Dear Roy,
When we spoke on the phone, you suggested that it was my duty, as an "addict and advocate" of Prozac, to start off this correspondence. I'm not sure that I can produce the cheer-leaderly zeal suggested by that phrase. However, I'll give it a go and leave you to judge whether our positions are sufficiently opposed to constitute an argument.
I was put on Prozac by a psychiatrist in New York, eight months ago. I have been subject to bouts of depression for as long as I can remember, but at the time, I had been seriously depressed for at least a year and was finding it increasingly difficult to function normally. In a very short space of time after I had started taking the drug-three weeks, I guess-my behaviour and outlook underwent a significant change. To name some of the most tangible results: I stopped lying in bed in the middle of the day. I stopped crying all the time. I began to entertain visions of my future that were, if not entirely rosy, then at least not entirely gloom-laden. Perhaps most significantly, I found myself able to halt the chain reaction of morbid anxieties that, in my depressive state, was frequently set off by the most minor of incidents. (In the US, and so far as I know in the UK too, Prozac has been officially approved for the treatment of serious depression and of obsessive-compulsive disorder. The connection between these two ailments is interesting to me because depression has always struck me as obsessional in nature: instead of being merely sad, one becomes obsessively sad, compulsively fretful.)
A brief word about the chemistry: Prozac is the first of a new generation of anti-depressants known as selective serotonin re-uptake inhibitors, or SSRIs. Its development was based on the theory that depression is related to the decreased concentration of certain neurotransmitters-among them, serotonin-in the brain's synapses. Instead of doing their job-i.e. carrying impulses from one nerve cell to another-the neurotransmitters in a depressed person are being "taken back" into the transmitting cell and destroyed by certain enzymes. Previous anti-depressants have worked by attempting to inhibit this "re-uptake" process. Prozac is simply the first drug to target the re-uptake of serotonin, without affecting the other transmitters. Prozac doesn't seem to be more effective at relieving depression than previous drugs: its rate of success is in the same 65 to 70 per cent range. It is just easier to take and it gives rise to fewer side effects.
Since it was introduced in 1987, a number of fairly nutty claims have been made on Prozac's behalf. In his book, Listening to Prozac, the American psychiatrist, Peter Kramer, claims that Prozac might give rise to a new era of "cosmetic psycho-pharmacology," enabling people to "extend social popularity, business acumen, self-image, energy, flexibility, sexual appeal" as they wish. While it seems perfectly likely that a person overcoming a bout of depression may find that he or she feels more attractive and on the ball (people in the depths of depression are not, generally speaking, a lot of laughs at cocktail parties), the implication that such benefits may be enjoyed by non-depressives-that Prozac can be used as a generalised personality-enhancer-seems to me highly suspect. Such claims encourage the impression that Prozac is a self-indulgent American fad. Certainly, Prozac has been used to fuel a fond American faith in the perfectibility of life, but it seems unfair to condemn a drug because of some of the inappropriate causes it has been made to serve.
The chances of anyone who is not authentically depressive staying on Prozac, for any length of time, seem slim. Prozac doesn't lend itself easily to recreational purposes. Some people report a mildly speedy effect during the first few weeks, but this is the sort of buzz you might get from drinking too much coffee. And though the adverse side-effects-nausea, headaches, diarrhoea, night sweats and so on-are fewer than with earlier anti-depressants, they are still not much fun.
Am I entirely happy to be taking Prozac? Not really. I have as much puritan distaste for the idea of being reliant on a drug as the next woman. If the effects of Prozac had been even slightly less dramatic, I think I would have probably given it up by now. It has been pointed out to me by fellow Prozac-eaters that if I suffered from diabetes, I would have no scruples about injecting myself regularly with insulin. The problem is that the relationship between levels of serotonin and depression is nowhere near as scientifically established as the relationship between insulin and diabetes. More than that: depression itself, is much more difficult to define and quantify than diabetes. I have friends who question whether my depression was sufficiently chronic to warrant pharmaceutical intervention. I'm not sure. All I can say for certain is that I was miserable for a long time and now I'm not. Where fresh air, exercise, therapy, vodka and iron pills all failed, Prozac seems to have done the trick.
Yours,
Zoe Heller
November 22nd 1995
Dear Zoe
Funny thing, serendipity. Your Prozac thoughts reached me just when all the talk here was about drugs and depression. As I write, Britain is glued to the sad case of Leah Betts, who took her first Ecstasy tablet at her 18th birthday party, fell into a coma and died-accompanied by tabloid hysteria.
Just as the story broke I happened to be paying a visit to my ex-step-daughter, also 18, who's just gone off to university. The conversation turned to "substances." For her the issues were clear as crystal. Cigarettes and dope were one thing: all her generation smoked ("in moderation"); it was their way of coping and relaxing (lung cancer? well, you only live once). But Ecstasy and "hard drugs" were a different story. They were cultish-don't mess with those things, she told me, you never know what they might do to your head, especially mixed with alcohol. And Prozac? Never heard of it!
It was intriguing chatting to someone so near to myself yet so far (a whole generation), and swapping our lines on what were once called "good scenes" and "bad trips," with respect to what goes into our bodies. And all right, it's time to out myself: I knock back the coffee and the Chardonnay, counteract with Nurofen and vitamin C, and still slaver over roast beef-"Oh, please, Roy, do try to break yourself of the habit," she implores, "it's so bad for you, with all the mad cow disease." Ashamed, I gaze at my boots and remember Astrov as Sonya begs him to lay off the bottle.
The other thing buzzing round my mind when your letter arrived was the Princess Di television interview, particularly the bit where she came clean about her old bulimia and self-mutilating behaviour. Pressures had built up, depression deepened, and the bingeing had served both as symptom and relief-all that before she'd undergone treatments (pre-Prozac, I guess) to break those harmful habits. I watched, reflecting: I've never binged and puked myself, I've never slashed my wrists, I've never lain in bed all day so gripped by leaden-eyed despair that I just can't stir; I've never popped a Prozac. What do I make of this? Do I say: there but for the grace of God...? Do I think: thanks to this, that and the other, I'm "normal"? (Thanks to what?-because I came from a loving family? Because through some fluke my serotonin and dopamine levels make me Mr Meridian?) Or do I say: look at yourself and admit: when it comes to obsessions, over-compensation, displacement behaviour and the rest you've got enough on your case-notes to confine the average neurotic to the also-rans?
All that's by way of prologue to explaining why I feel so unsure about Prozac. There's an old argument going round in the UK that runs like this: Prozac must be a bad thing because it's a quick fix. Happiness, as the worthy John Stuart Mill pronounced, isn't something you can patent or purchase; there are no chemical short cuts. The proper thing to do is to stiffen your upper lip and fight the good fight; through will-power and character you will achieve autonomy-and maybe just a smidgen of cheer.
Well, that's not an objection I buy: that brand of muscular individualism was all too often Victorian hypocrisy dolled up to mask the smugness of the successful. And anyway, it's humbug, because we all harbour some fix of our own, some private addictions that keep us going. All of us make secret deals with our minds and bodies-another swig for Dutch courage, a Mars bar sugar fix now (work it off later). Even that most earnest of Victorians, Thomas Carlyle, was hooked on his baccy and gingerbread (now there's a new one). One man's Prozac is another man's poison, so we should all pick our own poison-and never forget that opium kept Thomas de Quincey writing for 50 years.
But it would bother me if Prozac (or anything else) were to be accepted as some kind of pleasure principle panacea, bringing to pass Huxley's Brave New World fears. Sure, millions are stressed and depressed, but that may be because we live in times in which anxiety and anger are the right responses-even healthy ones. Social disintegration, job insecurity, ceaseless pressures, the devaluing of all that's decent by the "greed is good" philosophy. All these spread distress and menace our sanity. And if that's so, we ought to pause before opting to sweeten the system by swallowing stimulants or sedatives. That's not to say we should yell "Stop the world-I want to get off" like gaga hippies. But if it's the way things are that makes us depressed, surely what we need is not chemicals but change: politics, not happy pills.
So answer me this question. What we Brits are hearing from America is that the Prozac revolution is now snowballing well beyond helping the individual, into a sort of national nostrum. Prozac Nation is no longer confined to Elizabeth Wurtzel's arty fast-lane fantasies: our papers are now talking of 10m Americans on the better-than-well pill, and of eight-year-old addicts. Or is this just another panic cooked up over here to make you lot all seem as mad as Manhattan? Reassure me! Please!
Roy Porter
November 25th 1995
Dear Roy,
I thought you were kidding when you first called me a Prozac-addict, but since you have used the term "addict" again, in reference to the mythical hordes of eight-year-old Prozac eaters, I think I should risk pedantry and clear this up. Prozac is not an addictive drug. (By the way, it is just silly to place cigarettes, gingerbread and Prozac under the same naughty-but-nice heading. Cigarettes are poison by any objective standard and gingerbread patently is not). My larger objection, however, is to your take on depression. You talk about your own neurotic behaviour and wonder why you shouldn't be considered a suitable candidate for Prozac. I don't know you well enough to be certain, of course, but I'd guess that none of your symptoms are sufficiently severe to indicate chronic depression or obsessive compulsive disorder. In other words, Prozac isn't meant for people who feel a bit down in the dumps, or who fret about things too much. Those feelings, as you suggest, are the occupational hazards of being human and any effort to banish them permanently from human experience would not only be sinister, but doomed to failure.
By the same token, Prozac cannot and isn't meant to replace political action by pacifying people who have rational, material reasons for discontent-for example, the homeless, the jobless, or the recently bereaved. Unlike you, I do agree with Mill that happiness cannot be purchased or patented. But Prozac doesn't purport to make you happy; it merely counters a chemical predisposition to being unhappy. Prozac takers are still subject to the normal human share of sadness, anger and anxiety; it's just that those feelings tend to have specific causes rather than being perpetual, irrational states of mind.
Clearly, when one starts talking about "rational" and "irrational" unhappiness, one is treading on very dodgy ground: who, after all, is to define what constitutes the "irrational" blues? As I acknowledged, clinical depression is a much woollier medical concept than, say, diabetes. I don't think that this diagnostic vagueness has led to quite the Prozac-frenzy in the US that you speak of, but yes, I am quite certain there are Prozac takers, here and in the UK, who would be better off in therapy, or doing aerobics. One psychiatrist I recently met at a party gleefully informed me that he had taken to dispensing Prozac as a sort of marital aid for couples who weren't getting on with each other. He had found it particularly useful, he said, in treating "nagging wives" and their "self-righteous husbands." This struck me as a very misguided and frivolous use of the drug. (Whatever "benefits" he claimed to have witnessed seemed much more likely to do with the fact that the couples in question were talking sensibly to each other, than with increased concentrations of serotonin.)
I suspect, however, that the medical establishment's love affair with Prozac is peaking and that, sooner or later, passion for the new wonder drug will give way to a more sober assessment of what it can and can't do. Like Valium-once hailed as the housewives' saviour-Prozac will cease to be the latest craze and take its rightful place in medicine's pharmacological armoury. Reassuring enough?
Best wishes,
Zoe Heller
November 28th 1995
Dear Zoe
Points taken! And I certainly don't want to be a dog in the manger. But my problem-because I earn my living as a historian-is that I'm haunted by the past.
As long ago as 1700, a pre-Prozac wonder drug was being praised. "Providence has been kind to us beyond all expression in furnishing us with a certain relief, if not a remedy, even to our most intense pains and extreme miseries," trumpeted the great Scottish physician, George Cheyne. It had no side effects, no drawbacks, and doctors prescribed it with abandon. It was opium.
A century later, they'd wised up a bit, but fortunately pharmacologists had by then extracted from the divine but dangerous poppy a positively non-addictive extract: morphia, perfect for quelling pains and soothing troubled souls. Luckier still, the hypodermic syringe was invented in about 1850, so that doctors could prescribe morphine to the millions who could then inject it for themselves. It was, as one practitioner put it, "the greatest boon given to medicine since the discovery of chloroform." The predictable crop of morphine-dependent "dope fiends" appeared. But the medics soon solved that problem by coming up instead with heroin, touted as far safer than morphia; and then with cocaine-which the young Sigmund Freud (among others) liberally prescribed, to wean his patients off their morphine habit.
History keeps on repeating itself, so I'll cut a long story short and zoom to the present. In about 1950 the psycho-pharmacological revolution was proclaimed. Psychiatrists claimed that, thanks to new psychotropic drugs, mental illness would be a thing of the past by the year 2000. Now we know such drugs turned thousands into zombies. In the 1960s the new pill for people who were down was Valium. Unlike the widely prescribed amphetamines, the new tranquillisers (the drug companies reassured us) were absolutely non habit-forming. What's more, just like those other two miracle drugs of the times, the Pill and Thalidomide, they had (so it was said) positively no side effects.
The historian's perennial temptation is to deal the Judgement card, turning the past into the great punisher, and parading precedents proving that whatever you do, you'll pay for it. All that Horsemen of the Apocalypse stuff-we had a bellyful with Aids-is obviously best avoided. But the sobering fact remains: over the centuries the panaceas promoted by the doctors and puffed by the drug firms have had a nasty way of creating unforeseen side effects and dependencies. Prozac, I grant, might just be different; we may have the unbelievably good luck to be living at precisely that moment when, for the first time ever, a wonder drug really lives up to its promise; but short memories are dangerous.
I have no doubt that Eli Lilly's scientists have run all possible trials, and will put their hands on their hearts and swear Prozac is non-addictive. But that's been said of so many smart drugs in the past that it can't be worth the paper it's written on until we have some decades of experience to judge by. Prozac's just coming up to eight years.
And that brings us back to the dreaded "A" word. You're quite right to resent the term "Prozac addicts," because "addict" conjures up all kinds of images-junkies shooting up in toilets or groaning in the gutter. In truth, we'd all be better off if the demon image of the "addict" were towed out to sea and sunk. This talk is mainly the fantasies of twisted tub thumpers; or, when real, such addicts are essentially the offshoots of criminalising legislation and punitive attitudes. I go along with those who maintain that today's "drug problems" are more the product of public attitudes towards drugs than the substances themselves; that the "war against drugs" mainly profits politicians, police and pushers; and that a key step towards solving drug problems lies in decriminalisation.
So if I have reservations about Prozac, it's not because I have a banning mentality-far from it. My fear is that, like all other wonder drugs, Prozac will prove a double-dealer. Or let me put it this way. You say Prozac isn't meant for people who are just down in the dumps. Quite right. But then we're told that 10m Americans are on Prozac and the numbers are soaring. Does that mean that 10m Americans are profoundly depressed? Or that use has already turned to abuse? In the end, it's not the Prozac that worries me, it's why it's been seized upon like a new salvation.
Cheers,
Roy Porter
December 8th 1995
Dear Roy,
The medical establishment is a little more wary than it once was, and the procedures for testing new drugs are rather more sophisticated. But you are right, of course: to meddle with one's internal chemistry is not-and will never be-risk free. I have tried to measure the risk of taking Prozac against the known discomfort of depression and have ended up opting for the former. The point is: I have opted. You, on the other hand, seem to be taking a rather mealy-mouthed line. You say you don't want to turn the past into "the great punisher," but what then, is the point of the precedents you cite? Play Cassandra by all means, but at least do it with some conviction: tell us we should take Prozac off the market at once. Tell the chronic depressive whose life has been dramatically improved by Prozac that you don't want him taking the drug any more. Otherwise, what are you doing, except hedging your bets? ("No, no, I'm not saying you shouldn't-but don't say I didn't warn you...")
It is also only fair to point out that most of the drugs you mention, in your list of wonder-cures-gone-horribly-wrong, continue to serve, in some revised form, useful medical purposes. Morphine may not have been "the greatest boon given to medicine" but it certainly makes dying from cancer a lot less grim than it once was. This was what I meant when I suggested that, sooner or later, the Prozac-frenzy would die down and the drug would find its proper value. Should 10m Americans be on Prozac? I would think not (although I'd still like to know where you got that figure). Should doctors be responsible and restrained when prescribing drugs, particularly new ones? Yes. Should patients be encouraged to take an active interest in their own health and the pills they put in their own bodies? Yes. Should we appreciate that much of what is now branded "dysfunction" is merely the necessary stuff of being human? Yes. But do I plan to stop taking my beautiful, green and white, 20 mg pill every day? As my cab-driver said to me this morning, when I gave him a $20 bill to pay a three dollar fare-no freaking way.
Zoe Heller
December 10th 1995
Dear Zoe
But what you say doesn't follow. If I say something may be dangerous, it doesn't commit me in the next breath to trying to ban it. John Stuart Mill sorted that out over a century ago, and I'll stick by his defence of personal liberty any day. In any case, the social consequences of all sorts of prohibition are usually counter-productive.
There's a difference between choosing to dice with danger and pretending that at last we've got something that's risk-free-the message that seems to waft across from the Prozac pushers.
Let me suggest a compromise: why not have an unseen but implied Surgeon General's History Warning on every pack of Prozac (and cigarettes, and bourbon, and whatever), saying "On Your Own Head Be It." That'll make sure the imp of the perverse stays alive and kicking.
Be warned, be well, beware-and keep taking the tablets.
Roy Porter
