The Transformation of Personality

Admittedly; there are several downsides to expecting a pill to do too much. For one thing, any drug can be misused or abused; many cause side effects. Further, overprescription of any medication may promote the idea that everyone is mentally ill, that everyone needs help. And, perhaps most important, by looking inward to a reaction in our brains for a solution to our discomfort, we may be ignoring the "external" problems of the world that underlie depression and other related disorders and difficulties.

Yet we'd feel that we hadn't done our jobs if we failed to report on a drug that transforms approximately 10 to 20 percent of its users, alleviates depression in another 50 to 60 percent, and has no effect, either positive or negative, on the final 25% or so. (These figures, incidentally, are not confined to depression, but have been demonstrated in patients treated for obsessive-compulsive and eating disorders as well.)

Jerrold Rosenbaum, M.D., of the Clinical Psychopharmacology Unit at Massachusetts General Hospital, sums up both the caution and the excitement: "People who don't need this medication shouldn't take it. Yet it has allowed me to treat beyond the boundaries of where I used to treat before." - Ed.

My first experience with Prozac involved a woman named Tess, the eldest of 10 children born to a passive mother and an alcoholic father, who was physically and sexually abused as a child. When Tess was 12, her father died and her mother entered a clinical depression from which she had never recovered. Tess-one of those inexplicably resilient children who flourish without any apparent source of sustenance-took over the family.

In time, Tess made a business career out of her skills at driving, inspiring, and nurturing others. Still, her personal life was unhappy. Tess stumbled from one prolonged affair with an abusive married man to another. As these degrading relationships ended, she would suffer severe demoralization. The current episode had lasted months, and, despite psychotherapy, she was progressively less energetic and more unhappy.

When I first met Tess, I ran down the list of signs and symptoms of clinical depression, and she had them all: tears and sadness, absence of hope, inability to experience pleasure, loss of sleep and appetite, guilty ruminations, poor memory and concentration. But for her many obligations, she would have preferred to end her life.

Had I been working with Tess in psychotherapy, we might have begun to explore hypotheses regarding the source of her social failure. (For the past four years her principal social contact had been with a married man named Jim who came and went as he pleased and finally rejected Tess in favor of his wife.) Instead, I was relegated to the surface-to what psychiatrists call the phenomena.

Depression is a relapsing and recurring illness. The key to treatment is thoroughness. If a patient can put together a substantial period of doing perfectly well-five or six months, some experts say-the odds are good for sustained remission. But to limp along just somewhat improved is dangerous. The partly recovered patient will likely relapse as soon as you stop the therapy, or as soon as you taper the drug. And the longer someone remains depressed, the more likely it is that depression will continue or return.

When Prozac was released by the FDA, I prescribed it for Tess for entirely conventional reasons-to terminate her depression and to return her to her "premorbid self." My goal was not to transform Tess but to restore her.

But medications do not always behave as we expect them to. Two weeks after starting Prozac, Tess reported that she was no longer feeling weary. In retrospect, she said, she had been depleted of energy for as long as she could remember, and had almost never known what it was like to feel rested and hopeful. She had, it now seemed to her, been depressed her whole life, and she was astonished at the sensation of being free of depression.

With this new demeanor came a new social life. Within weeks of starting Prozac, Tess settled into a satisfying dating routine. I'd never seen a patient's social life reshaped so rapidly and dramatically. Low self-worth and poor interpersonal skills-the usual causes of social awkwardness-are so deeply ingrained and difficult to influence that ordinarily change comes gradually, if ever. But Tess blossomed all at once.

"People on the sidewalk ask me for directions! " she said. They never had before.

The change went further. "I never think about Jim," she said. And in the consulting room, his name no longer had the power to elicit tears.