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by Joseph Glenmullen
Simon & Schuster, 2000
Review by Christian Perring, Ph.D. on Jun 30th 2001

Prozac Backlash

I was skeptical about this book before reading it. I'd read a few reviews, and I got the impression that is was alarmist and self-serving. The reviews focused on Glenmullen's discussion of severe side effects of SSRI (selective serotonin reuptake inhibitors) antidepressants, such as bodily tics and powerful muscle spasms, and reported that these problems were comparable to the tardive dyskinesia that sometimes results from antipsychotic medications. The symptoms can persist even after one has discontinued the medication, sometimes for months, and maybe longer. This all sounded very similar to the criticisms of Peter Breggin and psychiatric survivors groups, who tend to overplay their hands, and who have been making alarming claims about the side effects of medication for many years.

However, on reading Prozac Backlash I found it to be a far more careful and balanced book than I expected, and, for me, its most important message is about the power (and abuses of power) of pharmaceutical corporations. Glenmullen's descriptions of the way the major psychotropic drug manufacturers place business above truth and patient welfare, and how they are capable of influencing the decisions not only of the psychiatric profession but also the FDA are shocking. I'd strongly recommend that anyone involved in the mental health profession and people who are taking or considering medication to read at least a few crucial chapters of this book. It will provide a foil to the simplistic and deceptive advertisements that now appear regularly on TV and in national magazines for Prozac, Zoloft, Paxil, and other SSRIs, and to the beguiling talk of "chemical imbalances" that is pervasive not only in popular culture but also among mental health professionals.

The discussions of the side effects of SSRIs is disconcerting, and Glenmullen makes a strong case that the drug manufacturers and the psychiatric establishment have downplayed these serious side effects. He documents all his sources (there are thirty five pages of notes at the end of the book) and leaves little room for doubt that there are at least strong reasons to worry about the effects of Prozac and its relatives. Chapter one is about tics, muscle spasms, fatigue, and neurological agitation, and it draws parallels to the effects of the antipsychotic drugs and neurological diseases. Chapter two is about the effects of going off SSRI medication, which is what he calls "Prozac backlash." Often people feel bad when they discontinue their medication, and they conclude that they need to resume taking it. But Glenmullen argues that in many cases, the proper conclusion is that the medication should be tapered more carefully and there is often no reason to think the medication continues to be necessary. The fact that SSRI medication can have withdrawal effects means that it can be hard to kick the habit of medication, and is in a sense addictive. This is a conclusion that the manufacturers of these drugs do not want society to come to.

Chapter three is about the rather well known sexual side effects of SSRIs and ways to deal with them. More interesting is chapter four, in the possibility that Prozac and similar medications can make people violent or suicidal. Glenmullen documents the evidence about the effects of the Prozac. However, far more alarming are the steps that its manufacturer, Eli Lilly, has taken to keep this information from the general public and the psychiatric profession. This story shows the power of corporations to control information in the United States, and in much of the western world. Chapter five follows up with similar themes, looking more at how popular reporting of the causes of depression is so often simplistic and is biased in favor of pharmacological treatment. There is no serious evidence that depression is usually caused by depleted levels of the neurotransmitter serotonin. The evidence that SSRI medication is a better way than placebos to relieve depression is patchy, and non-existent in the case of children. Looking at the effects of Prozac, he concludes that "the term 'antidepressant' is virtually meaningless and seriously misleading" (216). He gives evidence that the effects of the drugs are very similar to those of stimulants such as cocaine and amphetamine at prescription doses. He goes on to argue that HMOs and medical schools are financially implicated with pharmaceutical companies to such an extent that they have lost their ability to make objective and unbiassed judgments affecting patients.

The final three chapters deal with alternative treatments from prescription medication, such as psychotherapy, St. John's Wort, and exercise. They are effective treatments for depression, anxiety, addiction, and eating disorders. Often they are more effective and long lasting than using medication alone.

Glenmullen is not against the use of SSRI medication: he often prescribes Prozac, Zoloft, Paxil, and the like to his patients. His message is that those doing the prescribing should be extremely careful when using these medications, because of all the problems that come with them. These medications should not be used as a long term solution for mild cases of mental disorder. They should never be used on their own, but only in combination with other non-medication approaches. It is alarming that we are so ready to rely on medication when its benefits are so unclear and there are so many indications of the problems that come with it.

I have some reservations about the style and length of the book. It could be shorter than its 338 pages of text, not including the notes. The final three chapters could be condensed into one, and some of the other chapters could be shortened. One feature of the book that it shares with most psychology books aimed at a general readership is its use of case histories. These are a sine qua non of the publishing industry these days. The Introduction starts with a student, Ann, who comes in to his office demanding a prescription for Zoloft because of her depression over her break up with her boyfriend three years ago. Chapter one starts with Maura, who is experiencing uncomfortable bodily tics, and soon moves on to Leslie, who was experiencing extreme apathy. Every section of the book seems to start with a new patient. It's a formulaic style, and its grows tiresome. I know that it helps to make rather technical issues more palatable for a general readership, drawing them into the details, helping relate the scientific and ethical issues to their own lives. It makes technical issues less dry to lay readers. Nevertheless, this way of sweetening the bitter pill of seriousness has its limitations, and I think it could be used a little more sparingly.

I suspect that part of the problem is that Glenmullen is trying to do too much in this book. He is giving accounts of the problematic side effects of SSRI medication, the way that multinational corporations have interfered with the legal system to protect their reputations, the popular discourse of medication in modern society, and the multitude of alternatives to medications as treatments for psychological problems. He is aiming both at general readers (presumably hoping for a bestseller with a title like Prozac Backlash) and also more specialized readers. The result is that the book is sprawling and unwieldy. The solution for readers is to be selective in which chapters they read. Most health care professionals will have little to learn from the last three chapters, while lay readers may want to skip some of the more detailed scientific exposition in the earlier chapters.

Prozac Backlash is an important book. It is not a shrill condemnation of psychiatric drugs, but rather a powerful reminder that these medications can have extremely serious side effects. It does not say that most people should stop taking antidepressants, but instead encourages people to be conscious of the dangers. Given the way that the medical profession has been structured, under the influence of the pharmaceutical corporations and HMOs, patients may have to fight to get the appropriate kind of help for themselves. Used carefully and in conjunction with other forms of treatment, SSRI medication can be extremely useful in the treatment of mood disorders, anxiety, and other psychological disorders. For those readers who are concerned with not just individual treatment of emotional problems, but with the wider role of the mental health business in society, Prozac Backlash provides good reasons to think that the current arrangements are very troubling, and we need to think hard about how to stop the motive of profit making playing such a profound and intrusive role in the way that we provide psychiatric treatment.

© 2001 Christian Perring. First Serial Rights.