Prozac®, as Carl Elliott writes in the introduction to Prozac as a Way of Life, may have begun life as a brand name for the active ingredient fluoxetine, but it is now a descriptive epithet for the entire family of selective serotonin reuptake inhibitor drugs (SSRIs), and, by extension, a lifestyle. When people say Prozac they may well be talking about something else, for Prozac has been so successful since being launched on the market that it has reared offspring: Paxil® (paroxetine), Luvox® (fluvoxetine), Zoloft® (sertraline), Effexor® (venlefaxine) and Celexa® (citalopram). And the number of disorders these drugs are licensed to treat has broadened well beyond depression to include conditions all but invisible until the 1990s: social phobia, panic disorders, eating disorders, post-traumatic stress disorder and sexual compulsions. When Eli Lilly’s patent for Prozac expired in 2001 it was marketed under a different name, Sarafem®, as a treatment for ‘premenstrual dysphoric disorder’. The bottom line would seem to be: if you want to sell drugs, sell the disorder first.
Prozac as a Way of Life, eleven essays by different hands, is an unusually literate attempt to take the measure of the world that made Prozac and its corollary: the world that Prozac is making. Prozac has been with us long enough now for it to have gone the way of all drugs: first its acclamation as the universal panacea, then media boosting, followed by the slow emergence of doubt, media quickening of doubt, and finally the backlash (we are currently between stages four and five).
If Prozac has the ability to alter feelings and actions, reshaping what we call empathy, the bonds of mutuality between individuals, then it has the ability to reshape the fabric of life itself. What can be said about the place in society that the SSRIs have come to occupy? Does it bear any resemblance to the situation in the 1960s, when Valium®—‘Mother’s little helper’, as the Rolling Stones mocked it—was prescribed in large quantities to help women endure what Erik Parens in this book calls ‘patently unjust social arrangements and attitudes’? Can Prozac truly be a liberating drug, as many of its supporters claim, when its use increases dependency, if only the minimal dependency of patient on industry (not to mention medical profession)? If the bulimic consumption of antidepressants betrays an essential lack, what is it people are missing? Or do antidepressants in some as yet poorly understood way ‘recruit’ those patients who are likely to respond to them? And then there is the libertarian twister: if every culture has its licit psychoactive substances, from betel nuts and kava to alcohol and nicotine, why should the medical profession be the sole guardian of access to SSRIs?
Depression is our contemporary diagnostic black hole. Consider the statistics: from being a rare diagnosis (affecting perhaps fifty people per million) in 1957, when the first antidepressant was discovered, by 1970 the number of depressed persons was estimated by the psychiatrist Heinz Lehmann to be one hundred million worldwide. The Swiss pharmaceutical company Geigy actually decided not to develop imipramine in the 1950s on the grounds that the market was too sluggish to provide a return on investment. In the 1980s, the number of depressed patients on treatment in France alone increased by one million. In the USA prescriptions for SSRIs increased by 20.9% in a single year (1999– 2000). According to the World Health Organization, depression and cardiovascular disease are set to be the two major public health problems of the third millennium: the prevalence of depression in the world’s population is three percent. Prozac has excited the philosophers and ethicists in a way that imipramine did not (as exemplified by Peter Kramer’s best-seller Listening to Prozac).
This suggests we are facing a phenomenon not just of medical or sociological importance, but a radical anthropological change, and a mutation in the way we think about ourselves. You can’t argue with success, but it looks as if we should, and in fairly sober words. Calling Prozac ‘Zen medicine’, as Susan Squier does, merely ushers us all the more completely into a kind of semantic overload while obscuring the material origin of signs in the bodies whose productive activities provide the continuity that might help us, as subjects, to avoid full-scale medicalisation.
The key essay in the collection is David Healy’s conference paper ‘Good Science or Good Business?’ It was publication of this account of a possible link between Prozac and suicide in the Hastings Center Report which led, controversially, to the rescinding of Healy’s appointment to a post in Toronto. (The event brought into question the very impartiality of bioethicists in the United States, all too many of them being in receipt of funding from corporate bodies.) Healy outlines how the regulatory response to the thalidomide disaster in the 1960s—in which thousands of infants were born with congenital defects after the German company Grünenthal marketed it as an over-the-counter remedy for nausea in pregnant women—gave rise to the ‘disease states’ that are now essential to secure FDA approval for any new medication. For years the pharmaceutical industry has been putting vast resources into gathering and disseminating information to influence treatment lobbies and the manner in which doctors prescribe. Nearly all university research has some involvement with the industry, which may also be funding some patient support groups (Eli Lilly funds the National Alliance for the Mentally Ill in the USA, for instance). Experts often rotate between sectors, so that a government adviser may previously have worked for the private sector, or directly for the industry itself. As Laurence Kirmayer says in his article on the quite different cultural experience with Prozac in Japan, ‘professional autonomy rides the tail of marketing’. The advertising budget for Prozac actually exceeds the already bloated budget for Nike running shoes. Even those last bastions of objectivity in science, the medical journals, are not protected from the pressures and forces of the market: Richard Horton, editor of The Lancet, has written that ‘[they] have devolved into information-laundering operations for the pharmaceutical industry’. Studies have shown that doctors tend rather complacently to underestimate the hold the pharmaceutical industry has over them. Furthermore, most practitioners are naïve realists—which is to say that they treat their patients in good faith, assuming them to be genuinely ill—and patients present with genuine symptoms (which must be genuine since they’ve just been ticked off on the symptom list). Nobody appears to be trying to put one over on anyone else. Yet Healy suggests that Prozac is less likely to ‘work’ when its effects are evaluated using patient-based, non-specific quality of life arguments rather than clinician-based rating scales (as would be adopted in a single- or double-blind trial). We also know that approximately one third of all depressed patients respond positively to a placebo, though this finding is manifestly of little interest to the pharmaceutical companies.
So what order of phenomenon are we dealing with? Can it be that modern psychiatry is based on something like a category error brought about by the triumph of the biological model of disease in a society that values individual initiative above all else while blinding itself to those aspects of mind that reveal it as something shared?
This is the contention defended by Thomas Szasz, who in his defence of classic liberalism has repeatedly and paradoxically drawn attention to the fact that mental disorders are above all metaphorical illnesses. ‘What people nowadays call mental illness, especially in a legal context, is not a fact, but a strategy; not a condition, but a policy.’ If depression did have an infectious cause, the figures quoted above would be alarming though not altogether surprising: in the lack of anything like a necessary and sufficient cause, the only statement we can confidently venture is the circular argument that depression is the state of mind which antidepressants are able to act upon.
Wherein lies the ‘contagion’ then? One possibility we are forced to consider is that the mind is a rather susceptible receiver of electromagnetically-mediated image-driven consciousness rather than the producer of the rare and difficult predicative knowledge (of the form ‘A is B’) that is a feature of genuine science. Wasn’t that precisely why Plato sought to condemn the scandal of mimetic poetry and myth in Book 10 of The Republic? Isn’t that the whole force of the religious critique of idolatry?
Prozac as a Way of Life lacks the historical long view. One thread that ought to be running through it is the (American) search for the authentic self, although those who chase the drug bandwagon are manifestly slaves to a conformism that makes the whole idea of authenticity look like a bad joke. The body-blow dealt by the Vietnam War to the onward march of the American dream surely deserves consideration: the rise of post-traumatic stress disorder (PTSD) offers an intriguing parallel with that of depression. This label gave war veterans a kind of moral legitimacy, and guaranteed them a disability pension. The Victorian imperial personality—disciplined, rule-observant, respectful of authority and fairly sure of its entitlements—survived until the 1950s, and perhaps a few years longer in Britain (which had its 1968 revolt twenty years after everyone else); the new individual of the age of bounty is caught on the rack between what is permitted and what is possible. Choice is the mantra, although the ‘choices’ increasingly look stage-managed. One aspect of the old-fashioned bourgeois life that is easily overlooked is its dignity, but it was a dignity that insisted on making distinctions between realms of experience in order to wring order from a truculent and harsh reality. The cost of contemporary liberation from socially ascribed rituals, practices and even family links is a kind of free-floating anxiety. For the one condition that describes our life is its optionality. Many commentators bemoan ‘the loss of values’ in contemporary society, the fact that people don’t ‘believe’ in anything any more. Who’s kidding whom! Every aspect of contemporary life is bogged down in morality, especially the morality of doing your own thing while looking over your shoulder to make sure that next door is doing hers too. It would seem that the desire to authenticate the stirrings of the will is essentially a form of Puritanism. Despite the rhetoric of liberation, we are still within the tight little orbits of Calvinist self-justification.
In the old Soviet Union, people who criticised the system were sent to psychiatric institutions for ‘correction’ or ‘re-education’: the putative citizens of the expertocracies of the twenty-first century, on the other hand, are likely to be so well-trained that if they feel a phobic phase coming on (i.e. an urge to criticise the radiant society erecting itself around them) they won’t commit themselves to an institution—they’ll just self-medicate. Well, that was what radical critics used to promote in the 1960s when almost every commodity in Western culture pretended to offer some kind of psychedelic experience; but it is salutary to remember too what Orwell wrote about Swift’s Houyhnynms: ‘They had reached, in fact, the highest stage of totalitarian organisation when conformity has become so general that there is no need for a police force.’
Odd as it sounds, the more private and uniform (that is, the more autistic) it becomes, the more the techno-pantheistic self is forced to model its behaviour on others. It is a kind of liberated false consciousness bound by the same logic as Chesterton’s brilliant quip in Heretics about ‘the globetrotter living in a smaller world than the peasant’. That is why the latest generation of psychoactive drugs is almost certainly, to borrow a phrase from Karl Kraus, the disorder to which it purports to be the cure.
In the ever more complex and impersonal division of labour in modern society, depression might be seen as a kind of decompression of the individual working part, clueless as to its place in the meaningful whole: this decompression is one of the inevitable ‘transaction costs’ incurred by the complexity of the system, and one which can be cynically accepted provided the system continues to be ever more productive. Antidepressants will therefore intensify the problems they appear to resolve (and that goes for other ‘pharmacratic’ developments such as Ritalin® and the so-called ‘attention deficit hyperactivity syndrome’). Kraus’ aphorism restates our syllogism: supply leads demand, rhetoric prompts discourse, outcome trumps genesis. It suggests that in our society, which posits agency in terms of the individual actor making decisions, it is actually the robust, impersonal and pragmatic empiricism of the great social experiment embarked upon several centuries ago (look: no Experimenter!) that now carries the day: last things come first. Reality has become the endless speculative fairground described by Leibniz even though we still don’t understand anything very much at all about the relationship between consciousness and its physical embodiment: who we are, where we are or even when we are.
Prozac as a Way of Life provides some helpful approaches towards an understanding of how depression has become an epidemic. As Robert Burton suggested, in his solid and (I presume) widely unread classic of the English language The Anatomy of Melancholy, published in 1621 when the humoral theory of disease was about to be overtaken by the new vocabulary of contagion and commodities, one of the symptoms of melancholia is not to know its cause. That cause may be civic in origin, not just a sickness of the soul.
Mention of Burton reminds me that I was once moved, in what I thought was a refreshing turn of honesty but probably came over as a brutal quirk of exasperation, to suggest to one of my patients at the end of a long and not very productive consultation, ‘You’re not depressed, you’re unhappy, and only you know why.’ My patient looked shocked: how should I know what is wrong with me when he refuses to say? That was the last I saw of her.