Keeping the synapses busy
- Listening to Prozac by Peter Kramer
Fourth Estate, 409 pp, £16.99, April 1994, ISBN 1 85702 233 5
Of all professionals perhaps doctors are the most gullible; and psychiatrists are perhaps the most gullible of all doctors. Over the last hundred years they have treated mental illness with cold douches, removal of the ovaries or thyroid, castration, hysterectomy, cooling almost to the point of death (and at least once beyond it), extracting the teeth and tonsils, enucleating the cervix, drilling holes in the skull, inducing coma through insulin, using metrazol to cause convulsions and slashing through a large chunk of the frontal lobe. All these savage and useless treatments were praised by their inventors and most were acclaimed by other psychiatrists.
Modern treatments are more effective and much less cruel, but there is still a tendency to hail the latest pill as a wonder drug before the evidence is in. Prozac, a new type of antidepressant, has given rise to extraordinary hype in the United States, where it is known as ‘the happy drug’: physicians are besieged by patients requesting prescriptions for it, even though they are not in the least mentally ill.
Peter Kramer is a bit more cautious, but he does make one seemingly remarkable claim. He asserts that the drug gives people who are unhappy but not depressed (‘dysthymics’ in the esoteric language of psychiatry) great self-confidence and the ability to accept rejection without being upset. He supports this claim with a series of case-histories drawn from his own patients. Unfortunately psychiatric case-histories are a modern form of fairy story, whose fallibility is well documented. First, the expectations of the psychiatrist can distort his judgment. Second, there is massive evidence that people pay more attention to positive instances than to negative ones: the psychiatrist will be struck by cases that support a certain thesis, and is likely to forget those which don’t. Finally, the psychiatrist only sees the cases he treats. He administers a drug and many of the patients (though not all) improve. But it is well known that almost everyone recovers from mild depression and the psychiatrist cannot tell whether there is any difference in recovery rates between those he has not treated and those that he has.
A controlled clinical trial was, of course, carried out with Prozac before it was licensed, and it was indeed found to have anti-depressant effects, though these were no stronger than those of the two types of drug already in use, the mono-amine-oxidase inhibitors (MAOIs) and the tricyclics. It appeared, however, to have some advantages over existing drugs. MAOIs can produce fatally high blood pressure if the patient eats certain foods – for example, cheese – while the tricyclics have unpleasant side-effects, like dryness of the mouth. Although they may possibly be less severe, Prozac, too, has side-effects; to name but a few: rash, nausea, vomiting, diarrhoea, headache, insomnia, anxiety, tremor, dry mouth, dizziness and difficulty in reaching orgasm. There is no such thing as a free lunch when taking medicines. Moreover, as Kramer acknowledges, the tricyclics sometimes work better than Prozac and vice versa – which anti-depressant works best with a given patient is largely a matter of trial and error.