1 Boring Old Man

Prozac and SSRIs: Twenty-fifth Anniversary
Dr. David Healy
06 Feb 2013

^{One Prescription for Every Man, Woman and Child}

^{Prozac was approved in 1987 in the US, and launched in early 1988, followed by a clutch of other SSRIs. Twenty-five years later, we now have one prescription for an antidepressant for every single person in the West per year. Twenty-five years before Prozac, 1 in 10,000 of us per year was admitted for severe depressive disorder – melancholia. Today at any one point in time 1 in 10 of us are supposedly depressed and between 1 in 2 and 1 in 5 of us will be depressed over a lifetime. Around 1 in 10 pregnant women are on an antidepressant. No one knows how many new cases of depression there are per year partly because modern depression is a creation of the marketing of Prozac. Until recently what is now called depression was called anxiety, nerves or a nervous breakdown. SSRIs can help some cases of nerves but they are of no use for depression proper – melancholia. But the money for companies lies in treating nerves not melancholia – and as a result any of us with severe depression is likely to get worse treatment now than we once did.  We’ve gone backwards.}

^{How Many Hooked?}

^{By 1999 the number of us taking SSRIs chronically equaled the number starting an SSRI each year. By 2003, over 6 million Americans were taking an antidepressant semi-permanently – along with over 6 million Europeans. The number of prescriptions for antidepressants is increasing by 5-10% each year, while the figure for people starting each year remains the same. This means that there is an increase of 5% to 10% in the number of people hooked to antidepressants each year.}

^{Lives Lost}

^{There is no research evidence to suggest that anyone’s life is saved by taking an antidepressant but if there are lives saved the research makes it clear that for every life saved there must be another lost. There are probably something between 1000-1500 extra suicides in the US each year, triggered by an antidepressant – an extra 2000-2500 in Europe. The data is similar for violence. There are probably between 1000-1500 extra episodes of violence in the US each year that would not have happened without antidepressant input and between 2000-2500 extra episodes in Europe.  Some of these will include school or other mass shootings which were unheard of twenty-five years ago.}

^{Aborted Families}

^{About 4000 families in the US have children born with major birth defects each year because of antidepressants taken in pregnancy. Up to 20,000 women per year have a miscarriage because of these drugs and a large number have voluntary terminations linked to antidepressants. Miscarriages are among the biggest single predictors of later mental illness and substance misuse in women.  In Europe these figures likely run at an extra 6000+ birth defects, 30,000+ miscarriages, and who knows how many extra voluntary terminations. Most children born to mothers who have been on these drugs do not have obvious birth defects. But it increasingly looks as though these children may show cognitive delay and other autistic spectrum features.}

^{The Dead Doctor Sketch}

^{Perhaps the greatest casualty of Prozac has been holistic medicine. Imagine you have numbness in an arm or pain in a shoulder. If referred to an orthopedic or neurology department you will have every conceivable scan or test to pinpoint the problem. Chances are the clinic will find abnormalities and attempt to put things right – abnormalities that are not the source of your problem. A good generalist, who knows your circumstances, relationships, difficulties at work and the community from which you come, can spot when aches and numbness stem from strain or tension – they see you rather than bits of you. Prozac has killed Generalism. It did so by focusing attention on mood in the way neurologists hyper-focus on nerves. Psychiatrists have become the doctors who deal in heroic combinations and doses of pills rather than doctors who, like generalists, step back and take a broader view. Prozac has also killed therapy – just like Prozac CBT has a hyper-focus on thoughts rather than the big picture. CBT has also become a conduit into antidepressant prescribing as therapists regularly suggest softening up a depression with pills.}

^{Psychiatry leads the Way}

^{Many see or saw psychiatry as a medical backwater with grim, overcrowded hospitals, and a dim understanding of the disorders it treats. In fact it was the first branch of medicine to have specialist hospitals and journals, the first to discover the bases for and eliminate several serious disorders, the first to adopt rating scales and controlled trials. And with Freud’s son-in-law, Edward Bernays, it was the first to step into public relations. Twenty-five years ago, no one could have imagined that the bulk of the treatment literature would be ghostwritten, that negative trials could be portrayed as glowingly positive studies of a drug, that controlled trials could have been transformed into a gold-standard method to hide adverse events, or that dead bodies could have been hidden from medical academics so easily.  Twenty-five years ago no one would have believed that a drug less effective for nerves or melancholia than heroin, alcohol or older and cheaper antidepressants could have been brought on the market and that almost as a matter of national policy people would be encouraged to take it for life.}

When Dr. Healy says that "Twenty-five years ago, no one could have imagined that…" he is completely correct. But from my perspective, twenty-five years ago I couldn’t even imagine what had already happened in psychiatry and was once again personally making another mid-course correction. The part of Dr. Healy’s post that I relate to the most is The Dead Doctor Sketch. I had come to psychiatry from Internal Medicine because I realized that many of the people I saw were primarily in need of help with their lives and matters mental, and I had become dissatisfied with just dealing with the physical part. When psychiatry medicalized in the early 1980s, it went off and left me and the whole reason I was there in the first place. So the way I see it, Prozac didn’t cause the things he mentions. It was the drug the newly revised psychiatry had been waiting for – a biological messiah fulfilling the prophesy of the neoKraepelinians, and it was followed by a series of latter-day saints.

In The Dead Doctor Sketch, Dr. Healy mentions CBT – Cognitive Behavior Therapy. Aaron Beck, its founder, was dissatisfied with the psychoanalysis of his training and came up with a therapy based on his observation that depressed people think depressively, dream depressively, and live depressively. He proposed seeing their depressive cognition as a behavior and applying the principles of behavioral therapy to their depressive cognition, and later to other cognitive styles. He was right about that kind of thinking and had some measurable success in changing it. Now, everyone is a cognitive behavior therapist, primarily because it is sanctioned as an "evidence-based" therapy. What Dr. Healy says is exactly right. Mental Health practitioners send their clients to psychiatrists for "meds" and then do counseling of various kinds. For all the talk about CBT, I haven’t run into many people who actually do formal CBT. I’m sure they’re out there, but I think it’s more something fresh graduates do until they find a style of their own. But no matter what they end up doing, they sure send their clients for "meds," and the psychiatrists sure prescribe them. In the US, there’s a third party involved – the insurance carrier. So patients now talk about a number of things: my therapist, my psychiatrist, and my plan – the latter being a major ingredient. All three forces point to the fourth thing – my meds. I couldn’t have imagined that set-up twenty-five years ago either.

^{A good generalist, who knows your circumstances, relationships, difficulties at work and the community from which you come, can spot when aches and numbness stem from strain or tension – they see you rather than bits of you. Prozac has killed Generalism. It did so by focusing attention on mood in the way neurologists hyper-focus on nerves.}