Product of the Century
Prozac, the world’s most widely used antidepressant medication, is a little pill that promises big things. Notes manufacturer Eli Lilly on its website: “Chances are, someone you know is getting better because of Prozac.” And this is no idle boast. Prozac has been used by 35 million people in 100 countries worldwide, 17 million in the United States alone. It is this commercial success that led Fortune Magazine to call it one of the “Products of the Century,” in such heady company as television, the internet, Band-Aids and penicillin. Clearly, this product has made an impact on millions of lives.
Indeed, clinical depression is more common than you might think, but exact numbers of sufferers are hard to come by. Estimates of Americans suffering from severe depression range from less than one in fifteen to as many as one in eight, and each year 18 million people undergo treatment for the disorder. Although the causes of depression are not completely understood, one leading culprit appears to be levels of neurotransmitters, molecules that allow nerve impulses to travel through the nerve cells of the brain. An imbalance of neurotransmitters is believed to prevent brain cells from communicating with each other properly, leading to a host of psychological abnormalities, including mood disorders, depression, anxiety, and even obsessive behavior. Thus, psychological disorders may be due in large part to chemical imbalances of the brain, rather than being “all in your head.”
How Prozac Works
Prozac is one medicine in a class of antidepressants called selective serotonin reuptake inhibitors, or SSRIs, that work to fix these chemical imbalances. As the name suggests, SSRIs work by preventing the neurons in the brain from reabsorbing serotonin, making more of this important chemical available for the brain to use. The nerve cells that produce serotonin are located in the brain stem, the “primitive” base of the brain that controls many vital bodily functions. These serotonin-producing nerve cells have long projections that reach into many areas of the brain. Here, they release serotonin to aid in the transmission of nerve signals across the brain. When a nerve impulse travels through a neuron, serotonin carries the nerve impulse across the synapse, or gap, between neighboring brain cells. After the nerve impulse has been transmitted, the serotonin is reabsorbed, making the brain cell ready to receive the next impulse. It is believed that in some people, serotonin is reabsorbed too quickly, interfering with proper transmission of those electrical impulses. SSRIs such as Prozac block some of the receptors that reabsorb the serotonin, keeping more of the neurotransmitter available in the synapse for a longer period of time. When the brain’s serotonin balance is altered through drugs, over time, the number and sensitivity of serotonin receptors in the brain changes, and scientists believe that Prozac’s therapeutic effect is due to these chemical changes in the brain.
Testimonials
Testimonials abound that credit Prozac with giving individuals their lives back. Because of such success stories, Prozac has been well received by patients and medical professionals. It has also done well in a competitive drug marketplace is because it has fewer side effects than other antidepressant medications. Tricyclic antidepressants (TCAs) often cause dizziness and fainting spells and, in an overdose, can lead to deadly disturbances of heart rhythms. Monoamine oxidase inhibitors (MAOIs), another class of antidepressant medications, can cause dangerously high blood pressure if taken with certain foods, including beer and cheese. With Prozac, there are no potentially dangerous food interactions to worry about, and deaths due to overdose are rare.
Prozac is FDA approved to treat not only depression but also bulimia nervosa (binging and purging) and obsessive-compulsive disorder, or OCD. OCD is a condition where the sufferer engages in uncontrollable, ritualistic behaviors, such as hand washing, cleaning, counting or checking, that interfere with school, work or social life. In addition, Prozac is approved for use in geriatric patients. This is important because elderly patients have slower metabolisms and may not react to medications in the same way as younger adult populations. Prozac is also preferred because it does not cause fainting and dizziness, which in the elderly leads to falls resulting in broken hips and often-fatal bouts of pneumonia.
With so many positives, Prozac certainly deserves its laurels. But no drug this popular comes without its critics. Like any medication, Prozac does not work for everyone. SSRIs, including Prozac, do have the side effects, one fairly common and often distressing one being diminished sexual desire and performance. In addition, SSRIs break down very slowly in the body, and thus breakdown products can stay in the patient’s blood stream for weeks after they stop taking the drug. Prozac is metabolized by the liver through a collection of enzymes called the cytochrome P450 system, and if sufficient time is not given to clear the system of Prozac breakdown products, taking certain medications may result in the sometimes fatal “serotonin syndrome,” which includes a racing heart, high blood pressure, sweating and tembling. And because its mechanism of action is not fully understood, Prozac has come under criticism for causing a wide range of undesired side effects.
Cons and Controversy
Popular culture has been quick to jump on the Prozac-investigation bandwagon. It is a drug that has spawned its own cottage industry of literature, including controversial accounts by psychiatrists, including such books as the best-selling (and pro-fluoxetine) Listening to Prozac and the more negative Prozac Backlash. The drug has even entered the cynical imagination via Prozac Nation, a novel about being young and depressed in America. Following the 1989 case of Joseph Wesbecker, a disgruntled former employee who was taking Prozac when he killed eight printing-plant employees and himself, the “Donahue” talk show even had a segment entitled “Prozac—Medication That Makes You Kill.” While much of what is reported in the popular press is clearly meant to generate ratings or book sales, not all the criticisms of Prozac are completely unfounded.
There is concern that the manufacturer has underreported serious side effects, including suicidal tendency and sexual impotence. While Lilly pointed to studies that indicate Prozac actually lowers the incidence of suicidal thoughts and actions in depressed patients, anecdotal evidence for individuals who became suicidal while on Prozac continued to circulate, and Lilly announced in mid-2000 that suicidal tendencies were a significant side-effect of the medication. Lilly also initially stated that sexual dysfunction was a side effect in less than 7% of patients, but after other studies suggested that it may be as high as 60%, the company is planning to amend the package insert to indicate an updated sexual dysfunction side-effect rate closer to 30%.
Another serious concern is that the long-term effects of the drug have not been fully studied, even as many patients continue to take Prozac for years on end. Because Prozac metabolism can saturate the liver’s cytochrome P450 enzyme cascade, and because at least one study suggests that brain levels of Prozac are much higher than blood plasma levels, researchers have expressed concerns about long-term damage to organs such as the brain and liver. While Prozac has a good safety record to date, more studies are needed to examine the effects of long-term exposure of the drug on all the systems of the body.
Perhaps most disturbing are allegations that we have embarked on an era of “cosmetic psychopharmacology,” where the definitions of depression and anxiety have become so broad that it has become all too easy to prescribe medications like Prozac for “ailments” such as shyness, sensitivity, moodiness, poor concentration or lack of confidence. Many wonder whether using a drug to treat psychological ailments, a much cheaper and faster approach than extensive psychotherapy, isn’t just whitewashing serious cultural problems in the same way that Valium was used to calm “hysterical” housewives in the 1950s and 60s. Is Prozac alleviating the symptoms of a serious medical illness and helping previously debilitated people to live happier, healthier lives? Or are we creating an army of “happy” people who have lost sight of their own unique challenges in favor of a blissful acceptance of serious social ills? In the end, it might be a little of both. However, such questions will be the most difficult to answer, because no scientific study is likely to provide solutions to problems that deal so personally with an individual’s position in a free society. And so it will remain up to the individual patient, working in tandem with a qualified medical professional and carefully weighing all the options, to make an informed medical decision in the search for an improved quality of life.
Prozac Web Site Links
Prozac - Ely Lilly product homepage
Internet Mental Health Website - Prozac and other drug monographs, plus useful mental health links
U.S. Government Food and Drug Administration (FDA)
The Other Side Resource - information and links to essays and books critical of Prozac and other psychiatric drugs
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