June 5 2000 FEATURES Prozac is increasingly under attack. But here John Diamond reveals how it helped to save his sanity In praise of Prozac Twelve years or so ago I split up with my first wife. It happens. I got depressed. That happens too. The depression specialist at the local hospital's psychiatric unit prescribed Amitriptyline, the standard antidepressant at the time. It took a couple of weeks to kick in properly, but eventually, as the drug started to work and I got further away from the trauma of leaving the marital home, I stopped being depressed.

Yes, the drug had its side-effects: it was too sedative, my libido was screwed to hell, I felt a little too detached from the world for real comfort, but then again who would expect a drug that worked on the brain's chemistry at such a fundamental level to offer a free therapeutic lunch?

At least, though, nobody suggested that by taking the pills I was being indulgent, cheating on myself, or on my soul, not facing up to the realities of my new life. Eventually I cheered up, stopped taking the drug, remained - within the usual limits - cheerful. End of chapter.

Two years ago I had my tongue removed - the biggest operation in a series of increasingly desperate interventions to try to rid me of cancer. Five days before the operation, and already depressed about the cancer and its prognosis, I asked to be put on an antidepressant.

I knew that however successful the operation was, I would awake from it in a world rather more different and, as I prophesied it, infinitely more depressing than the one I lived in when I was put under.

I was given the new antidepressant of clinical choice: Prozac. Or, to be accurate, Seroxat, a newer relative of its more notorious predecessor, but a Selective Serotonin Reuptake Inhibitor (SSRI) nonetheless, and thus a drug that works in precisely the same way.

(And, much as pharmacologists may argue the toss, so long as I'm not writing for The Lancet I'll continue to use Prozac here as a generic term for all SSRIs.)

I thought I was doing the sensible thing and using an appropriate drug to deal with a clinical complaint. Aspirin for headache, Milk of Magnesia for stomach ache, Prozac for mind ache. My doctors thought the same.

But no. For according to a substantial, and growing, school of thought, Prozac is a cheat, an easy self-indulgence, the drug one badgers out of a biddable doctor in order to avoid the honest way of dealing with life's inevitable problems.

Prozac, according to this school, is the drug that replaces the old and trusted remedies of pulling one's socks up, getting a grip, setting one's upper lip to the correct level of stiffness. As a Prozac user, I am at best a wimp, at worst a gullible trend-follower, a man who chooses his personal pharmacy from the pages of the glossy magazines or after a boozy conversation at the Groucho Club.

I know this, because the booming anti-Prozac lobby, with its strident pieces in the middle-market tabloids, its raucous sites on the World Wide Web, its bestselling books, tells me so. The Scientologists, a cult that has long believed itself to have a spiritual monopoly on the treatment of mental disorder, is campaigning hard against Prozac use, as are groups of people who grandiloquently describe themselves as Prozac Survivors, as if they are a heroic minority among those millions who do not survive it.

And of course, and particularly in the US, there are the lawyers who would love to get a slice of the action and the three billion dollars or so that Prozac's makers, the pharmaceutical giant Eli Lilly, take in Prozac sales worldwide each year. Prozac isn't the first drug to attract its detractors. But while other drugs have been scorned for good pharmacological reasons - thalidomide, Valium, temazepam, the list grows each year - Prozac is the first member of the legal pharmacopoeia to attract such moral disdain.

True enough, like almost every prescription drug, Prozac has its downside.

Indeed, it is, generally speaking, because of those downsides that so many drugs have to be prescribed by doctors rather than being available off the shelf at Boots. For a start Prozac works only for around 60 per cent or so of its users. For a small but substantial number of users it has side-effects that range from mild anxiety to - according to the most recent research - the possible triggering of suicidal tendencies. And, true, it is a drug that is inappropriately prescribed more regularly than any drug since Valium was first offered as a solution to every problem presented to an overworked GP.

It is reckoned, for instance, that in some parts of America up to 15 per cent of schoolchildren are given Prozac, sometimes to deal with serious depressive illnesses, but also to deal with events which, in a previous era, might have been dealt with by being sent to one's room without supper.

Around a million Americans between the ages of six and 18 are prescribed it, often at the behest of teachers who see it as an easy way to cope with classroom indiscipline, and much was made by the anti-Prozacists of the fact that one of the teenagers who shot dead his classmates at the Columbine High School massacre 14 months ago, had once been on a Prozac-like drug. And yes, Prozac is too often prescribed by lazy doctors who would once have doled out scrips for Valium, and touted by pharmacological evangelists of the sort who, in the 1960s, were boosting acid as a universal panacea. There are Prozacophile psychiatrists who would put the stuff in the water supply if they were allowed to and others who, with no real scientific evidence to back up their point of view, prescribe the stuff for everything from bed-wetting to shopping addiction.

None of which would be a problem for those who are genuine candidates for Prozac use were it not for the new Prozac moralists who use the genuine fears about Prozac and its side-effects as a cover for their moral opprobrium. It has become the equivalent of, say, a group of committed Roman Catholics setting up an anti-abortion campaign in which they rarely refer to abortion as the taking of life - the real reason for their stance - but instead talk about the physiological effects botched abortions can have on the cervix or the womb.

Last week, for instance, the Daily Mail ran the latest of the anti-Prozac pieces under the headlines "Is this the end of the Prozac dream?" and "Prozac Drove Me Mad". In the past the Mail has tended to attach the word "trendy" to Prozac as a matter of course and in the knowledge of what Mail readers are expected to think about trendiness;

this piece talked mainly about the recently discovered dangers of Prozac use and in particular of one piece of research which suggests that certain users are more prone to attempt suicide. The connection is by no means proven and even the team that produced the research agrees that the numbers are tiny, and so for good luck and because the tabloids try not to confuse their readers with shades of grey, the reporter added some more details about the evil that is Prozac.

There were the users who had started having strange thoughts when they took the drug, some more suicide references which were outside the scope of the research, reports of users who had committed various acts of manic mayhem including a man who had killed himself and his wife 11 days after starting a course of Prozac, and a demand from a local coroner that suicide warnings be printed on the Prozac packet after a man had topped himself after two days on the drug. (An interesting proposal under the circumstances, given that the first thing every Prozac user is told is that the drug doesn't start to take effect for at least ten days and more often longer.)

A couple of days later I found myself talking to a woman friend who'd been thinking of taking Prozac for what seemed to me (and, more importantly, her doctor) perfectly good reasons. But she'd read the Mail piece and had decided that Prozac was too dangerous a drug to countenance.

Is it, though?

One of the problems with anecdotal evidence about the dangers of Prozac, and indeed much genuine scientific research, is that the drug is by definition given to those with some degree of mental disturbance including, most often, depression. The suggestion made by the anti-Prozac lobby is that suicides among Prozac users are a direct result of a chemical effect of the drug on the brain. But then between 50 and 70 per cent of all suicides are committed, unsurprisingly, by those who are clinically depressed, and it is reckoned by some authorities that between 10 and 15 per cent of those who are clinically depressed commit suicide.

To discover that the suicide rate is high among those who take drugs to treat depression is hardly much of a discovery at all and although there are cases still pending in the UK and US, so far whenever somebody has tried to persuade a court that a loved one's suicide is the result of taking Prozac they've had the case thrown out of court.

In fact the clinical information inside the packet does list any number of possible, but usually unlikely, side-effects, none of which is life-threatening. I suffered from one or two of the minor ones myself, but from where I sit all of them are infinitely preferable to the impenetrable misery and hopelessness of genuine depression.

As importantly, the side-effects are generally fewer and less intrusive than those that come from the older forms of antidepressant.

It is precisely because doctors believe the side effects to be, in the case of most users, negligible that they have been happy to prescribe it in cases which probably wouldn't have merited treatment by the older drugs.

For all that - and for all that the percentage of the million Britons on Prozac who report adverse effects is small - I'm happy for those genuinely concerned about the side effects of the drug, known and suspected, to argue that more research should be done on it; that its prescription should be limited to those with symptoms for which Prozac has a known and proven benefit; even that the defensive press releases from Eli Lilly should be taken with a pinch of salt, given that company's vested interest in its widespread use.

But then there's the moral argument.

In its most recent article, the Mail referred to Prozac in the disparaging shorthand that used to be Valium's own: they are "happy pills". Describing a medicine thus is to suggest that its use is either recreational - a sort of legal dope, if you like - or self-indulgent. In Britain we are suspicious of unwarranted happiness:

it means we're not taking our responsibilities seriously enough, we're denying reality, we're not facing up to things. If He'd wanted us to be happy then God would have made us frivolous Tahitians rather than sober Britons. The Victorian descriptions of the lesser races and lower orders, from grinning piccaninnies to cheery Cockneys, show what we think of the too-happy-by-far.

If we are unhappy then, say the moralists, the chances are that we are unhappy for good reason: either we have broken the rules of temperate middle-class existence - divorce, job loss, financial difficulty - or we are simply not man enough for the tough job that is life. Regaining the modicum of happiness we're allowed is a matter of self-discipline;

using pills to get happy is simply cheating. Worse, according to this principle, the sort of happiness induced by pills, be they Valium, Prozac or purple hearts, is a bogus happiness and somehow different from the real thing.

Well, possibly. The lotus-eater debate about whether a permanent drug-induced euphoria is a satisfactory way of living a life is an ancient one. But while its principles are being applied to the straight pharmacological debate about the safety and use of Prozac, they really shouldn't be. For all the claims made for the drug, Prozac is an antidepressant like any other and like all antidepressants it blunts the highs as well as the lows. It doesn't make you happier than you "should" be, whatever "should" means, nor give you an extra dose of happiness above your natural allotment, but deals with a clinical dysfunction, a chemical imbalance, which can occur for the most obvious external reasons or for more opaque internal ones.

Depression isn't just about feeling a bit lower than you think you should feel, but a medical complaint every bit as real as a broken leg or a ruptured spleen. It's about not being able to move, to think, to penetrate the cloud of utter misery that descends and which stops the sufferer from performing even the most basic tasks, let alone the ones that the brisk pull-yourself-together merchants suggest as the solution to the depression.

Prozac gives a breathing space, a period to muster the internal resources to deal with the external problems. Suicide-inducing? My guess is that the number of people on Prozac who would have attempted suicide had they succumbed to the fears put about by the scaremongers and the absurd view of life promoted by the high-minded moralists and stayed off the drug, exceeds by far the number who have - possibly - died because of it.

Certainly keep the stuff away from naughty children in America and lifestyle experimenters in Soho and make sure doctors prescribe this drug with the restraint they've learnt to exercise in the case of Valium and its relatives. And certainly carry on with the research to try to determine just what the side- effects can be.

But let us not pretend that Prozac is a drug that should be prescribed only to the morally sound.

A couple of years ago I lay in my bed at home and, for the first time in my life, contemplated suicide. You would have too in my position. I was a couple of days out of hospital, tongueless, unable to eat or speak and with the prospect of never being able to do that, and a lot more, ever again.

Four weeks ago I started weaning myself off the Prozac that, at the time of my suicide reveries, had yet to kick in. Coming off the drug has its side-effects as well, but it's been a fortnight since I've taken my medicine and I am writing this beside a pool in Ibiza where I'm coming to the end of one of the most joyous holidays of my life with friends and family I love, taking a genuine and non-drug-induced pleasure in the sun and the holiday jokes and in life.

I might, of course, have got this far without Prozac, but it would have been a ride too rocky to contemplate. Prozac works. Not for everyone, true, but that's no reason for the tight-lipped moralists to have their way.

Copyright 2000 Times Newspapers Ltd. This service is provided on Times Newspapers' standard terms and conditions. To inquire about a licence to reproduce material from The Times, visit the Syndication website.

||||| From: "Starshadow" <starshadowlovesxenu@starshadow.net>
Date: Sun, 4 Jun 2000 21:22:42 -0700
Message-ID: <8hfa5k$6ta$1@nntp9.atl.mindspring.net>
(snip) Thanks for posting this, Sue. Very compelling.

Now when I was on Prozac, I was not only suffering from depression (being bipolar) but also from agoraphobia and panic disorder, and was very close to suicide because I was tired of not being able to cope nor explain to people why I couldn't leave my house like ordinary people did. I also have the added problem of being clinically allergic to almost every other medication type usually used for depression.

Prozac was literally my only hope, because it was the only SSRI out there--and having since had my caregiver try to prescribe another SSRI for a migraine preventative, and finding out I can't tolerate *it*--Prozac may be my only hope if ever I get back to the point of needing a psychotropic medication again.

If it isn't available thanks to scientology, I just might wind up a casualty.

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