunate, but you can’t blame that on the drug.”
So far, juries have tended to agree. Of the 23 criminal cases where lawyers have tried the so-called “Prozac defense,” more than half have resulted in convictions, and the others, which were either plea-bargained or dropped, exonerated Prozac.
Similarly, in civil court, of the nearly 100 civil suits against Eli Lilly, 11 have been dismissed thus far, and none has been decided against the company.
Medical experts testified that as much as 6 percent of the population in any year may be afflicted with moderate to severe depression; that women are twice as likely to be depressed as men; and that depressed people who are left untreated face a one-in-six risk of suicide. No wonder, in the face of such misery, doctors have responded so overwhelmingly to the magic of a small, once-a-day capsule that can alleviate that depression in almost 80 percent of the patients taking it.
Despite such testimony, the flurry of bad publicity about Prozac was sure to tempt competitors, and in March, one stepped into the market. In the past two months, representatives of Pfizer have handed out thousands of samples of Zoloft, or sertraline hydrochloride, to Arkansas psychiatrists, general practitioners, internists, gynecologists, and every other type of doctor who might conceivably prescribe it.
A Pfizer spokesman in New York said that Zoloft sales so far have amounted to about $20 million. That’s just drop in the depression-market bucket — Prozac’s sales last year were estimated at $900 million — but the upstart’s future seems virtually assured.
Owings, at Charter, sees the stigma that has attached to Prozac, however unwarranted, as Zoloft’s big advantage. “It’s not clear that there’ s any particular advantage of Zoloft,” he says, “but my guess is that it will be an enormous success; it offers all of the benefits, and it’s not Prozac.”
He explains, “Depression and anxiety often go together. A lot of people are anxious about Prozac because of things they’ve read. So for them, there’s no reason not to prescribe Zoloft. It offers them one less anxiety.”
Owings and McMillan both point out that, as Owings put it, “There’s more to treating depression than writing out a prescription for pills and saying, ‘Come back in a month.’ A lot of people are depressed for a reason that’s more than biochemical, and for them, medicine is too easy an answer.”
But for thousands of Arkansans, Prozac has proven to be an easy cure for a debilitating malaise. Now Zoloft is coming on strong. And there are indications that an increasing number of doctors are prescribing the drugs for symptoms that go beyond depression.
Manufacturers are not allowed to market drugs for other than its approved use, but it is legal — and common — for doctors to prescribe drugs for other uses, where they think they might be beneficial.
Thus, prescriptions are now being written daily for Prozac and Zoloft for people complaining of premenstrual syndrome, weight loss, weight gain, bulimia, alcohol and drug addiction, panic and personality disorders, and even as an aid to stop smoking. Such experimentation is one of the ways new uses for a drug are discovered. So the full potential of drugs like Prozac and Zoloft may not yet be known.
“For a psychiatrist to talk about depression is like a surgeon talking about pain,” Owings says. “It’s one of the global symptoms that something isn’t right.”
In 1899, scientists developed acetylsalicylic acid. Aspirin is still the world’s most widely used drug for pain, and new uses for it are still being discovered.
If depression is to the mind what pain is to the body, could it be that a new class of drugs — — a sort of aspirin for the psyche — has emerged?