A Short History of the SSRI

COMMENTARY

The documentary short film titled Prozac: Revolution in a Capsule was produced by freelance journalist Sarah Gross for The New York Times online, where it was featured in the “Retro Report” section, under “U.S and Politics,” on September 21, 2014. A link to the video can be found here.

Although my supervisors had always spoken about the sea change that marked the introduction of Prozac (fluoxetine), it was only after watching Prozac: Revolution in a Capsule that I realized the totality of the change they described. Through archival footage and interviews, the documentary does a remarkable job of capturing the time when this change transpired, and how it ignited the collective imagination.

Before the introduction of Prozac, antidepressants, albeit effective, were accompanied by a plethora of adverse effects. They required closer monitoring and were far more dangerous in the event of an overdose. SSRIs, starting with Prozac, provided psychiatrists with a new tool for the treatment of depression and opened the door for primary care physicians to treat depression and anxiety. The medication helped many patients whose depression was refractory, or who were reluctant to take antidepressants because of the distressing adverse effects. Prozac opened up the conversation about depression to thousands of people, some of whom are featured in the documentary.

The producer of the documentary, Sarah Gross, who spoke with this writer on behalf of Psychiatric Times, describes the impact of Prozac: “On the one hand, it has benefited the general depressed population, and more people are receiving treatment. It may also have created a backlash, as some people may feel like everything is being pathologized.”

[[{"type":"media","view_mode":"media_crop","fid":"30118","attributes":{"alt":"SSRIs depression","class":"media-image","id":"media_crop_8165865969912","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3146","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","title":" ","typeof":"foaf:Image"}}]]This issue of the adequate recognition and treatment of depression is a vital one. At first glance, considering the vast number of people who are now taking antidepressants, it may seem as though depression is at the very least being diagnosed and treated, if not over-diagnosed. However, this picture can be deceptive. Owing to a variety of factors such as the stigma still attached to psychiatric illness and the limited access to psychiatric services, depression is often missed or treated inadequately, particularly in vulnerable populations, such as the elderly, the medically ill, and new mothers-to name only a few.

As a psychiatrist, I perceive that the public image of SSRIs as “light drugs” can sometimes detract from the seriousness of depression and the importance of receiving comprehensive and effective treatment. Depression affects the patient’s adherence to medical treatment, which has been demonstrated in different medically ill populations, ranging from patients on hemodialysis to those receiving treatment for seizure disorder.^1,2 Depression treatment has been associated with reduced all-cause mortality in post–myocardial infarction patients.³ It is of utmost importance to recognize the need to identify and treat depression in vulnerable and underserved populations.

The collaborative care model aims to further integrate primary care and mental health treatment models. Ms Gross expressed concern that the downside of primary care practitioners prescribing antidepressants may be its impact on lower utilization of psychotherapy in conjunction with antidepressants and incomplete treatment that is terminated too abruptly or before an effective dose has been achieved.

Another aspect of the video that stands out is its coverage of the marketing of Prozac, including the effort that was put into engineering its name. I was struck, as always, by the persuasive power of marketing and the ethical questions this raises in the sphere of health care, which require continued consideration. As Sarah Gross says, “Prozac was the first antidepressant to be marketed directly to the consumer. On the one hand, it is valuable to have the public empowered, educated, and invested in their own mental health. On the other hand, perhaps we risk that people may perceive deficiencies where they don’t exist and we need to be careful about that.”

The term “cosmetic psychopharmacology” was coined by Dr Peter Kramer, whose interview is featured in the video. Contemporary psychiatric practice guidelines recommend the use of medications for the treatment of a specific condition, or for reduction of symptoms. Dr Kramer speaks of patients who described themselves as not having been depressed before but who felt better and “more like themselves” following the medication, a notion that garnered some controversy. The concept, although not commonly drawn on in daily psychiatric practice, can help deepen the discussion about the relationship between states and traits, the difficulties in diagnosing depression in special situations, and the corrective role of pharmacology in ameliorating human suffering.

The documentary brings many questions into focus, and its most important message may well be that although the revolution is now over a quarter century old, the issues are still alive-and it is crucial that we continue the conversation.

Disclosures:

Dr Mutalik has completed fellowship training in geriatric psychiatry from Long Island Jewish Medical Center in New Hyde Park, New York, and in psychosomatic medicine and psycho-oncology from Memorial Sloan Kettering Cancer Center in New York. She looks forward to the next phase in her career as a psychiatrist in the United States Army.

References:

1. Weisbord SD, Mor MK, Sevick MA, et al. Associations of depressive symptoms and pain with dialysis adherence, health resource utilization, and mortality in patients receiving chronic hemodialysis. Clin J Am Soc Nephrol. 2014;9:1594-1602.
2. Ettinger AB, Good MB, Manjunath R, et al. The relationship of depression to antiepileptic drug adherence and quality of life in epilepsy. Epilepsy Behav. 2014;36:138-143.
3. Zuidersma M, Conradi HJ, van Melle JP, et al. Depression treatment after myocardial infarction and long-term risk of subsequent cardiovascular events and mortality: a randomized controlled trial. J Psychosom Res. 2013;74:25-30.