Morning Reflection: Prozac Nation, Indeed

This past weekend's New York Times Magazine carried a fascinating feature about antidepressants in Japan. Apparently, driven in part by a significant drug company marketing campaign, the use of selective serotonin reuptake inhibitors (SSRIs) like Prozac and Paxil has dramatically increased, as Japanese have come to accept mild depression as a treatable disease. Most interesting of all, though, is that before this aggressive marketing effort, the Japanese didn't even have a word for mild depression. So a new term had to be invented: kokoro na kaze -- a Japanese who is mildly depressed now says that his "soul has caught a cold."

The article comes on the heels of some other interesting news related to SSRIs -- most notably a volte face by the U.S. FDA, which, in light of new research (and after sitting on similar findings for a year), has finally issued warnings regarding the increase in suicide risk for some children who are prescribed antidepressants. And antidepressants also are playing a role in a well-publicized murder trial, as the defendant, a minor, will argue that Zoloft made him do it. (It is unfortunate that this latter story in particular will probably drive a lot of the press coverage of this issue, as many will assume that the defense is merely grasping at whatever straws it can. That may well be true -- but it doesn't mean that the underlying issue is a frivolous one.)

The appearance of these press items suggests that the U.S. may finally be on the verge of having a conversation it has, in a way, been putting off for years now -- a conversation about whether these drugs, which are unquestionably lifesavers in cases of major depression, have attained a bit too benign a public image, and whether they are consequently being overprescribed in cases of mild depression. It really does seem that we have become a "Prozac Nation," after all. Here's an example: My wife, among other things, is a lactation consultant; as part of her screening interview for new clients, she routinely asks if they are taking any prescription drugs. "No," they've been known to respond, "just a little Zoloft" -- the clear implication being that, in the minds of some, these drugs are being equated to nonprescription meds like Tylenol and Claritin. To me, that seems a bit dangerous.

The thing we should be asking ourselves in many cases, I think, is whether these drugs are really treating the root cause, or whether they are merely treating the symptoms. There is no question that depression is a biochemical syndrome, likely involving neurotransmitter hormones, especially serotonin. And there's no question that, in some patients with major depression, attacking the biochemical imbalances that underlie depression is really the only safe and effective path. But what's causing those biochemical imbalances in patients with mild depression? Perhaps genetics or some ineluctable characteristic of personal biochemistry -- but perhaps other things, like stress, lifelong habits of negative thinking, or even sleep disorders, that can kick the neurotransmitter system out of whack. And these things might be treatable without bringing out the heavy artillery of SSRIs.

Again, I'm not saying that these drugs are bad -- only that we need, perhaps, to refine our thinking about when they should be prescribed. I hope to have a bit more to say about this in a future post.