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Why Change the World . . .
No need for a revolution from within -- or without. Let them eat Prozac.
LIKE MANY PSYCHIATRISTS, I GREET the introduction of new psycho-active medications with cautious optimism. I'm hopeful that the new drug will benefit some patients, but my clinical experience dictates caution. Historically, practitioners have been warned to hurry to treat their patients with a new drug before it loses its effectiveness -- an ironic admission of the fact that it is often the high expectations of results that help patients achieve them.
For the last few years, I have prescribed Prozac and other members of the selective serotonin reuptake inhibitors (SSRIs) family. Some of my patients have found the drugs very effective and easy to use. Others are bothered with unwanted effects, such as sexual dysfunction, and are unimpressed with the anti-depressant property of the drug. None have noted any changes in their personality or in their customary ways of reacting to the world. While SSRIs do represent a modest advance in the treatment of depression in certain types of patients -- they have not revolutionized psychiatric care. One would never know this, of course, from the astounding rapidity with which the Prozac miracle has entered our cultural vocabulary. This is due, in part, to huge drug company expenditures on marketing and to the outspoken support of practicing psychiatrists such as Peter D. Kramer, M.D., author of Listening to Prozac.
An enthusiastic supporter of better living through chemistry, Kramer recommends that women take advantage of the fruits of "cosmetic pharmacology" to change their personalities to better fit the requirements of society. He believes that some women are too timid or withdrawn to make the most of themselves in a "society [that] demands a kind of muscular assertiveness." But with the help of a "designer drug" to fine-tune the underlying biological factors which cause fear and introversion in some, a woman can look forward to "remaking the self" and becoming "socially attractive." This will help her find a spouse or the courage to ask her boss for a raise.
Interestingly, the legitimacy of social demands for assertive individuals with no doubt and ambivalence is taken for granted even in the anti-utopian best seller, Acceptable Risk, by Robin Cook, in which a Prozac-like drug is shown to have many disastrous consequences for those who hope to gain by it. "There is an eerie confluence between what Prozac does and what society demands," Kramer told an interviewer in Psychology Today. No need for revolution from within or in the outside world. In Kramer's view, this is already the best of all conceivable worlds, so we need to adjust to it. If this is a problem, solve it by taking Prozac.
Considering the harsh reality of depression in women and the fact that the newer anti-depressants are only a modest advance over previously available drugs, this romanticization and oversell of Prozac by a practicing psychiatrist seems most puzzling. That is, until one notices that an emphasis on biological factors and a devaluation of the role of experience in explaining human behavior has become the new vogue among the intellectual elite and opinion makers.
The social purpose of this trend is most obvious when we consider how intellectuals are once again mapping the proper place of each group in society on the bell curve of that mythical entity called intelligence. Masquerading as the voice of scientific objectivity, self-serving conservatives are using the I.Q. explanation to justify maintaining the status quo of social and racial inequality. Similarly, they justify economic injustices by insisting that genetic imperatives drive us to compete, dominate, and exploit one another. With innate factors, or the so-called "hard-wiring" explanations, gaining exclusive explanatory power, experts feel justified counseling inaction in the face of inequality and injustice.
This re-assertion of entitlement from established power is an intellectual backlash against the continuous demands of the disenfranchised in this society. Women have experienced this backlash on an overt level in recent months in the efforts to dismantle affirmative action programs.
In another arena, the medicalization of psychiatry has gained strength way beyond what is empirically justified from scientific study. Psychotherapy, with its emphasis on individual perception and its tolerance, and even encouragement, of doubts and questions about social imperatives, is being rationed and controlled by the managed care organizations that now control a good portion of American medical insurance benefits. The unique experiential history of the individual or the dynamic of differential power within the family are deemed of little consequence. Psychiatrists no longer need to listen with the third ear and without preconception and prejudice. Drugs have come to be enshrined not only as treatment for emotional illnesses, but as a panacea to cure the unease that women may experience from the threat of the resurgence of the reactionary ideology.
Depression: A Woman's Disease?
Like other anti-depressants, Prozac is consumed by a significant number of women. This is due to the fact that depression, regardless of what other name it has been called or how it has been described, has always been known to afflict women more than men. In any given year, about 5.4 percent of the U.S. population or about 9.9 million people suffer from a general state of misery and discontent or what in the official nomenclature of the American Psychiatric Association (DSM IV) is called dysthymia, according to studies by the National Institutes of Mental Health (NIMH). Another 5 percent or 9.2 million are sick with the most severe form of illness called major depression. More than two-third of these 19 million are women.
Causes of depression, whether in the major or the minor form, and the reasons for the differential rate between men and women, are not known. Studies have shown that from early adolescence onward, there is a steady increase in the number of women with complaints of depressive symptoms. Some experts believe that, at least in part, the gender differences in depression are due to the characteristic expression of the sense of unwellness by women. Others consider the manner in which these complaints are perceived and interpreted by professionals as partially responsible for the large number of depression diagnoses in women. Women are described as more inhibited, less assertive, and more pessimistic about their lives than their male counterparts in the professional literature of psychology, psychiatry and the related fields, regardless of time and place or the authors' professional background. These same characteristics are also usually associated with depression in men.
Depression is usually viewed in a social vacuum. Exploring of the effects of the established social order on the emotional health of the individual has never been encouraged in psychiatry or psychology. Indeed, adjustment to and acceptance of the social hierarchy is an implicit dimension of the definition of mental and emotional health of the individual. So mental health professionals are taught to ignore the very salient fact that women's survival in social and interpersonal realms require that they frankly accept a subordinate social position and voluntarily engage in appeasement strategies in order to escape male aggression themselves and/or protect their children. The self-sacrifice and self-betrayal required from women, and the powerlessness and insecurity associated with these postures, are major causes of women's dissatisfaction with their lives. That a relationship exists between the chronic state of frustration and non-fulfillment of women and the female preponderance in prevalence of dysthymia seems compelling.
One reason that the relationship between women's social role and psychological states has been ignored is that historically women have been underrepresented in all decision-making positions within the psychiatric establishment. Over 25 percent of psychiatrists and more than 40 percent of residency positions in psychiatry are now filled by women. But only three of the psychiatry departments of the 126 U.S. medical schools are chaired by women, and the NIMH has only two female section chiefs. Over the past 40 years, the American Psychiatric Association has published four versions of the standard classification of mental illnesses and several intermediate revisions -- classifications which become the bible for describing and diagnosing psychiatric disease and the basis for research. The committees that create these classifications have never had more than a few women among their members. Thus, naming and defining the standards by which normal and pathological behavior are differentiated has remained overwhelmingly dominated and determined by men.
The results of this exclusion of the female professional perspective is not limited to the blindness to women's social role. Labels such as postpartum psychosis, involutional melancholia, and premenstrual syndromes have been liberally coined and used to name and explain women's behaviors and feelings related to their biology. However, research into the actual relationship of women's biology and the menstrual cycle has been grossly neglected until quite recently. Now Dianne Schecter of Columbia University and her group have found evidence indicating that the menstrual cycle may play a part in the differential susceptibility of women to some psychiatric illnesses. And other researchers have shown that the menstrual cycle also affects how women respond to psychotropic drugs at different times during the cycle.
Dosages Fit for Men
Seventy percent of all psychotropic drugs are consumed by women. But very little is known about the interaction between anti-depressant and anti-anxiety medications and the changing hormonal levels in women's bodies due to menstruation and menopause, or contraceptive and replacement hormonal therapy. The Food and Drug Administration (FDA) considers women of childbearing age, between 15 and 55, unsuitable subjects for phase one and two drug trials. During phase one trials, drugs are given to healthy volunteers to judge the toxicity and the metabolism of medications at different dosages and over short periods of time. In phase two studies, the effectiveness and safety of the drug in the target population is evaluated. The FDA has not required that the specific effects of medications and their dosage on women, and the interaction between the drugs and the fluctuating hormonal states be known before drugs are allowed to enter the marketplace. Pharmaceutical companies have found this situation to their advantage, since additional testing and trials on women would increase the cost of drug development.
So for the purposes of pharmaceutical companies and the FDA, women are honorary men. Only a cautionary note about the inadvisability of prescribing medications for pregnant women and nursing mothers is required to make drugs tested on men equally acceptable for women. A good example of the dangers of this policy is the prescription of neuroleptics: the anti-psychotic drugs used to treat schizophrenia and depressive psychosis. In both schizophrenia and depressive psychosis, patients may be on neuroleptics for many years. Of the many side effects of neuroleptics, some are more frequent in women: these include lactation, weight gain, and certain kinds of involuntary movement disorders. The greater toxicity of neuroleptics in women may be due to the fact that determinations of the doses needed for the drugs to be effective have been partially based on their ability to curtail aggressive and violent behavior. Since these symptoms are more prevalent among male patients, women who need these drugs are treated with larger dosages than they may require and for symptoms that they do not have, and consequently, are exposed to unnecessary side effects.
In response from pressures from The Women's Congressional Caucus in 1993 and the Working Group on Clinical Trials the FDA has finally begun revising several policies in regard to drug trials for women. But the economic factors driving the medical practice favor a one-size-fits-all drug dosage system. Studies have shown both gender and ethnic group variations in drug sensitivity, rate of metabolism, and the presence or absence of enzymes necessary for breakdown of the chemical agents in the body. These cast serious doubt on the wisdom of universal medication or common dosage for all individuals afflicted with the same disease.
The Borders of Prozac Nation
While psychoactive drugs have undeniably helped women with psychiatric illnesses, they remain disappointingly limited in their effectiveness. Fifty years after the advent of modern psychopharmacology, and in spite of the potentially huge market and profits, only a very limited class of usable active agents have been identified. Over the years, new psychotropics have been introduced, withdrawn and even reintroduced because some practitioners have identified patients whose illness have been responsive to the specific drug or a combination including the drug in question. The multiplicity of names and colorful pills reflect the number of pharmaceutical companies producing "me too" drugs, rather than an abundance of choices.
Prozac and its look-alikes do represent a modest advance. Treating depression in patients with heart disease has become less worrisome because SSRIs do not have some of the unwanted side effects of the older anti-depressant drugs. But the SSRIs are no cure-all for depression. Some patients are already requiring more than the one pill a day--the dose once thought to be adequate. The long term effects of the medication are not as yet known. In about one-third of depressed patients, Prozac is ineffective in any dose.
So Prozac is not the long awaited Soma of the Brave New World or the magic arrow to straighten the distorted personality. Just as years of cosmetic surgery have not added to our knowledge about the causes of aging or even postponed it, cosmetic pharmacology--even if materialized--will not be the antidote against the systematic poisoning of women's lives or the limitation and constraints imposed on their pursuit of self-realization. Even if, as Kramer promises, women become more adept at finding spouses or develop "a sense of self" strong enough to leave an abusive relationship, they will not be able to stop their former husbands from stalking and killing them. Professional women may be able to point to the glass ceiling, but no miracle drug will guarantee that they will not have their career ladders pulled from under them. Equal pay for equal work is not a goal that each women can pursue in her own isolated job regardless of how empowered she may feel by taking the fruits of cosmetic pharmacology. In an interview in which Kramer discusses his own status as a best-selling author and celebrity, he notes that: "It changes you very profoundly to be even modestly successful in America. You almost forget certain insecurities." It may be necessary to remind Dr. Kramer that women's insecurity and timidity are caused by their repeated experiences of failure, the continuous thwarting of their will, the curtailment of their freedom, and their inability to make choices regarding their bodies and their lives. Success, even in small doses, but given more frequently, will obviate the need for the promised miracles of cosmetic pharmacology for women.
Mahin Hassibi, M.D. is clinical professor of psychiatry at New York Medical College in New York City.