In Prozac We Trust Health officials worry that nation is becoming over-medicated — (The Denver Post)

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The Denver Post

July 11, 2000

Author: Jenny Deam Denver Post Staff Writer

When Rosa, a striking, intelligent young woman in her 20s, arrived in Denver in 1994, she felt a little lost. Leaving her family and boyfriend behind in Latin America had made her lonely and anxious.  Because she had a history of depression, she went to a doctor for help.

Quicker than you can say wonder drug, her primary care physician wrote her a prescription for the anti-depressant Prozac. There were no warnings about side effects; no suggestion of accompanying therapy.

If it all seemed quite routine, in fact, it was. By some estimates as many as one out of every eight people in this country has taken Prozac or a similar type of anti-depressent in the past decade.

For the next four years Rosa, who asked that her last name not be used, took Prozac on and off. When she felt down, she renewed her prescription. When she felt better, she simply stopped taking it.  Because she went to her doctor infrequently, she was never monitored.

Then one day she decided it was time to die.   “It came out of nowhere,” she remembers, “I woke up and decided this world was crazy.” Clutching her rosary, she drank two cups of bleach to kill herself.

She was rushed to the hospital and saved.  But Rosa was terrified. She had never felt suicidal before, even in the depths of her depressions.  She went for a psychiatric evaluation.

There, it was suggested that Rosa might have had an adverse reaction to Prozac. About that time the first rumblings of criticism were emerging.  Perhaps Prozac wasn’t quite as safe after all. Critics were saying the medication triggered violent or suicidal behavior in some – a contention its manufacturer, Eli Lilly, has steadfastly denied.

Rosa briefly entered counseling and was switched to Paxil, another enormously popular anti-depressant. But the drug made her gain weight, so she quit. Cold turkey. Without any medical supervision. No one told her she needed it.

Soon she was feeling anxious again and went to yet another primary care physician at her HMO. S he was given a prescription for a third anti-depressant, Wellbutrin. Again, there was no talk of re-entering therapy or any long-term treatment plan.

“There’s got to be sometime in my life where I don’t need this anymore,” says Rosa, now a public health professional. “My friends ask, “Are you going to be on them (anti-depressants) for the rest of your life?’ I don’t know what to tell them. I don’t want to be. But that’s the dilemma. Yeah, you do lose weight, you do look good, you seem happy. But I know it’s not real. I don’t feel like me. I’ve lost me.”

In 1988, when the pharmaceutical giant Eli Lilly launched its new drug, Prozac, the drug was hearlded as revolutionary.

The psychiatric community, and soon the public, embraced these little pills, called selective serotin reuptake inhibitors (SSRI), as a breakthrough.

Prior to that, depression was treated with very powerful drugs linked to a host of serious side effects. Patients on the medications needed to be closely monitored.

Then came Prozac with promises that it was much safer, with few – if any – side effects.

Quick to follow were other pharmacuetical companies, introducing their own SSRIs under such names as Zoloft and Paxil. Throughout the 1990s, their popularity was as astounding as it was unwavering.

Last year, 146 million prescriptions for anti-depressants were written in this country, according to IMS Healthcare, a healthcare information company in Pennsylvannia.

Prozac was the nation’s third best-selling prescription drug (behind Prilosec antacid and Lipitor high cholesterol medication) with $2.5 billion in sales. Zoloft was No. 7; Paxil, No. 9.

And, as the zeal for anti-depressants continues to grow, so, too, do the number of conditions they are being used for. No longer just a medication for depression, they are also being prescribed to help patients quit smoking or lose weight, as well as for panic attacks and eating disorders. Last week the federal Food and Drug Adminstration approved Prozac as a treatment for premenstrual syndrome.

Additionally, it is no longer just psychiatrists prescribing them. If you combine the prescriptions written by family practioners, internal medicine doctors and osteopaths, the number is actually more than for psychiatrists, IMS reports – which is precisely what has some people worrying that we, as a nation, are becoming over-medicated.

“They can be prescribed cavalierly because there is that assumption of safety, without a full diagnostic evaluation,” says Dr. Doris Gundersen, president of the Colorado Psychiatric Society.

She calls the phenomenon yet another byproduct of managed care. Because primary care physicians are the first – and often only – doctors a patient sees, it is very efficient and cost effective to prescribe a drug rather than refer to a therapist and begin a protracted course of psychotherapy.

“Depression treatment has been reduced to writing out a prescription,” Gundersen complains.

Dr. Ruth Harada, medical director of in-patient services at the Behavioral Health Division of Presbyterian-St. Luke’s Medical Center, agrees. “People are going to try easy and cheap ways to treat patients. Prescriptions are easy and cheap ways. I think the question is, how many people truly need it?”

For some, Harada says, the SSRIs truly are a godsend. They are easily available and very effective. Their popularity has served to destigmatize depression and brought many people into treatment. Those people may very well be on medication for the rest of their lives.

For millions of others, though, the drugs simply are not necessary, Harada says. She does not believe them to be harmful, just not especially helpful – except perhaps for their placebo effect.

Limit the dependence

Or, if they once were needed – to help someone through a specific episode such as divorce or job loss – they probably should not be taken indefinitely. The government’s Agency for Healthcare Policy and Research recommends they should be used only for four to nine months after symptoms of depression disappear. Typically, that means a total of six months to a year total. But that is not what is happening. Many people once on the drugs are reluctant to give them up. Some worry of a growing psychological dependency as those taking the medication suspect they cannot cope without them.

Still, what really concerns Harada is the new research that indicates SSRIs can actually be dangerous to some people, especially those with bipolar disorders.

Harada estimates that as many as 30 percent of the millions of people now taking anti-depressants are at risk. The trick is to figure out which 30 percent.

How do you know? “You don’t,” she says.

Pattern emerges

Guy McConnell says the pattern is there, you just have to know where to look:

In the 1960s, when many women felt exhausted and overwhelmed with the demands of running a household and raising children, doctors thought nothing of prescribing amphetamines. They were nicknamed Mother’s Little Helpers.

In the 1970s, the prescrition of choice was Valium, thought to be a perfectly safe way to smooth the rough edges of a stressful world.

These days, McConnell says, it’s Prozac or one of its SSRI cousins. He says it’s only a matter of time before people begin to realize how potentially dangerous the drugs truly are.

McConnell, a retired construction worker from Alabama, is the national director of the Prozac Survivors Support Group. While he says he believes strongly that the drugs help many people, his mission is to make sure patients, and their doctors, are informed of potential risks. “They shouldn’t just be given out like candy.”

McConnell says he has firsthand experience watching Prozac run amok. His former fiancee is Gail Ransom, the California nurse who killed her mother. Ransom was taking Prozac, which, she claimed in her defense, triggered a psychotic reaction. Hers was one of the nation’s first so-called “Prozac defenses.” She served only 18 months of a three-year sentence for manslaughter.

Dr. Joseph Glenmullen, a Harvard Medical School psychiatrist and author of the new and controversial book, “Prozac Backlash,” also sees a pattern in history. He calls it the “10-20-30” cycle:

When a drug first hits the market it is seen as a wonder drug that can do no wrong.  By the end of the first 10 years, patients begin to complain of problems with the drug that the manufacturer, and often the medical community, dismiss.  After 20 years, the medical community also sees problems.  In 30 years, the regulatory agencies step in, and it is not unusual for a drug to be withdrawn from the market.

But by then the patent may have expired; the pharmaceutical company simply reintroduces a new version, Glenmullen says.

Indeed, it was recently reported in the Boston Globe that Eli Lilly is now working on new version of Prozac – set to be on the market by 2002 – that has a reduced risk of side effects. This comes as the company continues to downplay or dismiss any link between the drug and suicide.

It is no surprise that critics like McConnell and Glenmullen have drawn the wrath of the pharmaceutical company. In Glenmullen’s case, he says a media campaign was launched to not only discredit his book, but also his professional and personal credibility. “I think I pushed the right buttons,” he quipped.

Jeff Newton, a spokesman for Eli Lilly, called that nonsense.  He dismissed Glenmullen’s book as “a collection of ancedotes … totally out of line with mainstream medical research.”

He does not believe anti-depressents are being over-prescribed, he added.  If anything, he thinks just the opposite, considering that depression continues to be an under-diagnosed illness.

However, Newton said no SSRI should be prescribed without proper monitoring and followup.

Chronic problem

Still, with all of the millions now taking the drugs, the question remains: How and when will they ever get off them?

Rosa, the Denver woman who has gone on and off several anti-depressants through the years, said she was never fully warned about any withdrawal symptoms.  Or even if she was, she wasn’t paying attention.

“You have to understand a depressed person,” she says. “It’s very hard to accept you are one. You’re taught to be strong and disciplined and pull yourself out of it.  After you take them for a while you think, “I’m doing OK,’ so you stop.”

But is that safe?

New studies have indicated that as many as 85 percent of patients who take the drugs may have some kind of withdrawal symptom when they stop. That can range from flu-like symptoms and nausea to nervousness and melancholy.

Sometimes the withdrawl symptoms are so similar to the depression or anxiety they had in the first place that patients get right back on the drugs, thinking they have had a relapse.

Medical experts say withdrawl symptoms vary from patient to patient and from drug to drug. Prozac, for example, typically does not cause much of a withdrawal reaction because it is so slow-acting that it remains in the system long after you quit taking it. Paxil, on the other hand, is much quicker-acting, and therefore causes a more immediate effect when it is discontinued.

Gundersen, at the Colorado Psychiatric Society, says it is absolutely necessary to withdraw from anti-depressants under a doctor’s care. It can take weeks or even months to wean yourself from the drugs, she said.

Gundersen is the last to deny the need for these new drugs. As the numbers of people who suffer from depression continues to rise, the drugs truly are a breakthrough in the treatment of mental illness. Her concern, though, is that perhaps it has become too easy to look for a quick fix.

“I think it’s great that we have these new safe tools,” she says, “but at the same time, medication is not the panacea for all the ills of society.”

Copyright 2000 The Denver Post Corp.   Record Number:  1034587