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Prozac: Pro and Con

WebMD Feature

June 2, 2000 -- "I look so awful, I'm afraid to leave the house!" Maura, a graceful 39-year-old Irish woman, had been a psychotherapy patient of mine for about a year when she began developing strange, fluttering tics around her eyes. The tics eventually grew to include involuntary chewing motions and twitching of her lips. Her tongue darted in and out uncontrollably. She wore sunglasses and scarves to cover the disfiguring movements.

What happened to Maura is called "tardive dyskinesia," and it's one of the most worrisome side effects of many psychiatric drugs prescribed in America, including Prozac. Maura's primary care physician had put her on Prozac two years earlier because she'd been feeling anxious and weepy whenever she drove on highways. A year after that, she became my psychotherapy patient, and after she successfully completed therapy, we began cutting back on her Prozac prescription.

Still, what had started as mild facial tics became uncontrollable symptoms that confined Maura to her house. It took six months for the worst of these disfiguring tics to subside. She still has twitching around her lips.

Doctors are now seeing side effects with Prozac indicating a range of loss of motor control: tics, twitches, muscle spasms, immobilizing fatigue, and tremors. While this drug is marketed as a panacea, and the public's general impression is that it brings only incidental side effects, Eli Lilly and Co.'s (Prozac's manufacturer) official product information acknowledges that tremors alone occur in 10% of patients on Prozac. (Any side effect occurring in 1% or more of patients is acknowledged as "frequent" by the pharmaceutical industry.)

More than 28 million people have taken Prozac and other related antidepressant drugs such as Zoloft, Paxil, and Luvox, which are thought to increase levels of serotonin, a chemical messenger in the body associated with mood, among other things. Of these, about 70% get their prescriptions not from psychiatrists trained in diagnosing and treating depression, but from primary care physicians who often have neither the time nor the expertise to fully evaluate their patients' mental health and advise them about different therapies. Many primary care doctors aren't happy with this state of affairs, but they feel pressured by health insurers not to refer patients to specialists.

The "if depressed, then Prozac" model puts millions of people needlessly at risk of serious side effects. The most dangerous of these is an "overstimulation reaction" that has been linked to compulsive thoughts of suicide and violence. This risk of suicidal thoughts, which occurs in an estimated 1% to 3% of patients, so alarmed the German equivalent of the U.S. Food and Drug Administration that a warning appears in Eli Lilly and Co.'s official information on Prozac in Germany.

Suicidal thoughts and loss of motor control are not the only side effects of these antidepressants. Others include:

  • Severe withdrawal. It can take patients months to wean themselves off an antidepressant like Paxil without suffering symptoms such as dizziness, anxiety, and difficulty balancing.
  • Significant weight gain, often after initial weight loss.
  • A loss of effectiveness. Prozac, for example, wears off in about a third of patients within a year.
  • Sexual dysfunction, reported in as many as 30% to 60% of patients.

These important concerns are downplayed by Prozac's manufacturer, Eli Lilly and Co. Moreover, the published risks are based on short-term studies. No one really understands how normal functioning of the brain may be impaired by Prozac-type antidepressants in the long run. Indeed, one worrisome study, published in the March 2000 issue of Brain Research, indicates that Prozac and Zoloft may be toxic to the very cells they target in the brain.

Does this mean that no one should take these antidepressants? Emphatically not. I still prescribe Prozac and related medications for patients in my practice. I've seen firsthand the benefits they offer. But any drug that also has the potential for serious harm should be prescribed only by experts, and then only with restraint and careful monitoring.

Patients should have moderate to severe depression symptoms that affect them to the point that they risk real damage -- the loss of a job or a relationship, or the abandonment of an important goal -- before they consider starting antidepressant medication. Even then, these drugs should be used in combination with other types of treatment, like psychotherapy, couples therapy, or 12-step programs in order to ultimately reduce long-term dependence on the drug.

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