If Everyone Were on Prozac ...

When Prozac arrived in the U.S. in 1987, with its catchy, computer-generated name and massive marketing campaign, it didn't just take over the market for antidepressants; it expanded that market many times over, quickly becoming one of the world's best-selling drugs. Although originally approved only for adults with "symptoms of depressive illness," Prozac and its imitators (Zoloft, Paxil, Celexa, Luvox) are taken today by millions of patients — including more and more children — who don't necessarily meet the textbook criteria for clinical depression. Veterinarians have even made Prozac their No. 1 choice for dogs with the blues.

Prozac and the other so-called SSRIs have been a breakthrough on several levels. Compared with first-generation antidepressants, they are remarkably effective and relatively free of serious side effects. They work by slowing the brain's absorption of the mood-enhancing neurotransmitter serotonin (thus the term selective serotonin reuptake inhibitor).

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What makes serotonin such an important brain chemical is that it affects everybody, not only depressives. According to Dr. Jonathan Metzl, author of Prozac on the Couch, if you were to go on the drug today, there's a good chance that you would feel better, even if you aren't depressed. Dr. Peter Kramer, author of Listening to Prozac, describes the effect as feeling "better than well."

And that raises an intriguing question about the future of mood-altering pharmaceuticals: If Prozac can make you feel better even if you are not depressed, why shouldn't we all be taking it? Is that the direction we're going, as the drugs become more socially acceptable and heavily marketed? (More than 11 million Americans already take some form of antidepressant.) It's a question that arises only because SSRIs are relatively mild and subtle medications. There are plenty of drugs that can make you feel better, at least temporarily — alcohol and heroin come immediately to mind — but they tend to be addictive or toxic or both. Prozac is neither.

The drug does have its risks. According to several clinical studies, Prozac is associated with insomnia, restlessness, nausea, weakness, loss of appetite and tremors. For up to 60% of users, Prozac will interfere with their sex drive. Given indiscriminately to manic-depressives, it can trigger serious manic episodes. And there is anecdotal evidence linking Prozac with suicide and other violent behavior, although whether Prozac or the underlying depression is to blame is still an open question.

But what if antidepressants like Prozac were one day made completely free of side effects and served only to elevate mood? Would there be an objection to prescribing them for the entire nation? Every psychiatrist I spoke with still answered "probably." Some see SSRIs as a kind of mental shortcut that relieves patients of the need to work through their problems. Others fear that a nation on Prozac would miss the inherent value of struggle and strife. Dr. Kramer thinks there may be an intrinsic virtue in what he calls the "unmodified personality." Although this month the FDA approved Prozac for treating children and adolescents ages 7 to 14, Dr. Jerry Rushton, a pediatrician at the University of Michigan, bemoans its use for kids, fearing that it may interfere with their emotional development.

Maybe that's something we should all worry about. It doesn't take anything away from the good that modern antidepressants have done for the clinically depressed to say that if what we are seeking is something of real and lasting value, we will probably never find it in a pill.