The Long Hello: Coming Of Age In Prozac Nation

Richard Friedman, a Cornell psychiatrist, opines in the New York Times about patients who've been on anti-depressants since their teens and what they bump into once they climb into adulthood--all kinds of identity questions since they have little psychological development absent a diagnosis and medications--and how medicine hasn't really tackled some of the key questions around long-term anti-depressant use.

Anyway, one of his patients pressed the subject into Friedman's forebrain:

"It was not an issue I had seriously considered before. Most of my patients, who are adults, developed their psychiatric problems after they had a pretty clear idea of who they were as individuals. During treatment, most of them could tell me whether they were back to their normal baseline.

"Julie could certainly remember what depression felt like, but she could not recall feeling well except during her long treatment with antidepressant medications. And since she had not grown up before getting depressed, she could not gauge the hypothetical effects of antidepressants on her emotional and psychological development."

I was fairly rough on Friedman over an earlier opinion piece a few months ago, but I am going to be more charitable this time out. He's asking the right questions, regardless of how I feel about his answers. I hope that readers won't be interested in nitpicking him to death, but will instead focus on the larger issues.

We're 20 years into the psychopharmacological party in America, and Gen X and Gen Y are the ones growing up with voodoo in their veins and brains. Regardless of your views of diagnoses and meds, we need to have a big old sociocultural reckoning on these matters. What are we setting people up for in terms of their human development and their core identities if they've spent most of their lives on anti-depressants (or mood stabilizers or antipsychotics)? What's normal human development in abnormal psychology? What's their sex life going to be like if they've hardly ever been horny due to taking anti-depressants? How do you "know thyself" when your self has been partially shaped by the fine folks at Eli Lilly and GlaxoSmithKline? And so on.

Friedman admits he doesn't have the answers--no one does at this point--and he's a whole lot sunnier about the long-term use of psych meds than I'd ever be:

"We know a lot about the course of untreated depression, probably more than we do about very long-term antidepressant use in this population. We know, for example, that depression in young people is a very serious problem; suicide is the third-leading cause of death in adolescents, not to mention the untold suffering and impaired functioning this disease exacts.

"By contrast, the risk of antidepressant treatment is small. A 2004 review by the Food and Drug Administration, analyzing clinical trials of the drugs, did show an elevated risk of suicidal thinking and nonlethal suicide attempts in young people taking antidepressants — 3.5 percent, compared with 1.7 percent of those taking a placebo. But since the lifetime risk of actual suicide in depressed people ranges from 2.2 to 12 percent, risk from treatment is dwarfed by the risks of the disease itself."

I wouldn't consider the risk of suicide and suicidality, on or off-meds, to be the only worrying metric for doctors and patients to consider, or by which to evaluate long-term risks and benefits. What about brain development? Sexuality? Reproductive organ damage? Drug dependence? Long-term akathesia? Kidney and liver damage? Diabetes? Muscle rigidity? We already know that antipsychotics cause brain shrinkage in non human primate studies, so we do need to take a serious look at that in our human populations or we are doing them a gross disservice. It'd make sense to be just as concerned about anti-depressants and the whole shooting gallery of psych meds, especially since we are starting children on them at much younger ages than we even did in the 1990s.

Friedman blames the lack of answers on how psych meds are tested and approved and used in our culture--short term scientific trials for approval and barely-tested long-term use in a culture that demands that these medications be used for life. I don't think it's just the culture of FDA approval that's at fault. I think doctors have been lazy about asking these questions and I think patients are just as much to blame. Too often doctors and patients accept short-term clinical success for long-term prospects.

We need to face facts: We've been conducting the largest behavioral and medical experiment in human history right here on Spaceship America (and Spaceship Britain) over the last 20 years, and few have bothered to ask the questions that needed asking. I give Friedman props for opening his mouth.

One place where I'd criticize Friedman's piece, however:

"What do I say to a depressed patient who is doing well after five years on such a drug but can’t stop without a depressive relapse and who wants reassurance that the drug has no long-term adverse effects?"

He doesn't even nod his head to the possibility that the depressive relapse might have little to do with depression and quite possibly everything to do with the medication. I know of too many cases of people who've been on Prozac since its introduction in 1987 (there is data showing that over 500,000 Americans have been on anti-depressants for over 15 years, but I cannot locate it at the moment) and cannot get off the drug because they've developed a physical need for its "chemical balance" and simply lose all their energy and human oomph when they try going off it. This is a known phenomenon and if doctors cannot appreciate its dynamics and its pressing cultural importance, then us patients are going to have to shove it in their faces. (For further reading: the wonderful Bipolar Blast blog is an ongoing account of one brave woman's attempt to get off all medications after being on them for longer than I was. And that's a long time.)

My own thinking on these issues is far from complete, just like my own off-meds experiment (a doctor approved experiment I'll add for newbies) which is now at almost nine months. I'm in no position to state whether I think what I am learning is of any use to anyone else. But I do think it's a legitimate idea that for anyone who the medical paradigm of mental health argues should be on psych meds for years and years then there should be some kind of off-meds trial built into our treatment algorithms and practice guidelines and doctors should be encouraged to help patients find out what makes them tick underneath the medicated self.

The one thing I've learned in my nine-month adventure is that I have a level of freedom now that I cannot put into words. But whatever you'd call it, it's certainly built on the freedom to succeed and fail as a human being and as a human self.

I kind of like that.

Posted by Philip Dawdy at April 15, 2008 12:07 AM
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