In the 1980s, historian of pharmacology Mickey Smith wrote that new blockbuster medicines enter society by a three-step process. First, a wild popular embrace, driven by overestimation of the drug’s potential, leads to overuse; next, the sudden discovery of “problems” with the drug leads to a backlash; and finally, a state of equilibrium is reached, in which the drug is used judiciously, its real benefits and limits seen clearly at last. Smith called these three stages the “law of the wonder drug.”

I remembered Smith’s formula not long ago, while talking to an old friend on a summer ramble around New York City. The substance of our conversation was that antidepressants – a topic we’d bandied back and forth together for almost 20 years, in various states of using them ourselves and not – had begun to seem quaint. Maybe even a little retro, like lava lamps or tube socks.

So begins a short, cutting essay on antidepressants.

The piece is timely: once considered miracle drugs for depression, this medication class has come under sharp criticism, and yet has gained wide acceptance. In my clinical work, I’m surprised by the large number of patients – particularly younger patients – who hesitate about these medications; I’m also surprised by the large number of patients – particularly younger patients – who are on these medications.

This week’s Reading: “The silence of prozac” by author and essayist Katherine Sharpe, which was just published in The Lancet Psychiatry.

Katherine Sharpe

You can find the essay here:

For the record, Sharpe doesn’t argue that antidepressants are “obsolete.” She reports early in the piece that antidepressants are frequently prescribed. But she notes that the enthusiasm has waned, following Smith’s prediction – from “miracle technology” to “a familiar – even frumpy – part of modern furniture.”

I highlight a few points:

· As of 2011, antidepressants are the most prescribed class of drugs in the United States.

· “Largely, though, antidepressants now appear neither so miraculous nor so threatening because we know them better – our sense of their power both to hurt and to help has diminished.”

· She makes note of the STAR*D study showing that a third of patients were symptom free after one medication trial and, after 4 medication trials, the rate is 70%, “though many patients drop out before getting there.”

What makes this piece colourful is the author’s description of her own journey with antidepressants. She describes her own ambivalence:

Back then, I deeply resented ‘having’ to take the drugs, largely out of fear that they might change things about myself that I valued. (In hindsight, I believe talk therapy would have helped more, but it was not offered at the time – it was the late 1990s, and Freud, after all, had been declared irrelevant in Time.)

In discussing the cultural treatment of Prozac, she writes about various books, from Listening to Prozac to Generation X. She concludes by noting:

This is antidepressants as most who know them know them now: helpful sometimes, imperfect certainly, often a pain, yet mercifully there if you need them.

A few thoughts:

1. I think this piece provides a nice and eloquent explanation of the cultural rise and fall of Prozac.

2. Last year, as part of its “Retro Report” series, The New York Times produced a nine-minute video looking back at the early enthusiasm for Prozac. The video complements this essay well. Here’s the link:

3. Of course, Prozac didn’t just elicit a cultural response; there was also a professional response, as psychiatrists and family doctors reached quickly, perhaps too quickly in some cases, for their prescription pads. A Prozac trial isn’t akin to a lobotomy procedure, but those of us in the field must always be mindful of the lessons of history and the importance of evidence.

4. As we develop a more mature relationship with Prozac, we are slowly seeing treatment not as being a matter of meds vs. no meds, but as including different tools in a toolkit. There is Prozac and her sister drugs in that toolkit, yes. There are also other evidence-based interventions, like exercise and CBT. Culturally we have moved past Prozac, but our public policy hasn’t, with therapies like CBT still inaccessible to many Canadians.

Reading of the Week. Every week I pick a reading — often an article or a paper — from the world of Psychiatry.