When I woke up this morning - and let's be honest here, it was more like this afternoon - I began my day by swallowing two Prozac capsules. I also took some lithium, the salt substance that was long ago established as an antidote to manic depression and other mood disorders. On top of that I had a pink caplet called Depakote, the brand name for valproic acid, an anti-seizure remedy once prescribed for epilepsy, but now used to combat mood swings. And finally, I chased down the other pills with a blood-pressure medication called atenolol - my 92-year-old grandmother also takes this - to alleviate the Parkinson's-like handshake that I get from taking all these drugs.
Later in the day, probably with dinner, I will take nortryptaline, a tricyclic anti-depressant, one of the pre-Prozac variety that acts on the dopamine and neuropene phrine systems of the brain. At the same time, I will down my evening doses of lithium and Depakote, along with some more atenolol for the kind of shakes that by dinnertime can make it awfully hard to get a fork and food to my mouth, and have been mistaken by many for delirium tremens.
Strangely, although this crazy salad of pills makes me exhausted and lethargic all day, I often cannot get to sleep at night. My energy level is mysteriously invigorated at midnight. So, in an attempt to get my circadian rhythms attuned to the rest of the world's, sometimes I take Ambien, a non-narcotic, non-addictive sleep remedy that seems to have a blackout, knockout effect. Tomorrow morning, I will wake up and do the same thing again. I have been doing this - different pills, same routine - for the past 11 years.
If you have any doubt that Prozac has changed the world, consider the drug regimen I am on. And consider the chemical cocktails so many people have been taking since Prozac was launched in 1988. In just one year - 1997 - 65 million anti-depressant prescriptions were filled in the US alone. More to the point, Prozac has swelled the market for psychotropic drugs. Its minimal side-effects allowed physicians to prescribe it, if not exactly on a whim, then at the first note of a patient's pained whimper. And then, if Prozac was not sufficiently effective, other medications could be prescribed.
Suddenly there were all these doctors whose entire practice involved a prescription pad and the occasional use of a blood-pressure monitor. They called themselves psycho-pharmacologists, and all they did was try to get the right mix of medications to keep patients relatively sane. Although no one really knows how these psycho-pharmaceuticals work, the existence of experts resulted in a tendency to pretend there was real know-how in a process that is mostly trial and error marked occasionally by alchemy: one pill was said to be good for the rejection-sensitive, another for those with object-constancy problems, and blah blah blah.
In spite of my tendency to mock psycho-pharmacologists, I saw one for a period when I was not in therapy with a medical doctor - I referred to him as the Pusher-man. And it's difficult to say which is worse: a specialist in prescriptions, or a general practitioner who gives Prozac to a patient he barely knows because, well, it probably won't hurt and it may help. And this kind of thing happens a lot. In the US, where there is no National Health Service and the doctor's duties are dictated by insurance companies, Prozac has been a perfect solution to the financial unmanageability of mental health care - indemnifiers would no longer cough up for therapy sessions, but they would gladly pay for a pill.
Essentially, Prozac became the shrug drug, it was one big "why-not?" The Food and Drug Administration, which controls the licensing of drugs in the US, eventually endorsed it to cure obsessive-compulsive disorder, obesity, attention deficit disorder - a whole range of emotional bogeymen. And this may well be Prozac's permanent legacy: it medicalised mental health, even when the damage was rather mild, the symptoms fairly slight. Suddenly, you did not have to jump out of a window or run through the streets wearing nothing but your knickers for your behaviour to be worth more than just the talking cure. Often the therapist would suggest a visit to a psycho-pharmacologist for a consultation, with the assumption that until you were lifted out of your misery by biology, all the Freudian work that could be accomplished five days a week would not help at all. The depression itself was pushed out of the way, and your real fears could be explored. The little green and white pills delivered emotional expediency.
When I first went on Prozac, none of this was so. My trouble, the complaint I carried with me until my third year in college, was that I was crazy, that I felt waves crashing in my head for reasons I didn't know - but in spite of the persistence of emotional emergency, no one was going to listen to my plea as long as I was ambulatory. There was, I had no doubt, a fierce physicality to my depression - I knew it because I felt it - that no discussion of the slights I experienced in the playground at the age of three or the Picasso-vivid dreams I was awakened by each night could possibly penetrate. And I knew there was some medicine for these feelings. I knew there had to be because if not I was going to have to kill myself. I believed, as anyone who is depressed but resists suicide must, that there was something that could be done for me. I was a student then, with all the resources of a large university at my disposal, and I went from doctor to doctor, begging for a medicinal cure.
No one would help me.
Though a variety of classes of antidepressant was available and would certainly have helped me before Prozac, it wasn't until that drug arrived that a psychiatrist saw fit to offer me chemical aid. At the time I was sufficiently ill to be staying at the college infirmary, and still Prozac was the first antidepressant I was given. When I think now of how much sooner I could have been paroled from this prison-house of the mind, I am often angry, deeply angered for all the missing years.
Of course, the world is now completely turned on its head in its relationship to medication. In 1995 I participated in a college panel that essentially asked, "Prozac - pro or con?" For me, this was a ridiculous question: Prozac made people - sick, miserable people - feel better. It treated a mental state that I knew to be nothing less than a deleterious disease. It was astonishing for me to hear student opposition to the drug's use. It was difficult for me to understand its controversy in general, because to me it has always been simple: I felt a deep debt to the inventor of this lifesaving pill. But these students were upset by its depersonalising effects, by the way that when they went to their health services seeking therapy or emotional support of any kind, all they got was a Prozac prescription. They felt like toddlers being stuck in front of the television by a nanny who didn't care for them, rather than being hugged by a parent who did.
And when I went on a tour to support my book Prozac Nation, I'd frequently sign copies for teenagers - 14- or 15-year-olds - who would tell me that they were on Zoloft, but they were switching to Paxil, or they were on lithium but the new doctor thought they should try Depakote. And it was through meeting these young people that I started to understand the frightening, Huxleyan nightmare Prozac could create. You see, I, in a sense, had to work to earn my Prozac. I had spent years trying every other form of help that was available and I had lived for so long in complete darkness. I did not have to wonder if Prozac was necessary - I knew. But drugs were now being handed out so liberally that each wretched little pill represented a resentment, a neglect, a shrug.
Dr Sterling, the psychiatrist who first put me on Prozac, and who was a wonderful therapist in every way, now runs a mental health clinic in California. No long-term therapy goes on there - in fact not much counselling of any kind goes on there. What does happen is a lot of prescription writing. When Sterling sees people to refill their drug orders she gets a chance to talk to them and find out what they need to cope by way of medication. And she builds up some sort of bond with patients over time. In her limited capacity, Sterling feels that she is doing some real good. "Now, instead of some people getting a lot of help, a lot of people are getting some help," she says.
But it isn't like it was with me, and she says this is her choice: seeing suicidal patients with extreme needs exhausted her and deprived her of any emotional wherewithal for her husband or her children. It's not just patients who are desperate for whatever relief Prozac can provide - doctors, too, are overwhelmed. The needs that their deracinated, unstable and alienated clients bring to therapy in an age of divorce are almost too much to be handled without non-human intervention.
Recently there was a newspaper article about "uplift anxiety", examining how recovery from depression with Prozac and other drugs "can bring a new array of personal problems, from social uneasiness and crises of identity to professional and marital strains". I understand this - one of the reasons I believe that medication must be taken in conjunction with some sort of therapy is that Prozac is helpful, but the miracle of overcoming a depression requires a more strenuous overhaul than any pill can contain. But the article still seemed absurd - after living under the weight of depression for many years, the lightness of life seems a very luxurious problem. I don't believe there is such a thing as too much joy.
Besides, these popular notions about Prozac tend to overstate its transformative power. No antidepressant is a happy pill, and if you emptied out a Prozac capsule, cut its contents into lines and snorted them up, you would not get high. Dream on! All this family of drugs has ever offered is access to the part of a person that wants to be happy, but has been cordoned off. Once you get through those velvet ropes, it is up to you to learn to enjoy the party.